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CPT CODING FOR YOUR MEDICAL HOME

Richard Lander, MD, FAAP

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: http://www.aap.org/member/SectionMbrreq.htm.

http://www.aap.org/member/SectionMbrreq.htm�

CPT FOR THE MEDICAL HOME Whose home is it?

MEDICAL HOME

Julian’s mom brings him complaining that he is tugging on his right ear.

After an examination you diagnose him with an acute otitis media and discuss treatment

Is this a medical home?

MEDICAL HOME

Erica admits to you she has had an alcohol problem for the last 6 months.

You help her find the appropriate care Is this a medical home?

MEDICAL HOME During your lunch break you take a

phone call from the pediatric gastroenterologist about your mutual patient Jeffrey. The GI doctor wants him to see an ENT and you agree

to take care of this Is this a medical home?

MEDICAL HOME The answer to all these questions is a

resounding YES. The pediatrician’s office has always been

a medical home. We invented it years ago!

CPT FOR THE MEDICAL HOME

The AAP gave birth to the medical home as Pediatricians we have coordinated care for our

patients So what is Patient Centered Medical Home? it is the same thing but now with Internists and

Family Practitioners embracing the concept, it has a fancy name


PATIENT CENTERED MEDICAL HOME

doing more for your patients than you did before to keep them in you home

face-to-face visits evaluation and treatment of ADHD treatment of warts minor surgery non-face-to-face visits care coordination

CPT FOR THE MEDICAL HOME So how do I code for what I do in the

PCMH?

What is coding and why is it important to me? Coding is how you will

make your living It tells the insurers and

auditors what the patient’s problems were and what you did for them

It’s how you get paid

Increase Reimbursement and Decrease Liability Through Physician Knowledge and Use of Coding

Increase revenues by increasing productivity without working harder !


Basic CPT coding remains the same Learn the CPT codes as you coordinate

care for your patients Medical Team coding Physician and Non-Physician Prolonged services coding Category II codes

Well visit codes Very simple Only need to know if patient is “old” or “new” and the age

New patient – one not seen by you or the practice in 3 years

Well visit Codes –New Patients

99381 – under 1 year 99382 – 1 - 4 years 99383 – 5 - 11 years 99384 – 12 - 17 years 99385 – 18 – 39 years

Well Visit Codes – Established Patients

99391 – under 1 year 99392 – 1 – 4 years 99393 – 5 – 11 years 99394 – 12 – 17 years 99395 – 18 – 39 years

Evaluation and Management Codes

Routine sick visits Based on severity of illness and work done

If more than 50% of visit is counseling, then time is an element

E/M Codes

New patient codes require all 3 elements 99201-5 Established patients only require 2 out of 3 elements 99211-5 99211 – doesn’t require the presence of a physician

Office Visits – New Patient Codes 99201 99202 99203 99204 99205

History Problem Focused

Expanded Problem Focused

Detailed Compre hensive

Compre hensive

Exam Problem Focused



Compre hensive

Decision Making

Straight forward

Straight forward

Low complex

Moderate complex

High complex

Time FF 10 20 30 45 60 Key # 3 of 3 3 of 3 3 of 3 3 of 3 3 of 3

Codes 99211 99212 99213 99214 99215 History Not

Required Problem Focused



Required Elements

HPI 1-3 ROS N/A PFSH N/A

HPI 1-3 ROS 1 PFSH N/A

HPI 4+ ROS 2-9 PFSH 1/3

HPI 4+ ROS 10+ PFSH 2/3

Exam Not Required

Problem Focused



Required Elements

1 Area 2-4 Areas

5-7 Areas

>8 Areas

Decision

Not

Straight

Low

Mod

High

CPT FOR THE MEDICAL HOME Perhaps as a PCMH you will be providing

more services to you patients, i.e. procedures or as I like to call them the

PROCEDURES

INTEGUMENTARY SYSTEM 10040 ACNE SURGERY 10060 I&D OF ABSCESS 10061 COMPLICATED OR MULTIPLE 10120 I&D FOREIGH BODY SUBQ 10140 I&D OF HEMATOMA OR FLUID COLLECTION

PROCEDURES

16000 INITIAL TREATMENT FIRST DEGREE BURN-LOCAL TREATMENT

16010-30 DRESSING AND/OR DEBRIDEMENT WITH/WITHOUT ANESTHESIA SMALL TO LARGE

17000-4 DESTRUCTION(ACTINIC) 17110-11 DESTRUCTION WARTS 17250 CHEMICAL CAUTERIZATION

PROCEDURES

26641 CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION THUMB WITH MANIPULATION

26670 NOT THUMB 26720 CLOSED TREATMENT OF PHALANGEAL SHAFT

FRACTURE WITHOUT MANIPULATION

PROCEDURES

30300 REMOVAL FB INTRANASAL 94150 NEWBORN CIRCUMCISION 54162 LYSIS OF PENILE POSTCIRC ADHESIONS 54450 FORESKIN MANIPULATION INCLUDING LYSIS

OF PREPUTIAL ADHESIONS

PROCEDURES

99173 SCREENING VISUAL ACUITY 94150 VITAL CAPACITY 94640 INHALATION TREATMENT FOR ACUTE AIRWAY

OBSTRUCTION 94664 DEMO OR EVALUATION OF PTUSE OF

NEBULIZER OR MDI 94667 MANIPULATION OF CHEST WALL

WELL AND SICK VISITS 3 y/o Joey comes in for her well visit. She

is wheezing and has subcostal retractions What do you do? a. cancel the well visit and treat the

asthma b. do both well and sick visits c. send her to the hospital d. check her insurance

WELL AND SICK VISITS d. check insurance first If the insurance company will not pay you

for both visits you have a decision to make-

a. do both visits and lose money b. perform the well visit and send her to

the ER c. treat the asthma and have the family

reschedule the well visit

WELL AND SICK VISITS

There is no “right” answer Personally I think that none of us should choose to

lose money because the patient’s insurance won’t pay for both visits.

The patient’s have chosen their insurance and they have to learn to live with the affects of their decisions


Erica has come into the office wheezing. Here are your findings:

cc, hpi-5 items, ph, fh, ros-3, physical exam includes 7 systems

You give Erica a pulmonary function test and based on that a nebulizer treatment with Xopenx.

You then code the visit as 99214, 94010 and 94640 (if you purchased the Xopenex add j7614


Let’s say that Erica needed a second nebulizer treatment. You would then notate the 94640 and repeat it with the modifier 76 after it. This tells the MCO that the same physician, on the same day performed the same procedure on the same patient again.

CPT FOR THE MEDICAL HOME Let’s change the scenario again. You send Erica

home after the first nebulizer treatment. You too go home. Erica gets worse, returns to the office where one of your associates evaluates her and repeats the nebulizer.

You now code the visit as 99214, 94640, 94640-76, 94010 a. True b. False

CPT FOR THE MEDICAL HOME b. false The repeat 94640 should not have the 76 modifier

as it wasn’t the same doctor. The 77 modifier is for the same patient, the same

day, the same procedure repeated but by another doctor.

So with the 77 modifier we are okay

a. true b. false


b. false Everything is okay except for the 99214. With the

extra work provided by the second doctor in the afternoon you could now use 99215 and get paid more money!

MODIFIERS

SOMETHING DIFFERENT WAS DONE -25 SIGNIFICANT, SEPARATELY IDENTIFIABLE

E&M SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE

NOT TO BE USED WHEN A DECISION IS REACHED TO PERFORM SURGERY

MODIFIERS

-63 PROCEDURE INFANT < 4KG -76 REPEAT PROCEDURE BY SAME PHYSICIAN,

SAME PT, SAME DAY -77 REPEAT PROCEDURE BY DIFFERENT PHYSICIAN, SAME PT, SAME DAY

MODIFIERS

-50 BILATERAL PROCEDURES -51 MULTIPLE PROCEDURES -53 DISCONTINUED PROCEDURE -59 DISTINCT PROCEDURAL SERVICE

You have spent 70 minutes with Jeffrey and want to be paid for your time.

a. 99215 b. 99215-25 c. 99215, 99354



a. 99215-you lost money (code for 40 min) b. 99215-25 why? c. 99215, 99354 99354 prolonged face-face, 30-74 minutes

office or outpatient setting 99355 for each additional 30 minutes after

99354


IN THE PCMH THERE WILL BE TIMES WHEN THE PATIENT CARE IS NOT FACE-TO-FACE


PROLONGED SERVICE WITHOUT PATIENT CONTACT

may be reported on a different date i.e. record review must relate to service where direct care

has or will occur total duration of time on specific date


PROLONGED SERVICES WITHOUT DIRECT PATIENT CONTACT

99358 30-60 minutes 99359 each additional 30 minutes must be at least an additional 15 minutes


MEDICAL TEAM CONFERENCE minimum 3 qualified healthcare

professionals face-to-face evaluation must have

taken place within 60 days time related to record keeping and

report generation not reported


MEDICAL TEAM CONFERENCE, DIRECT CONTACT WITH PATIENT &/or FAMILY

99366-30 minutes+ nonphysician

MEDIAL TEAM CONFERENCE, WITHOUT DIRECT CONTACT

99367-30 minutes+ with physician 99368-nonphysician


CARE PLAN OVERSIGHT SERVICES reported separately from the other

codes we have discussed services within a 30 day period only one physician may use this for a

given period of time-sole or predominant supervisory role

does not include low intensity or infrequent supervision


CARE PLAN OVERSIGHT 99374-physician supervision of a patient

under care of home health agency, requiring physician development &/or revision of plans, patient status, etc

15-29 minutes per month 99375- 30 minutes or more


CARE PLAN OVERSIGHT 99377-supervision of hospice patient 15-29 minutes 99378-30 minutes or more

99279-supervision of nursing facility

patient 15-29 minutes 99380-30 minutes or more


COUNSELING RISK FACTOR REDUCTION no specific illness present diet and exercise substance abuse sexual practices injury prevention


PREVENTIVE MEDICINE, INDIVIDUAL COUNSELING

99401 15 minutes 99402 30 minutes 99403 45 minutes 99404 60 minutes


BEHAVIORAL CHANGE INTERVENTIONS for behavior that is an illnesss to change harmful behavior that has not

yet become an illness


99406-tobacco cessation 3-10 minutes 99407 greater than 10 minutes

99408-alcohol &/or substance abuse

structured screening and intervention 15-30 minutes

99409 greater than 30 minutes


GROUP COUNSELING

99078 for patients with symptoms or

established illness 99411 preventive counseling or risk factor reduction


NON-FACE-TO-FACE Telephone physician to patient cannot use if seen in next 24 hours cannot use if problem previously

addressed in last 7 days Online and must be permanently stored once in 7 days for a particular service cannot be used if previous e&m service


TELEPHONE 99441 5-10 minutes 99442 11-20 minutes 99443 21-30 minutes

ONLINE 99444


Since you want to have a medical home you also want to have a strong, and busy medical home

To help do this you will need to be able to recall your patients for vaccines and well visits

RECALL OR NOT TO RECALL ADVANTAGES

BRING PATIENTS INTO THE OFFICE Opportunity for annual examination CPT 99381-95 Opportunity to discuss health risks CPT 99401-4 Behavioral change interventions CPT 99406-9 Opportunity to vaccinate

RECALL OR NOT TO RECALL I’m so busy now how can I see more

patients and why should I? the why is easy,-it is to protect your

patients against the vaccine preventable diseases

RECALL OR NOT TO RECALL

Monetary advantages of bringing the patient in for a well examination

if you added one additional well visit per day to your schedule and were paid $100.00 for that visit you would increase your revenue for a 50 week year by$25,000.00

if you used any screening tools (PHQ9) and or the CPT codes 99401-9 (counseling/prevention) you could add an additional $7500.00

ADDITIONAL REVENUE

PROFIT ON THE VACCINE ITSELF 10-25% OVER ACQUISTION COST PEDIATRICIANS SPEND $100,000/doc profit $10-25,000

ADDITIONAL REVENUE VACCINE ADMINISTRATION FEES PAID BY ALL MCO INCLUDING MEDICAID $10-30 per vaccine 2500 patients per doc if you immunized 50% of your practice for

influenza the fees generated would be $12,500-$37,500 for administration only this alone would pay for 1 fulltime staff


WHAT TO DO IF MANAGED CARE ORGANIZATIONS WON’T ACCEPT THE CPT CODES?

renegotiate your contracts demonstrates cost savings with the

medical home demonstrate improved patient

outcomes with the medical home


How else can you increase what you get paid for what you do?

NCQA Certification P4P Programs


What are category II CPT codes? There were developed to simplify

reporting of performance measures. These are directly related to Pay-for-Performance programs which if you qualify for them, will put more money in your pocket for the same amount of work done.

CPT CATEGORY II

These codes describe the performance of a clinical service. The regular CPT codes are also reported.

The codes are grouped within categories based on, history, physical findings, assessment, plan, etc.

CPT CATEGORY II

The categories are: Composite measures 0001F-0015F Patient management 0500F-0575F Patient history 1000F-1220F Physical exam 2000F-2050F Diagnostic screening 3006F-3573F Therapeutic, preventive, other interventions 4000F-4306F

CPT CATEGORY II

Follow-up, other outcomes 5005F-5100F Patient safety 6005F-6045F Structural measures 7010F-7025F

CPT CATEGORY II

There are four different modifiers 1P-exclusion due to medical reasons 2P-exclusion due to patient choice 3P-exclusion due to system reason(not covered,

resources not available) 8P-not performed, not otherwise specified

CPT CATEGORY II

An example courtesy of the AAP: A patient presents as a follow-up for moderate,

persistent asthma on albuterol and inhaled steroids. His history, physical exam and medical decision

which includes continuing his meds contribute to the CPT code of 99213 with the ICD-9 of 493.00

CPT CATEGORY II You also report the following with the

493.00 1005F-persistent asthma 1038F-persistent asthma 4015F-persistent asthma, long-term

control medication prescribed Since you participate in a P4P program

this documentation will support the extra money you now receive

CPT FOR THE MEDICAL HOME Learn CPT and ICD-9 coding Document your notes appropriately Capture all your services on the superbill Review your EOBs to update your fee

schedules Negotiate good contracts with the MCOs-

don’t be afraid to drop your poor payors MAKE MONEY caring for your patients

The Truth: ”No Margin-No Mission”

• Physicians choose the best practices for quality care for children

• Then must use the coding and contracting

systems to fund the services • Those established services (such as vaccine

delivery) that are undervalued may end

A DAY IN THE LIFE Let’s call it a day-go home early and relax

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