Coding and Informatics

Coding and Informatics – Babatunde Carew, Elizabeth Ann Yakes

Background

  • ICD 10 Codes: International Classification of Disease Codes, 10th Revision. Used to categorize all diseases and symptoms.
  • CPT Codes: Current Procedural Terminology Codes: Numeric codes assigned to every task and service a physician may provide to a patient including medical, surgical, and diagnostic services. They are used by insurers to determine the amount of reimbursement that a practitioner will receive.
  • E&M Codes: Evaluation and Management Codes. These are a category of CPT codes and are the most frequently used. There are different levels of E&M codes, which are determined by the complexity of a patient visit and documentation requirements. Example: 99204 (new patient, level 4) or 99213 (established patient, level 3).
  • Preventive Service Codes: A category of CPT codes used for annual wellness exams. Example: 99395 (established patient, age 18-40).

 

Problem Oriented Visits

  • Return and new patients for which you are mainly addressing one or more acute or chronic problems should be filed under an E&M code.
  • Documentation for these visits only need to include what you as a physician think is medically appropriate.
  • The correct E&M code for the visit will depend on three categories: (1) medical complexity, (2) level of risk with testing/treatment, and (3) the amount/complexity of data reviewed. To meet criteria for a given code, the visit must meet the criteria in at least 2 of the 3 aforementioned categories.

 

Code 99213 (Established) or 99203 (New) - you will sometimes have a level 3 visit when addressing only one problem or providing no prescriptions

Low Problem Complexity

Low Risk of Diagnostic Testing/Treatment

Limited Data

(1 Subcategory Required)

Two or more self-limited or minor problems

 

OR

 

One stable or chronic illness

 

OR

 

One acute of uncomplicated injury

 

Low risk of morbidity from additional diagnostic testing/treatment

Subcategory 1 (any 2 elements)

 

You reviewed and summarized a note from an external source

You reviewed a test result

You ordered a test

 

Subcategory 2

You obtained additional history from someone other than the patient

 

Code 99214 (Establish) or 99204 (New)

- most of your visits will fall into this category

 

Moderate Problem Complexity

Moderate Risk of Diagnostic Testing/Treatment

Moderate Data

(1 Subcategory Required)

 

Two or more stable chronic illnesses

OR

One or more chronic illnesses with exacerbation, progression, or side effect of treatment

OR

One undiagnosed new problem with uncertain diagnosis

OR

One acute illness with systemic symptoms

OR

One acute complicated injury

Moderate risk of morbidity from additional diagnostic testing/treatment

 

Examples:

You are managing prescription drugs

 

Decision regarding minor surgery with identified patient or procedure risk factors

 

Decision regarding major elective surgery without identified patient or procedure risk factors

Diagnosis or treatment significantly limited by social determinants of health

Subcategory 1 (any 3 elements)

You reviewed and summarized a note from an external source

You reviewed a test result

You ordered a test

You obtained additional history from someone other than the patient

Subcategory 2

You interpreted a test independently of the official interpretation which is planned to be performed by someone else

Subcategory 3

 

You discussed management or test interpretation with another physician or qualified health personnel

 

 

Code 99215 (Established) or 99205 (New) - you will rarely have a level 5 visit due to the severity of the presentation required to meet criteria

High Problem Complexity

High Risk of Diagnostic Testing/Treatment

Extensive Data

(2 Subcategories Required)

 

One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment

 

OR

 

One acute or chronic illness or injury that poses a threat to life or bodily function

 

High risk of morbidity from additional diagnostic testing/treatment

 

Examples:

 

Drug therapy requiring intensive monitoring for toxicity

 

Decision regarding hospitalization

 

Decision regarding elective major surgery with identified patient or procedure risk factors

 

Decision regarding emergency major surgery

 

Decision to make DNR or deescalate care due to poor prognosis

 

Subcategory 1 (any 3 elements)

 

You reviewed and summarized a note from an external source

 

You reviewed a test result

 

You ordered a test

 

You obtained additional history from someone other than the patient

 

Subcategory 2

 

You interpreted a test independently of the official interpretation which is planned to be performed by someone else

 

Subcategory 3

 

You discussed management or test interpretation with another physician or qualified health personnel

 

           

 

Annual Wellness Visits (Not Medicare)

  • Return and new patients you are seeing for a preventive annual exam should be filed under a preventive service code.
  • Documentation for this visit MUST include a comprehensive update of PMH, Surgical Hx, Meds/Allergies, Social Hx and Family Hx, a 14-point ROS (i.e. your note must say something along the lines of “14 systems were reviewed and pertinent positives are noted in the HPI), and anticipatory guidance/risk factor reduction.
  • The correct preventive service code will depend on patient age and the ICD-10 code should be Z00.00
  • This visit can only be coded for once every 365 days (although some insurances may allow you to code an annual each calendar year, every 365 days is a safe bet)
  • CPT Codes:
    • Code 99395 (established) or 99385 (new): Preventive Annual Exam, age 18-40.
    • Code 99396 (established) or 99386 (new):Preventive Annual Exam, age 40-65.
    • Code 99397 (established) or 99387 (new): Preventive Annual Exam, age 65+ (NOT Medicare patients).

 

Annual Wellness Visits (Medicare)

  • Return and new Medicare patients (not Medicare managed plans like Cigna Medicare, etc) you are seeing for a preventive annual exam should be filed under a Medicare specific preventive service code.
  • Patient must complete a health assessment form.
  • Documentation must include: (1) age specific screening questions (cognition, depression, and function, (2) family and social history, (3) medication reconciliation (include DME).
  • Personalized prevention plan services (PPPS) information (recommendations for screening/prevention) must be included in the after-visit summary (AVS).
  • Much of this can be completed by the nurse during intake.
  • Talk to your preceptor before seeing the pt if you need help with the logistics!!
  • G Codes:
    • Code G0402: Welcome to Medicare Visit, a one-time benefit visit only available within the first 12 months of Medicare Part B.
    • Code G0439 (established) or G0438 (new): Medicare Preventive Annual Exam. Does NOT include a physical exam. PPPS must be included in AVS. Ask your fellow residents or attending to share a PPPS dot phrase which may be inserted into patient instructions.

 

Modifiers

  • Modifiers are numbers/letters that are attached to CPT code for billing purposes
    • 25 Modifier: Alerts the payer that a significant, separately identifiable E&M service was provided by the same physician on the same day of the procedure or other service. (annual plus problem based visit or E&M visit plus procedure)
    • GC Modifier: Seen by a resident and attending physician (must use for PGY-I during first six months)
    • GE Modifier: Seen by resident alone. If this modifier is used, the highest level billable is a level 3 (Note: due to COVID-19 restrictions, residents (and interns after January) can “solo” bill for Level 4/5 with CR (catastrophic response) modifier.
    • CR: Catastrophic Response (see above). 
    • GT: Telemedicine encounter