2013 Allergy Coding: ICD-10CM Are You Prepared?

2013 Allergy Coding: ICD-10CM Are You Prepared?

Presented by Teresa Thompson, CPC, CMSCS

TM Consulting, Inc Teresathom@

Objectives for Lecture

? Understand the principles of documentation in relationship to ICD10CM

? Understand the differences between ICD-9 and ICD-10 coding systems

? Identify strategies for implementing ICD-10 in clinical practice

? New CPT Codes for allergists in 2013

Principals of Documentation

? If it is not written, it was not done ? If it is illegible, it was not done ? If it is not signed, it was not done ? For 2014 ? specificity for

diagnoses documented???

Documentation

? Are skin tests signed or initialed? ? Are PFT's signed or initialed? ? ROS and past family and social

history obtained by someone other than the provider? ? EHR's ? if scanned in - initialed first? ? Are there separate reports for challenges, nebulizer treatments, MDI instructions? ? How often are the allergy injection records reviewed and documented as reviewed?

Principles of Documentation

? Chief complaint ? Relevant history ? Physical exam findings ? Diagnostic tests ? medical

necessity ? Assessment/impression and/or

diagnosis ? Plan/recommendation for care ? Time if it is counseling and/or

coordination ? Date & verifiable legible identity of

provider

5

5

Components of the E & M

? History ? Exam ? Medical decision making

6

Requirement for New/ Consult Patient

vs. Established Patient

? History, exam & medical decision making need to be at the same level or higher to support the level of care

? Two of the three of the components at the same level or higher to support the level of care

? The history and exam must be appropriate to the patient's presenting problem

7

CONSULT-HOSPITAL CONSULT-3 of 3 NEW PT- 3 of 3

99251 99241 99201

HISTORY CHIEF COMPLAINT HX of PRESENT ILL

REVIEW OF

SYSTEMS PAST HX FAMILY HX SOCIAL HX

Required Brief(1-3)

99252 99242 99202

99253 99243 99203

99254 99244 99204

99255 99245 99205

Required Brief(1-3)

Problem

Required Extended(4+)

Required Extended(4+)

Extended

Complete

Required Extended(4+

Complete

Pertinent (1) (2-9 System)

Pertinent-1 Pertinent-1 Pertinent-1

(10 + system)

Complete-1ea Complete-1ea Complete-1ea

(10+ system)

Complete-1ea Complete-1ea Complete-1ea

EXAM

Perform/

Perform/

document

document

1 organ 2-4

system organs

Perform/ document

5-7

Perform/ document

8 organ

Organ systems systems

Perform document

8 organ systems

MED. DEC MAKING MGMT OPT. & DX. AMT DATA &COMPLEX RISK OF COMPLICAT.

(2 of the 3 must be met or exceeded)

Minimal (1)

Minimal (1) Limited (2)

Minimal(1)

Minimal (1) Limited (2)

Minimal

Minimal

Low

Multiple (3) Moderate (3) Moderate

Extensive(4) Extensive(4) High

Difference Between 99204 and a 99205

99204

? Comprehensive Hx

? Comprehensive Ex

? Moderate MDM decision making

99205

? Comprehensive Hx

? Comprehensive Ex

? High medical decision making

Moderate Medical Decision Making (need two at same level or higher)

Number of Diagnosis: doing well, 1 or 2

3 est pblms

new problems

Amount of Data

3 or more

Lab

Radiographs

Medical records

Medicine tests not billed

Risk

Moderate:Prescription drug management, undiagnosed new problem, one or more chronic conditions with mild exacerbation, progression or side effects of treatment

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