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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