Coding and Billing

Beth Ann Yakes, who is awesome.

ICD-10 Codes - International Classification of Diseases

CPT - Descriptive terms and their codes to identify medical, surgical, and diagnostic services and procedures

E&M service codes - CPT codes - Evaluation and Management Codes

Preventive service codes - CPT codes for annual physical, non-medicare

E&M codes

Hx - CC and HPI - ROS - PFSH

Exam - # organ systems (out of 12 possible)

MDM - # and complexity of problems addressed - amount of data/complexity analyzed - risk level to pt

If established patient, does not need to have both hx or exam, can have one or the other.

Money amounts listed are for the professional fees, not necessarily including hospital fees, etc.

Average clinic day: 12 pts, ~2 $75, ~8 $110, ~2 $150 = ~$150 + $880 + $300 = ~$1330/day produced per provider

99213 (“level 3”) ~$75.

1 HPI (pt is here for sore throat)
1 ROS (pt denies fever or chills)
no PFSH
2 PE (general: pt looks well, HEENT: no exudates, mild erythema)
2/3 of the following
- address 2 minor/1 stable/1 acute uncomplicated problem
- review 2 pieces of data or use an independent historian (e.g. collateral from spouse)
- low risk tx and dx tests (e.g. OTC, simple PE maneuvers)

99214 (“level 4”) ~$110 (annual physical also about this amount).

this is the level to keep in mind for notes, even if the MDM is level 3, just to cover your bases
4 HPI (1. pt has not had CP or SOB, 2. pt has had normotension, 3. pt has been compliant with their medicines, 4. something else)
2 ROS
1 PFSH (at least copy and paste from old note, or click “mark as reviewed” - does NOT need to be an actual update)
5 PE
2/3 of the following
- address 2 stable/1 worsening/1 new w systemic sx/complicated hx/uncertain prognosis)
- review 3 pieces of data (inc ind historian), or interpret (I reviewed the CXR and do not see pna) (it's also ok to be wrong, just give good-faith effort) (lab data doesn't count, has to be radiographic or similar), or confer (does not have to be verbal conference - could be chart review of specialist's note)
- moderate risk tx and dx tests (rx meds - could be “cont lisinopril”, social determinants limit options, elective surgery w/o major risks)

99215 (“level 5”) - ~$150.

4 HPI
10 ROS
2 PFSH
8 PE
2/3 of the following
- 1 severe worsening or threat-imposing new problem
- 2/3 of what is listed in moderate
- higher risk tx or dx (rx req monitoring e.g. coumadin/opioids/chemo, hospitalization, emergent surgery)

Annual physical - ~$110.

No CC/HPI
14 ROS
PMH, FH, SH (c/p or “mark as reviewed” is sufficient)
address risk factors appropriate to age
multi-system PE targeted to pt
a/p including counseling, anticipatory guidance, risk factor mitigation
Identify note as “Preventive annual exam”
ICD-10: Z00.00
can add other ICD-10 codes as needed
billing code based on pt age
- 99395: 18-40
- 99396: 41-64
- 99397: >65, not medicare
no co-pay! (if w/in calendar year vs 365 days, depending on insurance provider)
tell the pt if you're not going to code the visit as annual physical, bc they'll be charged
can also bill for annual + problem (e.g. 99396 Z00.00 + 99213 R07.89 [CP])

Coding based on counseling time

Lvl 3: 15min
Lvl 4: 25min
Lvl 5: 40min
state “I spent X minutes with the pt with >50% spent on counseling regarding Y issue. We went over A, B, C, answered questions about Q, did teachback…”
pick the highest billing lvl bw coding based on time or based on problem severity (e.g. lvl 3 prob, lvl 5 counseling)
in Jan 2021, may be able to count time spent preparing for visit and reviewing afterward, as well as in-person time

last updated: 2020-08-27