Center Michael Bower CPC Wilce Student Health Center Wilce Student Health Center Wilce Student Health Center at The Ohio State University Autumn 2013 Enrollment 63964 57466 Columbus Campus ID: 904476
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Slide1
CODING 101Evaluation and Management (E&M) and Procedure Coding for Office Encounters in a Student Health CenterMichael Bower CPC
Wilce
Student Health Center
Slide2Wilce Student Health CenterWilce Student Health Center at The Ohio State UniversityAutumn 2013 Enrollment 63,964 (57,466 Columbus Campus)
Student enrollment is a requirement to use Wilce SHS
Wilce
Student Health Center
Slide3Wilce Student Health Center2012-201365,605 Total Patient Visits28,702 Primary Care
9,679 Preventive Medicine
6,401 Dental
7,460 Women’s
13,363 Other (Specialty, PT, Injection Therapy, Nutrition)118,382 Pharmacy, Laboratory Tests, Radiology
Wilce
Student Health Center
Slide4Insurance Options22% covered under Student Health Insurance PlanStudent Health Insurance OfficeWaiver Required to Opt out of SHIP61% covered under Contracted
Carrier
Wilce Student Health Center in network status with four (4) major commercial
carriers
Also in network status with OSU Employee HealthplanWilce Student Health Center
Slide5Audience SurveyRoleCoders, Providers, Ancillary Staff, AdministrationCurrent Billing Practice
Student Health Fee
Bill Student Health Insurance Plans
Bill Commercial Plans
Wilce Student Health Center
Slide6AgendaEvaluation and Management CodesHistoryExamMedical Decision Making
Three Types of Encounters
Problem-oriented
Preventive medicine
Office based proceduresCoding obstacles and errorsQ & A
Wilce
Student Health Center
Slide7Scenario DisclaimersScenario documentation for this presentation is abbreviated. It should not be construed as a complete chart note.E&M codes used in scenarios are for illustrative purposes. E&M codes selected must be supported by documentation in chart note. Coding practices may vary between institutions. Work with your Compliance Office and Administration to ensure coding practices fall within applicable state and/or federal guidelines.
CMS guidelines offer a sound starting place. Commercial carriers generally follow CMS guidelines – although specific carrier rules may also apply.
Wilce
Student Health Center
Slide8Evaluation & Management CodesProblem oriented – Physician work captured by Evaluation and Management Service codes (99201-99205, 99211-99215)New vs Established patientNew patient – patient who has not received any professional services, i.e., E/M service or other face to face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years.
Established patient – anyone not considered a new patient.
Wilce
Student Health Center
Slide9Evaluation & Management Code Selection Made EasyWell, easier anyway…Wilce Student Health Center
Slide10Key Components of E&M CodesKey Components of E&MChief Complaint (CC)History (HPI, ROS, PFSH)Exam
Medical Decision Making
Wilce
Student Health Center
Slide11Key Components – Chief ComplaintChief ComplaintConcise statement of presenting problem. Often in patients words. Documented by the provider.Wilce Student Health Center
Slide12Key Components – HistoryHistory of Present Illness (HPI)Chronological description of present illness from initial sign to the presentLocation - specific location of problem, e.g. right knee, throat
Severity – description of severity or rating on pain scale, e.g. moderate, 6/10
Timing – when or frequency, e.g. persistent, intermittent, in the morning
Modifying factors – what makes problem better or worse, e.g. OTC pain reliever, rest, exertion
Wilce Student Health Center
Slide13Key Components – HistoryQuality – characteristic or description of sensation or pain, e.g. dull, sharpDuration – length of time of symptoms, e.g. started this morning, three (3) daysContext – circumstances around or description of how symptoms began, e.g. while playing basketball, after eating week old leftovers
Associated signs and symptoms – additional symptoms offered by patient
HPI Levels -
Brief HPI (1-3 elements), Extended (4 or more elements)
Wilce Student Health Center
Slide14Key Components – HistoryReview of Systems (ROS)Inventory of body systems obtained through a series of questions seeking to identify signs and symptoms the patient may be experiencing.Assist provider in narrowing the range of differential diagnoses.While ancillary staff or patient may provide ROS in form of a questionnaire, the provider must review for accuracy, add to it when necessary and note the review in the chart.
ROS Levels –
None, Problem Pertinent (1 system usually related to HPI), Extended (2-9 systems), Complete (10 or more systems)
Wilce
Student Health Center
Slide15Key Components – HistoryPast, Family and Social History (PFSH)Past - patient experiences with illness, injuries, operations and treatments. Includes current medications and known allergies.Family – medical events in family including hereditary disease or those that present a risk to the patientSocial – age appropriate review of past and current activities
PFSH Levels –
None, Pertinent (1-2 new pat, 1 est pat), Complete (3 new pat, 2-3 est pat)
Wilce
Student Health Center
Slide16Key Components – HistoryLeft most element determines the level of history.Wilce Student Health Center
Slide17Key Components – ExamPhysical Exam 1997 General Multisystem Exam – located on CMS websiteWilce Student Health Center
1997 General Multisystem
1-5 bulleted elements
6-11 bulleted elements
12+ bulleted elements in 2+ systems
2+ elements for each of 9+ systems
Exam Type
Problem-Focused
Expanded
Prob Focused
Detailed
Comprehensive
Slide18Key Components – MDMMedical Decision MakingDiagnosis / Management OptionsSelf Limited Problem (1), Established Diagnosis Stable (1), Established Diagnosis Worsening(2), New Problem No Additional Work Up(3), New Problem Additional Work Up Planned(4)Type of Data
Order or Review Clinical Labs(1), Radiologic(1) or Other Diagnostic Tests(1)
Risk Assessment using Table of Risk
Presenting Problem, Diagnostic Procedure Ordered, Management Options Selected
MDM Levels – Straight forward, Low, Moderate, HighWilce Student Health Center
Slide19Key Components – MDMChoose column with 2 or 3. Otherwise use the middle column.Wilce Student Health Center
Dx Mgmt Options
1 - Minimal
2 - Limited
3 - Multiple4 - Extensive
Type of Data
1 - Minimal
2 - Limited
3 - Moderate
4 - Extensive
Overall Risk
Minimal
Low
Moderate
High
Level of MDM
Straight
Forward
Low
Moderate
High
Slide20New Patient E&M codeWilce Student Health Center
History Type
Problem-Focused
Expanded Prob
FocusedDetailed Comprehensive
Comprehensive
Exam Type
Problem- Focused
Expanded Prob Focused
Detailed
Comprehensive
Comprehensive
MDM
Straight forward
Straight
forward
Low
Moderate
High
Level
99201
99202
99203
99204
99205
Time
10 min
20 min
30 min
45
min
60 min
Slide21Established Patient E&M codeWilce Student Health Center
History Type
N/A
Problem-Focused
Expanded Prob FocusedDetailed
Comprehensive
Exam Type
N/A
Problem-Focused
Expanded Prob Focused
Detailed
Comprehensive
MDM
N/A
Straight
forward
Low
Moderate
High
Level
992011
99212
99213
99214
99215
Time
5 min
10 min
15 min
25 min
40 min
Slide22E&M Notes1995 Exam based on Body Areas or Systems1997 Exam based on General Multisystem ExamUsed at our facility to aid in consistency of provider documentationLess ambiguity
HPI, Exam and Medical Decision Making cannot be performed/documented by ancillary staff (RN, LPN or MA).
These areas credit physician work and medical decision making by gathering appropriate information in relation to the chief complaint and therefore should be completed and documented by the provider.
Wilce
Student Health Center
Slide23REMAIN CALM AND KEEP CODINGWilce Student Health Center
Slide24Problem Oriented Scenario #1 – Sore ThroatHPI: A 23 year old established male patient presents with a five (5) day history of sore throat. His symptoms are worsening over the last two (2) days. He rates his
pain level 8/10
on the pain scale. He is having trouble eating due to the
pain in swallowing
. He also notes ear congestion. No current medications or drug allergies.ROS: Review of systems reveals patient is positive for fever, chills , fatigue and body aches. Patient denies nasal congestion, rhinorrhea, sinus pain or pressure
,
cough or wheezing
.
Exam:
Vitals: 130/72, 88, 98.6
.
Throat exam
reveals moderate erythema, + bilateral white tonsillar exudates. Lungs are clear to
auscultation
and resonant to
percussion
.
External auditory canals patent with pearly TMs
.
Wilce
Student Health Center
Slide25Problem Oriented Scenario #1 – Sore ThroatDiagnostic Testing: Mono screen was negative. Direct strep was positive for group A beta strep.
Treatment Plan:
Amoxicillin 500mg
is ordered for the patient.
Documented Dx: Streptococcal sore throat. Wilce Student Health Center
Slide26Problem Oriented Scenario #1 – CodingCPT Procedure Coding:99214 – Evaluation & Management, established patient, level 486308 – Mono screen
87880 – Direct Strep
36415 – Venipuncture
ICD
9 Coding: 034.0 – Streptococcal sore throatICD 10 Coding:J02.0 – Streptococcal pharyngitis (sore throat)
E&M
Criteria - Detailed History, Expanded PF Exam, Moderate MDM
Wilce
Student Health Center
Slide27Established Patient E&M codeWilce Student Health Center
History Type
N/A
Problem-Focused
Expanded Prob FocusedDetailed
Comprehensive
Exam Type
N/A
Problem-Focused
Expanded Prob Focused
Detailed
Comprehensive
MDM
N/A
Straight
forward
Low
Moderate
High
Level
992011
99212
99213
99214
99215
Time
5 min
10 min
15 min
25 min
40 min
Slide28Problem Oriented Scenario #2 – Ankle SprainHPI: A 19 year old male presents with right ankle pain and swelling. He twisted his ankle
while running
this morning
. He is unable to bear weight. His
pain level is 7/10 on the pain scale. This is his first visit to our facility. ROS: Patient denies numbness or tingling. PFSH: He has no prior history of injury to the ankle or foot.
Exam:
Vitals: 130/72, 88, 98.6.
Ankle exam reveals slight
swelling
and moderate
tenderness to palpation
over the lateral malleolus. Limited
ROM
.
Posterior tibial pulse
is normal. Light touch
sensation
of the foot is normal.
Wilce
Student Health Center
Slide29Problem Oriented Scenario #2 – Ankle SprainDiagnostic Testing: Radiologic exam of the right ankle is ordered. Treatment Plan: Ankle brace and crutches are ordered. Patient is fitted with right ankle brace and instruction is given for use of crutches.
Rx for pain management declined
. OTC products reviewed for pain management.
Documented Dx: Results from radiology are pending and the provider documents ankle sprain.
Wilce Student Health Center
Slide30Problem Oriented Scenario #2 – CodingCPT Procedure Coding:99202 – Evaluation & Management, new patient, level 2
73610 – Radiologic examination, ankle; complete, minimum 3 views
L4350 – Ankle control orthotic, stirrup style, rigid
E0114 – Crutches, underarm, oth than wood, adjustable or fixed, pair
Wilce Student Health Center
Slide31Problem Oriented Scenario #2 – CodingICD 9 Coding: 845.00 – Sprain and strain of ankle, unspecified site
E001.1 – Activities involving running
ICD 10 Coding:
S93.401A – Sprain of unspecified ligament of right ankle, initial encounter
Y93.02 – Activity, runningE&M Criteria – Expanded PF History, Expanded PF Exam, Moderate MDMWilce Student Health Center
Slide32New Patient E&M codeWilce Student Health Center
History Type
Problem-Focused
Expanded Prob
FocusedDetailed Comprehensive
Comprehensive
Exam Type
Problem- Focused
Expanded Prob Focused
Detailed
Comprehensive
Comprehensive
MDM
Straight forward
Straight
forward
Low
Moderate
High
Level
99201
99202
99203
99204
99205
Time
10 min
20 min
30 min
45
min
60 min
Slide33Problem Oriented Scenario #3 – UTIHPI: A 29 year old female presents with a two (2) day history of urinary frequency. Based on our UTI protocol, a UA is ordered (diagnosis code 788.99 – Other symptoms urinary system) prior to being seen by the provider.
ROS: The patient denies
hematuria
,
fever, or bilateral lower back pain. Patient denies any vaginitis or abnormal bleeding. PFSH: The patient does have a history of UTIs
with the most recent in 2012.
Exam:
Vitals: 130/72, 88, 98.6.
External
genitalia
normal.
Bladder
&
Urethra
normal.
Cervix
and
uterus
normal. Abdomen
non tender
, no
organomegaly
.
Wilce
Student Health Center
Slide34Problem Oriented Scenario #3 – UTIDiagnostic Testing: Urinalysis (gross and microscopic) results indicate a large amount of blood, RBCs 30-49, bacteria, WBCs > 49/hpf and positive for nitrites.
Treatment
Plan: Macrobid
100mg is ordered for the patient.
Documented Dx: Acute cystitis. Hematuria.Wilce Student Health Center
Slide35Problem Oriented Scenario #3 – CodingCPT Procedure Coding:99213 – Evaluation & Management, established patient, level 3
81003 – Urinalysis, automated without microscopy
81015 – Urinalysis, qualitative, microscopic only
Wilce
Student Health Center
Slide36Problem Oriented Scenario #3 – CodingICD 9 Coding: 595.0 – Acute cystitis
599.72 – Microscopic hematuria
Note that dx 788.99 is not coded as the symptoms are an integral part of the disease process in the first listed diagnosis code.
ICD 10 Coding:
N30.01 – Acute cystitis with hematuriaE&M Criteria – Expanded PF History, Expanded PF Exam, Moderate MDMWilce
Student Health Center
Slide37Established Patient E&M codeWilce Student Health Center
History Type
N/A
Problem-Focused
Expanded Prob FocusedDetailed
Comprehensive
Exam Type
N/A
Problem-Focused
Expanded Prob Focused
Detailed
Comprehensive
MDM
N/A
Straight
forward
Low
Moderate
High
Level
992011
99212
99213
99214
99215
Time
5 min
10 min
15 min
25 min
40 min
Slide38REMAIN CALM AND KEEP CODINGWilce Student Health Center
Slide39Preventive Medicine EncountersNo Chief ComplaintAge and gender appropriate HistoryReview of Systems (ROS)
Past Family and Social History (PFSH)
Exam
Counseling/guidance/risk factor reduction interventions and ordering of lab/diagnostic procedures
Wilce Student Health Center
Slide40Preventive Medicine EncountersPhysician work captured by Preventive Medicine Visit codes (99381-99397).New vs Established PatientPatient Age ( <1yrs, 1-4yrs, 5-11yrs, 12-17yrs, 18-39yrs, 40-64yrs, 65+yrs)
Includes care for small problem that requires no extra physician work.
Code also immunization administration and products.
Code also significant, separately identifiable E&M services on the same date for substantial problems requiring additional work using modifier 25.
Wilce Student Health Center
Slide41PM Scenario #1 – Annual Gynecological ExamScenario: A 21 year old female presents for her annual gynecological exam. She is an established patient for our practice. She is currently feeling well with no complaints. ROS: Patient denies breast concerns, urinary symptoms, vaginal discharge or itching. Her last LMP was 05/20/2014. PFSH: Past medical history, social history and family history reviewed. She is currently sexually active. Number of partners in last year is 2. The patient has not had a pap smear in the past.
Exam: The exam revealed no abnormal findings.
Diagnostic Testing: Cervical cytology. Urine specimen for gonorrhea and chlamydia screening.
Wilce
Student Health Center
Slide42PM Scenario #1 – CodingCPT Procedure Coding:99395 – Periodic comprehensive preventive medicine evaluation88142 – Cytopathology, cervical 87491 – Chlamydia trachomatis
87591 – Neisseria
gonorrhoeae
ICD 9 Coding: V72.31 – Routine gynecological examinationV74.5 – Screening venereal disease
ICD 10 Coding:
Z01.419 – Encounter for gynecological examination
(routine
) without abnormal findings
Z11.3 – Encounter for screening infections with a predominantly sexual mode of transmission
Wilce
Student Health Center
Slide43Gynecological Exam RequirementsThe requirements to bill for a routine gynecologic exam requires seven (7) of the eleven (11) elements listed below to be completed.Inspection and palpation of breasts for masses or lumps, tenderness, symmetry, or nipple discharge. Digital rectal exam including sphincter tone, presence of hemorrhoids, and rectal masses.
External genitalia (general appearance, hair distribution or lesions).
Urethral meatus (size, location, lesions or prolapse).
Urethra (masses, tenderness, or scarring).
Bladder (fullness, masses, or tenderness).Vagina (appearance, estrogen effect, discharge, lesions, cystocele or rectocele).
Wilce
Student Health Center
Slide44Gynecological Exam RequirementsCervix (appearance, lesions, or discharge).Uterus (size, contour, position, mobility, tenderness, consistency, descent or support).Adnexa (masses, tenderness,
organomegaly
, or nodularity).
Anus and perineum
.Wilce Student Health Center
Slide45PM Scenario #2 – Annual Wellness Exam Scenario: A 20 year old male presents for an annual wellness exam. He is new to our practice. He is currently feeling well with no complaints. He does request STI screening. ROS: Patient denies any complaints. PFSH: Past medical history, social history and family history reviewed. He is up to date on immunizations with the exception of HPV and would like to begin the series. He is currently sexually active. Number of partners in last year is 2. Method of STI prevention is none.
Exam: The exam revealed no abnormal findings.
Wilce
Student Health Center
Slide46PM Scenario #2 – Annual Wellness Exam Diagnostic Testing: Urine specimen for gonorrhea and chlamydia, blood specimen for HIV and syphilis. Treatment Plan: HPV immunization is ordered and given.Wilce
Student Health Center
Slide47PM Scenario #2 – Coding CPT Procedure Coding:99385-25 – Initial comprehensive preventive medicine evaluation87491 – Chlamydia trachomatis87591 – Neisseria
gonorrhoeae
86703 – Testing for HIV antibodies; HIV-1 and HIV-2; single result
86780 –
Treponema pallidum 90471 – Immunization administration; 1 vaccine90649 – HPV vaccine,
quadrivalent
, 3 dose schedule
Wilce
Student Health Center
Slide48PM Scenario #2 – Coding ICD 9 Coding: V70.0 – Routine general medical examinationV74.5 – Screening venereal diseaseV04.89 – Vaccination, other viral diseases
ICD 10 Coding:
Z00.00 – Encounter for general adult medical examination without abnormal findings
Z11.3 – Encounter for screening infections with a predominantly sexual mode of transmission
Z11.4 – Encounter for screening for human immunodeficiency virus [HIV]Z23 – Encounter for immunization
Wilce
Student Health Center
Slide49PM Scenario #3 – Travel Assessment Scenario: A 22 year old male presents for a travel assessment. He will be traveling to Haiti in six (6) weeks with his church group. He will be staying in a hotel. He is up to date on his immunizations with the exception of influenza and typhoid.Treatment Plan: Travel guidelines and handouts reviewed with patient. Immunizations for influenza and typhoid are ordered and given.
Wilce
Student Health Center
Slide50PM Scenario #3 – Coding CPT Procedure Coding:99401-25 – Preventive medicine counseling and/or risk factor reduction intervention; approx. 15 minutes90471 – Immunization administration; 1 vaccine
90472 – Immunization administration; each additional vaccine
90658 – Influenza virus vaccine
90691 – Typhoid vaccine
Wilce Student Health Center
Slide51PM Scenario #3 – Coding ICD 9 Coding: V70.3 – Other medical examination for administrative purposesV04.81 – Immunization for influenzaV03.1 – Immunization for typhoid
ICD 10 Coding:
Z02.89 – Encounter for other administrative examinations
Z23 – Encounter for immuniza
tionWilce Student Health Center
Slide52REMAIN CALM AND KEEP CODINGWilce Student Health Center
Slide53Office Based Procedure Encounters Chief ComplaintHistoryHistory of Present Illness (HPI)Review of Systems (ROS)
Past Family and Social History (PFSH)
Exam
Medical Decision Making
Diagnosis / Management OptionsWilce Student Health Center
Slide54Office Based Procedure Encounters Type of DataRisk Assessment based on Presenting Problem, Diagnostic Procedure Ordered, Management Options SelectedMinor surgery with no identified risk factors – Low Management Options
Minor surgery with identified risk factors – Moderate Management Options
Skin biopsy – Low Diagnostic Procedure Ordered
Wilce
Student Health Center
Slide55Office Based Procedure Encounters Physician work captured by procedure codeE&M service included in procedure codeCommon office based procedure codesLaceration repair
Incision and drainage of abscess
Biopsy of skin lesion
Wart treatment
ColposcopyExcision of nail Wilce Student Health Center
Slide56Office Based Procedure Encounters Code also immunization administration and products.Code also therapeutic injection administration and products.Code also significant, separately identifiable E&M services on the same date for substantial problems requiring additional work using modifier 25.
Wilce
Student Health Center
Slide57Office Based Procedure – Laceration RepairCriteria for laceration repair code selectionComplexity – Superficial, Intermediate, Complex SiteSize
Wilce
Student Health Center
Slide58Office Based Procedure – Laceration RepairSuperficial Wounds CPT codes: 12001-12018Local anesthesia
Routine debridement and decontamination
Simple one layer closure
Sutures, staples, tissue adhesives, cauterization without closure
Total length of several repairs in same code category Wilce Student Health Center
Slide59Office Based Procedure – Laceration RepairSuperficial Wound SitesScalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet) Face, ears, eyelids, nose, lips and/or mucous membrane
Superficial
Wound Sizes
2.5 cm or less
2.6 cm to 7.5 cm7.6 cm to 12.5 cm12.6 cm to 20.0 cm
20.1 cm to 30.0 cm
> 30.0 cm
Wilce
Student Health Center
Slide60Office Based Procedure – Laceration RepairIntermediate Wounds CPT codes: 12031-12057Local anesthesiaRoutine debridement and decontamination
Closure of contaminated single layer wound
Layer closure (e.g. subcutaneous tissue, superficial fascia)
Removal of foreign material (e.g. gravel, glass)
Total length of several repairs in same code category Wilce Student Health Center
Slide61Office Based Procedure – Laceration RepairIntermediate Wound SitesScalp, axillae, trunk and/or extremities Neck, hands, feet and/or external genitaliaFace, ears, eyelids, nose, lips and/or mucous
membrane
Intermediate
Wound Sizes
2.5 cm or less2.6 cm to 7.5 cm7.6 cm to 12.5 cm12.6 cm to 20.0 cm
20.1 cm to 30.0 cm
> 30.0 cm
Wilce
Student Health Center
Slide62Office Based Procedure – Laceration RepairComplex Wounds – not performed at our facilityCPT codes: 13100-13153More complicated than layered repairExploration of nerves, vessels, tendons
Vessel ligation
Wilce
Student Health Center
Slide63Procedure Scenario #1 – Laceration RepairHPI: A 22 year old male presents with minor lacerations to his left hand. Patient states he broke a glass while washing dishes approximately 30 minutes ago. He was unable to control the bleeding at home and is here for treatment. Exam: The exam of laceration #1 shows a 1 cm laceration on the palmar surface of the fourth finger. Laceration #2 shows a 1.7 cm laceration on the palmar surface of the third finger. Both wounds were explored and no foreign bodies were found.
Treatment Plan: Wound #1 was closed using a skin adhesive. Wound #2 was closed with 3
Ethilon
sutures.
Documented Dx: Open wound finger.Wilce Student Health Center
Slide64Procedure Scenario #1 – CodingCPT Procedure Coding:12001 – Simple repair superficial wound; 2.6 cm to 7.5 cm
ICD 9 Coding:
883.0 – Open wound of finger without mention of complication
E920.8 – Accident caused by other cutting and piercing instruments or objects
ICD 10 Coding:S61.213A – Laceration w/o foreign body of left middle finger w/o damage to nail, initial encounterS61.215A – Laceration w/o foreign body of left ring finger w/o damage to nail, initial encounter
W25.000A – Contact with sharp glass, initial encounter
Wilce
Student Health Center
Slide65Office Procedure – I&D of AbscessIncision and Drainage of AbscessSimple or single (10 day global period)CPT code: 10060Carbuncle,
suppurative
hidradenitis
, cutaneous or subcutaneous abscess, cyst, furuncle or paronychia
Complicated or multiple (10 day global period)CPT code: 10061Carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle or paronychia
Wilce
Student Health Center
Slide66Office Procedure – I&D of AbscessIncision and Drainage of Pilonidal CystSimple (10 day global period)CPT code: 10080
Complicated (10 day global period)
CPT code: 10081
Wilce
Student Health Center
Slide67Procedure Scenario #2 – I&D of AbscessHPI: A 24 year old female presents with pain in the left axillae. She has a history of staph infections of the axillae. This pain began about 3 months ago.Exam: The exam shows several raised evolving furuncles in the axillae. The largest being 1.5cm x 1.5 cm in the mid posterior left axillae. Treatment Plan: The area is cleansed and an incision and drainage is performed. A small amount of blood and pus is released.
Diagnostic Testing: A culture is obtained.
Documented
Dx
: Hidradenitis.Wilce Student Health Center
Slide68Office Procedure Scenario #2 – CodingCPT Procedure Coding:10060 – Incision and drainage of abscess; simple87070 – Culture, bacterial; any other source except urine, blood or stool
ICD 9 Diagnosis Coding:
705.83 –
Hidradenitis
ICD 10 Diagnosis Coding:L73.2 – Hidradenitis suppurative
Wilce
Student Health Center
Slide69Office Procedure – Biopsy of Skin LesionBiopsy of Skin LesionSingle lesion (0 day global period)CPT code: 11100Skin, subcutaneous tissue and/or mucous membrane
Includes simple closure
Each additional lesion (0 day global period)
CPT code: 11101
Skin, subcutaneous tissue and/or mucous membraneIncludes simple closureList in addition to CPT code: 11100
Wilce
Student Health Center
Slide70Office Procedure – Biopsy of Skin LesionBiopsy is defined as a procedure to obtain tissue for a pathologic examination. These codes support a biopsy via means of provider choice, including shaving or punch methods. Even when the entire lesion is removed, the intent of the procedure is to obtain tissue and so the biopsy code is appropriate.
Wilce
Student Health Center
Slide71Procedure Scenario #3 – Biopsy of LesionHPI: A 21 year old female presents with two slightly raised skin lesions of the left shoulder. Patient indicates these have changed in size and color over the last several months. Exam: The exam shows one 3 mm and one 4 mm raised lesions with variable brown color. Treatment Plan: After reviewing diagnosis and treatment options, a shave biopsy is performed on each lesion.
Diagnostic Testing: Specimens are collected and sent to pathology.
Documented
Dx
: Neoplasm unspecified behavior.Wilce Student Health Center
Slide72Office Procedure Scenario #3 – CodingCPT Procedure Coding:11100 – Biopsy of skin, subcutaneous tissue; single lesion11101 – Biopsy of skin, subcutaneous tissue; each additional lesion
99000 – Handling of specimen for transfer from office to laboratory
88305 x 2 – Level IV – Surgical pathology, gross and microscopic examination
Wilce
Student Health Center
Slide73Office Procedure Scenario #3 – CodingICD 9 Diagnosis Coding: 238.2 – Neoplasm of uncertain behavior; skin ICD 10 Diagnosis Coding:
D48.5 – Neoplasm of uncertain behavior; skin
Wilce
Student Health Center
Slide74Office Procedure – Destruction of WartsDestruction of WartsUp to 14 lesions (10 day global period)CPT code: 17110Benign lesions other than skin tags or cutaneous vascular proliferative lesions
Includes laser surgery,
electrosurgery
, cryosurgery, chemosurgery, surgical
curettement.15 or more lesions (10 day global period)CPT code: 17111Do NOT code 17110
Wilce
Student Health Center
Slide75Office Procedure – Destruction of WartsOther site specific lesion destruction codes:Anus 46900-46917Penis 54050-54057
Vagina 57061, 57065
Vulva 56501, 56515
Wilce
Student Health Center
Slide76Procedure Scenario #4 – Destruction WartsHPI: A 19 year old male presents with concerns of several wart like lesions on the top of this left foot. They are aggravated by his shoe when walking or running. Exam: The exam shows 3 small warts, each measuring approx. 3 mm, on the top of his left foot, just distal to the ankle. Treatment Plan: Treatment options were reviewed and the patient elected to have these treated with liquid nitrogen.
Documented
Dx
: Viral warts.
Wilce Student Health Center
Slide77Office Procedure Scenario #4 – CodingCPT Procedure Coding:17110 – Destruction benign lesions, up to 14 lesions
ICD 9 Coding:
078.10 – Viral warts, unspecified
ICD 10 Coding:
B07.9 – Viral wart, unspecified Wilce Student Health Center
Slide78Coding Obstacles and ErrorsE&M Code SelectionNew vs established patient codesCorrect code level selectionDocumentation to support level selected
Charge Capture
Bundled and Unbundled Services
Therapeutic Injections and ImmunizationsAdministrationMedication or VaccineDME supplies
Wilce
Student Health Center
Slide79Coding Obstacles and ErrorsDiagnosis SelectionICD-9 CM GuidelinesGeneral Coding GuidelinesChapter Specific Guidelines
Symptoms vs Definitive Diagnosis
Signs and symptoms routinely associated with a disease process should not be assigned as additional codes
Factors Influencing Health Status – V Codes
Immunization codesPersonal and Family History codesClassification of External Causes – E Codes
E Codes are not used as first listed diagnosis codes
Dog bite, needle stick
injury
Wilce
Student Health Center
Slide80Coding Obstacles and ErrorsDiagnosis LinksEnsure services are correctly linked to all relevant diagnosis codes assignedCarrier rules may apply
Wilce
Student Health Center
Slide81Questions and AnswersWilce Student Health Center