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Accurate coding of diagnoses and procedures is the key to managing your reimbursement, limiting your write-offs, and avoiding fraudulent activity that could bring havoc to your practice. Proper ICD-9-CM coding (International Classifications of Disease, Clinical Modifications) and CPT coding (Current Procedural Terminology) should be documented for each patient encounter. This article provides basic information to aid physicians in expanding their knowledge of this critical component of a successful practice.
Accurate coding of diagnoses and procedures is the key to managing your reimbursement, limiting your write-offs, and avoiding fraudulent activity that could bring havoc to your practice. In this article we will analyze proper ICD-9-CM coding (International Classifications of Disease, Clinical Modifications) as well as CPT coding (Current Procedural Terminology). An encounter form (paper or electronic) should be completed for each patient at each office visit. Information on this form should include patient demographics (with a unique patient identifier number), a diagnostic code (ICD-9-CM) and a procedure code (CPT) for the visit. The encounter form should be checked by the physician for accuracy and correlation between the diagnosis and procedure performed prior to being submitted to the office personnel or electronically filed.
The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) has its basis in the World Health Organization's (WHO) official classification of diseases. The diagnosis codes are owned and updated by the WHO. There are hundreds of thousands of codes available which can be found in a book titled ICD-9 Codes, but fortunately as a colorectal specialist you can limit the ones you need for your practice to essentially 50 or 60. These should be included in your encounter form and checked for each patient visit.
ICD-9 codes are used to describe conditions, diseases, and symptoms. Because these codes cover symptoms as well as diagnoses, an individual patient can have one or more ICD-9 codes associated with his or her encounter. Let's consider several common scenarios as examples. A 28-year-old male presents with painful anal bleeding. After your history and examination, you determine that he has an anal fissure. You would select a diagnostic code of 565.0 (fissure-in-ano), 569.42 (anal pain), and/or 569.3 (anal bleeding). If this patient were also diabetic you could also include a code 250.03 (diabetes).
A second example is a 48-year-old female referred to you for colon cancer screening. She is otherwise healthy but has an uncle who has had colon cancer. She has no symptoms. You would then code “V76.51” which is a special screening for malignant neoplasms. The “V” prescript signifies a history of a problem. Next, you consider a patient who has a personal history of polyps or cancer, and the code is “V12.72” or “V10.05,” respectively.
There are numerous codes to use as your diagnosis code and they are all virtually self-explanatory. For instance, abdominal pain is coded 789.00, and other types of abdominal pain are subtyped according to location. The code for “left lower quadrant pain” is 789.04. Table Table11 provides the more common ICD-9-CM codes for colorectal diagnoses. The codes you select should be supported by documentation in your encounter note.
For the office, CPT codes will be limited to two categories: evaluation and management (E&M) and minor office procedures. Procedures performed in the operating room or ambulatory surgery center also have CPT codes and some of these are similar to the office codes. CPT codes have been developed by the American Medical Association and groups associated with the federal government. New codes are developed and older codes are updated by these groups. The E&M codes (Table 2) are those beginning with “99,” and these codes are based on three types of visits: (1) new patient, (2) consultation, and (3) established patient. A new patient is an individual who has not received any professional service from you within the past 3 years. A consultation is defined by a patient seeking your opinion or advice at the request of another physician and is documented in the patient record as such. Established patients have received professional services from you or your group in the past 3 years. Once a category of E&M coding has been determined, you must then determine the level of service.
The level of service depends on three documented components: (1) history, (2) physical examination, and (3) medical decision-making. History is defined by three areas which are the chief complaint, the history of present illness, and the past, family, and social history. The chief complaint should be a brief concise statement that explains the symptom, problem, condition, or current diagnosis. Next, the history of present illness (HPI) will consist of a description of the signs/symptoms of the patient. The number of signs and symptoms documented in the patient record determines the level of service you will be able to code. The following are the elements of an HPI:
The past, family, and social history is the third part of the history. Most practices develop a history form that the patient fills out at the initial visit and that can be incorporated into the office note. It is important to sign and date the history form every time a patient comes into the office to document that this review of the past, family, and social history was covered. Also, during the history portion, the number of reviews of systems (ROS) documented will also help in determining the level of service for which you will be able to charge. There are 14 ROS groups as described below:
In general, by including a review of systems, you can increase your level of E&M coding to increase your reimbursement. This does not apply, however, to a preoperative history and physical (99999) for established patients. These are coded and reimbursed as part of the global surgical fee which includes the history and physical visit and subsequent postoperative visits for the 90-day global period after surgery for procedures performed in the operating room, and for 30 days following office procedures (i.e., incision and drainage of an abscess). The actual global period can be confirmed by contacting your local Medicare chapter or referring to the Health Care Finance Act (HCFA).
The level of exam is defined by the elements identified by each system, according to the following guidelines.
Evaluate one to five elements within a system (i.e., rectal bleeding).
Evaluate at least six elements within a system or six systems (i.e., rectal pain, rectal bleeding, weight loss, diarrhea, pruritis, fever).
Evaluate at least two elements within six systems or at least 12 elements within two or more systems.
Evaluate the entire ROS and identify one or two elements per system.
The last component of the level of service is “medical decision-making.” This refers to the complexity of the diagnosis or management option and is measured by three areas: (1) the amount and complexity of data reviewed which include referring physician's notes, laboratory data, x-rays, etc.; (2) the number of diagnoses or management options; and (3) the level of risk. The levels of decision-making are low, moderate, and high complexity based on the three areas of medical decision-making. The guidelines for the levels can be found in the HCFA/CPT documentation guidelines, and you should document these levels in your office notes or dictation to justify the level of complexity of the visit.
Office procedures should be coded as described in the CPT handbook A yearly updated copy of this handbook can be purchased from the American Medical Association. Please refer to Table Table33 for the most common office procedure in a colon and rectal practice. Remember that the CPT code should correlate with the ICD-9-CM code. For instance, if you see a patient with a diagnosis of perianal abscess (566) and you drain the abscess in the office, you should code for an incision and drainage of a perianal abscess (46050), not a sphincterotomy (46080).
An important thing to consider when performing an office procedure is whether it is performed on the same day as an E&M visit. If an E&M service and an office procedure are performed on the same day, a modifier must be used to be reimbursed for both services. For example, if a new patient is seen in consultation for constipation (564.00), and in your workup you find that he or she has also had rectal bleeding (569.3), and you perform a flexible sigmoidoscopy with a biopsy (45331) to evaluate the rectal bleeding on the same day, a number 25 modifier must be used with the E&M service (99242). The following are two modifiers that are commonly used in office settings:
Unrelated E&M visit during postoperative period by the same physician/group.
Significant, separate, identifiable E&M service on the same day of a procedure.
Unfortunately, some procedures that are performed on the same day along with an E&M visit may not be reimbursed by your carrier. However, you should document what you have done and attempt to be compensated for your time. You should check with your insurance contracts to see what is considered inclusive and regularly review your collections to identify whether your carrier has changed its policy.
Accurate documentation and coding are critical to a successful practice. This process can be complex and many of the “rules” can have various interpretations. Unfortunately, several organizations have input into those rules (federal government, insurance carriers, American Medical Association, etc.) and the rules can be changed. Therefore, physicians must constantly expand their knowledge and review the process on a regular basis to strive for accuracy and appropriate reimbursement.