1 BILLING AND CODING
2 INFORMATION FROM CHIROCODE
3 DETERMINE THE EXTENT OF HISTORY OBTAINEDThe extent of the history is dependent upon clinical judgment and on the nature of the presenting problem(s). The levels of E/M services recognize four types of history that are defined as follows: PROBLEM FOCUSED: Chief complaint; brief history of present illness or problem. EXPANDED PROBLEM FOCUSED: Chief complaint; brief history of present illness; problem pertinent system review. DETAILED: Chief complaint; extended history of present illness; problem pertinent system review extended to include a review of a limited number of additional systems; PERTINENT past, family, and/or social history DIRECTLY RELATED TO THE PATIENT’S PROBLEMS. COMPREHENSIVE: Chief complaint; extended history of present illness; review of systems that is directly related to the problem(s) identified in the history of the present illness plus a review of all additional body systems; COMPLETE past, family, and social history. The comprehensive history obtained as part of the preventive medicine E/M service is not problem-oriented and does not involve a chief complaint or present illness. It does, however, include a comprehensive system review and comprehensive or interval past, family and social history as well as a comprehensive assessment/history of pertinent risk factors. AMA CPT 2009
4 DOCUMENTATION OF HISTORYMEDICARE LEARNING NETWORK 2010
5 DETERMINE THE EXTENT OF EXAMINATION PERFORMEDThe extent of the examination performed is dependent on clinical judgment and on the nature of the presenting problem(s). The levels of E/M services recognize four types of examination that are defined as follows: PROBLEM FOCUSED: A limited examination of the affected body area or organ system. EXPANDED PROBLEM: A limited examination of the affected body area or organ system and other symptomatic or related organ system(s). DETAILED: An extended examination of the affected body area(s) and other symptomatic or related organ system(s) COMPREHENSIVE: A general multisystem examination or a complete examination of a single organ system. NOTE: The comprehensive examination performed as part of the preventive medicine E/M service is multisystem, but its extent is based on age and risk factors identified. For the purposes of these CPT definitions, the following body area are recognized: HEAD, including the face; NECK; CHEST, including breasts and axillia; ABDOMEN; GENITALIA, groin, buttocks; BACK; EACH EXTREMITY For the purposes of these CPT definitions, the following organ systems are recognized: EYES; EARS, nose, mouth, and throat; CARDIOVASCULAR; RESPIRATORY; GASTROINTESTINAL; GENITOURINARY; MUSCULOSKELETAL; SKIN; NEUROLOGIC; PSYCHIATRIC; HEMATOLOGIC/lymphatic/immunologic AMA CPT 2009
6 DETERMINE THE COMPLEXITY OF MEDICAL DECISION MAKINGMedical decision making refers to the complexity of establishing a diagnosis and /or selecting a management option as measured by: The number of possible diagnoses and/or the number of management options that must be considered The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, review and analyzed The risk of significant complications, morbidity, and/or mortality, as well as comorbidities, associated with the patient’s presenting problem(s), the diagnostic procedure(s), and/or the possible management options Four types of medical decision making are recognized: straightforward, low complexity, moderate complexity, and high complexity. Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless their presence significantly increases the complexity of the medical decision making. AMA CPT 2009
7 DOCUMENTATION OF THE COMPLEXITY OF MEDICAL DECISION MAKINGMEDICARE NETWORK LEARNING 2010
8 CHIROCODE 2012
9 DECISION TREE FOR NEW VS ESTABLISHED PATIENTSAMA CPT 2009
10 SELECT THE CATEGORY OF OFFICE VISITNEW PATIENTS-NEW TO CLINIC OR OVER 3 YEARS ESTABLISHED PATIENTS-NEW PROBLEM OR SEEN IN CLINIC 1-2 YEARS 99201 99202 99203 99204 99205 99211 99212 99213 99214 99215 CHIROCODE 2012
11 NEW PATIENT-99201 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and /or family’s needs Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to face with the patient and/or family. AMA CPT 2009
12 NEW PATIENT-99202 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family AMA CPT 2009
13 NEW PATIENT-99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family. AMA CPT 2009
14 NEW PATIENT-99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family. AMA CPT 2009
15 NEW PATIENT-99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family. AMA CPT 2009
16 ESTABLISHED PATIENT-99211 Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services. AMA CPT 2009
17 ESTABLISHED PATIENT-99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family. AMA CPT 2009
18 ESTALISHED PATIENT-99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family. AMA CPT 2009
19 ESTABLISHED PATIENT-99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family. AMA CPT 2009
20 ESTABLISHED PATIENT-99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family. AMA CPT 2009
21 EXAMPLE: To qualify for a new patient office visit, your levels of service must meet or exceed all three of the stated requirements. CODE PRESENTING PROBLEM HISTORY EXAMINATION CLINICAL DECISION MAKING 99201 SELF LIMITED OR MINOR FOCUSED STRAIGHTFORWARD 99202 LOW TO MODERATE EXPANDED 99203 MODERATE DETAILED LOW 99204 MODERATE TO HIGH COMPREHENSIVE 99205 HIGH CHRIROCODE 2011
22 EXAMPLE: To qualify for a established patient office visit, your levels of service must meet or exceed two of the three stated requirements CODE PRESENTING PROBLEM HISTORY EXAMINATION CLINICAL DECISION MAKING 99211 NO KEY COMPONENTS ARE REQUIRED AT THIS CODING LEVEL 99212 SELF LIMITED OR MINOR FOCUSED STRAIGHTFORWARD 99213 LOW TO MODERATE EXPANDED LOW 99214 MODERATE TO HIGH DETAILED MODERATE 99215 COMPREHENSIVE HIGH CHRIROCODE 2011
23 QUESTION Which of the following is not used to determine the level of E/M services? HISTORY TIME TREATMENT PROVIDED EXAMINATION NATURE OF PRESENTING PROBLEM
24 REGIONS OF MANIPULATIONSPINAL REGIONS EXTRASPINAL (NONSPINAL) CERVICAL -(INCLUDES ATLANTO-OCCIPITAL JOINT) THORACIC-(INCLUDES COSTOVERTEBRAL AND COSTOTRANSVERSE JOINTS) LUMBAR SACRAL PELVIC- (SACRO-ILIAC JOINT) HEAD- (INCLUDING TEMPOROMANDIBULAR JOINT, EXCLUDING ATLANTO-OCCIPITAL) LOWER EXTREMITIES UPPER EXTREMITIES RIB CAGE (EXCLUDING COSTOTRANSVERSE AND COSTOVERTEBRAL JOINTS) ABDOMEN CHIROCODE CHIROCODE 2011
25 MANIPULATIONS SPINAL 1-2 REGIONS (PRE-SERVICE 2 MIN+INTRA-SERVICE 7 MIN + POST-SERVICE 3 MIN) SPINAL 3-4 REGIONS (PRE-SERVICE 3 MIN+INTRA-SERVICE 10 MIN+POST SERVICE 4 MIN) 98942-SPINAL 5 REGIONS (PRE-SERVICE 4 MIN+INTRA-SERVICE 12 MIN+POST SERVICE 5 MIN) 98943-EXTRASPINAL 1 OR MORE REGIONS (PRE-SERVICE 3 MIN+INTRA-SERVICE 8 MIN+POST-SERVICE 3 MIN) CHIROCODE AND ACA CHIROCODE 2011
26 SPINAL MANIPULATIVE TREATMENTCERVICAL-ALL MANIPULATIONS PERFORMED TO THE ATLANTO-OCCIPITAL JOINT, AND C1-C7 DURING ANY GIVEN PATIENT VISIT THORACIC-ALL MANIPULATIONS PERFORMED TO T1-T12, INCLUDING POSTERIOR RIBS (COSTOTRANSVERSE AND COSTOVERTEBRAL JUNCTIONS)DURING ANY GIVEN PATIENT VISIT. LUMBAR-ALL MANIPULATIONS PERFORMED TO L1-L5 ON ANY GIVEN PATIENT VISIT SACRAL-ALL MANIPULATIONS PERFORMED TO THE SACRUM, INCLUDING THE SACROCOCCYGEAL JUNCTION, ON ANY GIVEN PATIENT VISIT PELVIC-ALL MANIPULATIONS PERFORMED TO THE SACROILIAC JOINTS AND OTHER PELVIC ARTICULATIONS ON ANY GIVEN PATIENT VISIT. ACA ACA 2009
27 SPINAL MANIPULATIVE TREATMENTRegardless of how many manipulations are performed in any given spinal region (cervical, thoracic, etc.) it counts as one region under the CMT codes. FOR EXAMPLE: Chiropractic manipulation applied to the atlanto-occipital joint, C3 and C5, during one patient visit would represent treatment to one region (cervical) and , if these were the only manipulations performed during this visit, the appropriate code to use would be 98940 ACA 2009
28 EXTRASPINAL MANIPULATIVE TREATMENTHEAD-ALL MANIPULATIONS PERFORMED TO THE HEAD, INCLUDING THE TMJ, BUT EXCLUDING THE ATLANTO-OCCIPITAL JOINT, DURING ANY GIVEN PATIENT VISIT LOWER EXTREMITIES-ALL MANIPULATIONS PERFORMED TO THE HIP, LEG, KNEE, ANKLE AND FOOT DURING ANY GIVEN PATIENT VISIT UPPER EXTREMITIES-ALL MANIPULATIONS PERFORMED TO THE SHOULDER, ARM, ELBOW, WRIST AND HAND DURING ANY GIVEN PATIENT VISIT RIB CAGE-ALL MANIPULATIONS PERFORMED TO THE ANTERIOR RIB CAGE, INCLUDING THE COSTOSTERNAL JUNCTION BUT EXCLUDING THE COSTOVERTEBRAL JUNCTION, DURING ANY GIVEN PATIENT VISIT ABDOMEN ACA ACA 2009
29 EXTRASPINAL MANIPULATIVE TREATMENTUse code to describe CMT to one or more extraspinal regions, regardless of how many individual extraspinal manipulations are actually performed. The extraspinal CMT code can be used either by itself or in conjunction with a spinal CMT code. The appropriate code for cranial manipulation/adjusting is the extraspinal manipulative treatment code This code includes all manipulations performed to the head, including the TMJ, but EXCLUDING the atlanto-occipital joint. The atlanto-occipital joint, and C1 through C7, are included in the cervical region for the spinal manipulative treatment. ACA 2009
30 QUESTION The following manipulations took place:RRR C2-C3, ER C7-T1, ER T4-T6, POST R RIB 1. HOW WOULD YOU BILL THIS? 98940 98941 98942 98943
31 TIMED CODES HOW LONG IS 15 MINUTES?Historically, for decades “15 minutes” was accepted as up-to 15 minutes. However, in recent years more definitive approaches have been taken by payers. In 2000, in an effort to control fraud and abuse of costs, CMS adopted a policy of rounding to the nearest 15 minutes. It is a logical and simple concept. Accordingly, 8 through 22 minutes of hands-on care would be considered as one 15 minute unit of care, 23 through 37 minutes would be 2 units, etc. When more than one service code is performed the time is bundled, and the total units can not exceed the total hands-on time rule. Other policies might vary, but this CMS approach is inherently reasonable. If less than 8 minutes (one unit), it could be appropriate to append the modifier -52 and charge less accordingly. CHRIOCODE 2011
32 TABLE OF TIMED CODES 1 UNIT 8 MINUTES TO 22 MINUTES 2 UNITS 23 MINUTES TO 37 MINUTES 3 UNITS 38 MINUTES TO 52 MINUTES 4 UNITS 53 MINUTES TO 67 MINUTES 5 UNITS 68 MINUTES TO 82 MINUTES 6 UNITS 83 MINUTES TO 97 MINUTES 7 UNITS 98 MINUTES TO 112 MINUTES 8 UNITS 113 MINUTES TO 127 MINUTES The pattern remains the same for treatment times in excess of 2 hours. ACA NEWSLETTER 2010
33 TIMED CODES According to the December 2009 CPT Assistant, “…..it is important to recognize that a substantial portion of the 15 minutes must be spent in performing the pre-, intra-, and post service work in order to report the timed code. If only a few minutes are spent performing the physical medicine service, the code shall either not be billed or modifier -52 should be appended to the code. The provider has the responsibility to document that the services rendered are medically necessary, skilled, and of good practice.” Medicare guidelines are different and state that providers should report the code for the time actually spent in the delivery of the modality requiring constant attendance and therapy services. Pre- and post delivery services should not be counted in determining the treatment service time. In other words, the time counted as “intra-service care” begins when the therapist or physician or assistant under the supervision of a physician or therapist is delivering treatment services. The patient should already be in the treatment area(e.g., on the treatment table or mat or in the gym) and prepared to begin treatment. The time counted is the time the patient is treated. The time the patient spends not being treated because of the need for toileting or resting should not be billed. In addition, the time spent waiting to use a piece of equipment or for other treatment to begin is not considered treatment time. ACA NEWSLETTER 2010
34 TIMED CODES: CONSTANT ATTENDANCE MODALITIESConstant Attendance Modality Codes ( ) are used to report various physical agents applied to the patient for the purpose of producing therapeutic changes to biological tissue. The codes do require direct one-on-one for treatment. Direct one-on-one contact requires the provider maintain visual, verbal, and/or manual contact with the patient throughout the procedure. These time-based codes include the time required to perform all aspects of the service itself, including pre, intra-, and post-service effort. The language in the constant attendance modality codes indicates that these codes are reported once for each 15 minutes of service. ACA 2009
35 EXAMPLE: CONSTANT ATTENDANCE MODALITYIf manual electrical stimulation is applied to four areas for a total of 30 minutes, CPT code is reported for two units, once for each 15-minute interval. If a substantial portion of the 15 minutes time-based service is not provided, then the service should not be billed or the reduced services modifier (-52) should be appended to the code to identify the reduction of service ACA 2009
36 TIMED CODES: THERAPEUTIC PROCEDURESTherapeutic Procedure Codes ( ) were added to CPT 1995 to clarify the differences between Therapeutic Procedures, Modalities, and Tests and Measurements. A Therapeutic Procedure is defined as “a manner of effecting change through the application of clinical skills and/or services that attempt to improve function.” These procedures require direct one-on-one patient contact by a physician or therapist. The descriptions for most of these codes reflect 15-minute intervals. If a procedure lasts more than 15 minutes, the CPT codes can be reported for each 15-minute interval. Common components included as part of the Therapeutic Procedures include chart review for treatment, setup of activities and the equipment area, and review of previous documentation as needed. Also included is communication with other health care professionals and discussions with the patient’s family. Subsequent to providing the therapeutic service, the treatment is recorded, and typically, the progress is documented. The patient health record should list the duration of the procedure time ACA NEWSLETTER 2010
37 EXAMPLES: THERAPEUTIC PROCEDURESTherapeutic exercise is performed for 30 minutes, will be reported for two units. Manual therapy techniques were provided to one or more regions for 20 minutes, will be reported for one unit. Manual therapy techniques were provided to one or more regions for 30 minutes, will be reported for two units. ACA NEWSLETTER 2010
38 QUESTION Which of the following is not a timed procedure:Therapuetic Exercise IASTM Argyrol Heat PIR
39 MODIFIERS -25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of a Procedure or Other Service. It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding the modifier -25 to the appropriate level of E/M service. CHIROCODE CHIROCODE 2011
40 EXAMPLE: MODIFIER -25 A patient’s presenting problem is a suspicious knee complaint and injury, in addition to their normal visit for hypertension. The physician performs a detailed history for the knee complaint and completes a thorough examination including the following test, sign, and reflex studies: Abduction stress test, external rotation-recurvatum test, knee flexion stress test, and Dreyer’s sign. Afterward reviewing the tests and considering the treatment options, the physician performed a chiropractic adjustment of the knee to relieve pain. CODING EXAMPLE: 98943 CHIROCODE 2011
41 MODIFIERS -52 Reduced Services.Under certain circumstances a service or procedure is partially reduced or eliminated at the physician’s discretion. Under these circumstances the service provided can be identified by its usual procedure number and the addition of the modifier -52, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. CHIRCODE CHIROCODE 2011
42 EXAMPLE: MODIFIER -52 When a procedure is partially reduced, the -52 modifier should be used in reporting. This alerts the payer that the service was not completed to its full extent, and provides a means of reporting reduced services without disturbing the identification of the basic service. This code could be used when a procedure is performed that is described as “bilateral” by the CPT, but the physician only worked on one side. When procedures are aborted after commencing due to the patient’s condition, this modifier can be applied to surgical code as well CODING EXAMPLE: CHIROCODE 2011
43 MODIFIERS -59 Distinct procedure service.Under certain circumstances, it may be necessary to indicate that procedure or service was distinct or independent from other non- E/M services performed on the same day. Modifier -59 is used to identify procedures or services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier -59. Only if no more descriptive modifier is available, and the use of the modifier -59 best explains the circumstances, should modifier -59 be used. CHIROCODE CHIROCODE 2011
44 EXAMPLE 1: MODIFIER -59 An established patient’s complaint is cervical pain and ankle pain. CODING EXAMPLE: 98940 Use this modifier when more than one procedure is performed on the same day (date) or in the same surgery operative session by the same physician. The major procedure is listed first because it will receive full reimbursement. The secondary/lesser procedure is then listed and identified by attaching modifier -51. CHIROCODE 2011
45 EXAMPLE 2: MODIFIER -59 Modifier -59 is perhaps the most valuable of all modifiers for most chiropractic offices. The code Manual Therapy Techniques is commonly used in many offices to express trigger point or myofascial release. This code is for 15 minutes of service. Unfortunately, the American Medical Association (AMA) does not approve of this code (97140) being used at the same encounter at the same region as the chiropractic adjustment/manipulation. From their perspective the service is a component of the adjustment when performed at the same region. However, if the service is at a different region, the AMA approves its usage. CODING EXAMPLE: 98940 CHIROCODE 2011
46 MEDICARE MODIFIERS -AT Acute treatment (this modifier should be used when reporting service ) {Also known as active treatment by Medicare, which is a declaration that patients are in an active/corrective treatment phase of care} -GA Waiver of liability statement issued as required by payer policy, individual case (this is a declaration of the “ABN on file” -GY Item or service statutorily excluded or, does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit. (exams, x-rays, physiotherapy, etc.) -GZ Item or service expected to be denied as not reasonable and necessary ( which are part of maintenance care ) -Q6 Service furnished by a locum tenens physician. CHIROCODE 2011
47 QUESTION Which of the following modifiers is required for an existing patient with a new complaint where assessment and treatment were provided? 25 59 52 AT