Maximizing Third Party Reimbursement through Enhanced Medical Documentation and Coding

National Center for Health Care Capacity Building

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Maximizing Third Party Reimbursement Through Enhanced Medical Documentation and Coding March 2014 ! ! ! !

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TABLE OF CONTENTS Acronyms Used…………………………………………………………………………………………… 3 Current Procedural Terminology Coding……………………………………………………………… 4 Evaluation and Management Services…………………………………………………………

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E&M Components………………………………………………………………………………. 4 E&M Table of Risks……………………………………………………………………………..

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E&M Documentation Requirements…………………………………………………………… 8 Preventive Medicine Documentation Requirements…………………………………………..

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HIV Testing Documentation……………………………………………………………………. 10 Modifiers…………………………………………………………………………………………. 11 International Classification of Diseases, 9th Revision Clinical Modification Coding………………

HIV/AIDS Diagnosis Coding……………………………………………………………………

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Inconclusive HIV Coding……………………………………………………………………….. 13 ICD-9-CM Code Tips……………………………………………………………………………

ICD-9-CM Code Sequencing………………………………………………………………........

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Summary of Modifiers…………………………………………………………………………………… 15 Summary of Codes……………………………………………………………………………………….. 15 Evaluation and Management Codes……………………………………………………………

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HIV/AIDS ICD-9-CM Codes…………………………………………………………………… 16 AIDS Related Condition Codes…………………………………………………………………

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HIV/AIDS Screening Codes…………………………………………………………………….. 18 Well Visit ICD-9-CM Codes…………………………………………………………………….

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Miscellaneous Visit Codes………………………………………………………………………. 19 Supplemental Resources…………………………………………………………………………………. 20 Coding Resources………………………………………………………………………………… 20 Web Resources…………………………………………………………………………………… 21 State Medicaid Agencies………………………………………………………………………… 22

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Acronyms Used • • • • • • • • • • • • •

AMA – American Medical Association ARC – AIDS Related Complex CDC – Centers for Disease Control CLIA – Clinical Laboratory Improvement Amendments CMS – Centers for Medicare and Medicaid Services Dx – Diagnosis EIA – Enzyme Immunoassay ELISA – Enzyme Linked Immunosorbent Assay HHS – Health and Human Services HIV 1 – Human Immunodeficiency Virus 1 HIV 2 - Human Immunodeficiency Virus 2 OI – Opportunistic Infection WHO – World Health Organization

Coding Acronyms Used • • • • • • • • • • • • • •

CC – Chief Complaint CPT – Current Procedural Terminology E&M – Evaluation and Management HCPCS – Healthcare Common Procedure Coding System HPI – History of Present Illness ICD-9-CM – International Classification of Diseases, 9th Revision, Clinical Modification ICD-10-CM – International Classification of Diseases, 10th Revision, Clinical Modification ICD-10-PCS – International Classification of Diseases, 10th Revision, Procedure Coding System MDM – Medical Decision Making PDx – Principal Diagnosis PE – Physical Examination PMFSH – Past Medical, Family and Social History ROS – Review of Systems SDx – Secondary Diagnosis

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Current Procedural Terminology Coding The Current Procedural Terminology (CPT) was developed by American Medical Association (AMA) in 1966 and is updated annually. CPT codes describe the procedures and services that are performed to treat medical conditions. They are reported on professional (physician) claims for services rendered on an outpatient basis. CPT encompasses 6 sections: Evaluation and Management; Anesthesia; Surgery; Radiology; Pathology and Laboratory; and Medicine

Evaluation and Management Services E&M Codes (99201–99499) The Evaluation and Management (E&M) section is used to report medical (non-surgical) services provided by physicians and used by all specialties as appropriate. Each E&M code is incremental in nature and reflects the resources necessary to provide health care to patients. E&M codes reflect medical care, preventative care, and preventive counseling care.

New vs. Established Patient Definition • The E&M documentation guidelines provide a clear and concise definition of new vs. established patient: § New patient – has not received any face-to-face professional services from a physician within the same health care entity within the last three years § Established patient – has received face-to-face professional services from a physician within the same health care entity within the last three years o Commonly referred to as “follow up care”

E&M Documentation - Key Components Evaluation and Management Services Documentation is sectioned into three components: History, Physical Examination, and Medical Decision Making. Each component is made up of suggested guidelines and requirements.

History The first component of E&M documentation is history, a chronological description of the patient’s present illness related to the chief complaint. History includes Chief Complaint (CC), History of Present Illness (HPI), Review of Systems (ROS), and Past Medical, Family and Social History (PMFSH).

CC is a clear concise statement that describes the reason for the medical encounter, typically in the patient’s own words. It is usually the first sentence in the health record. The medical record should clearly reflect the CC. The patient statement “here for follow up care” is insufficient, as this does not clearly state the reason for the patient seeking medical care. Satisfactory statements include: § Patient here for HIV test results follow-up § Patient here for antiretroviral therapy follow-up Each type of history includes documentation of some or all of the following HPI elements:

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Location – symptomatic areas Quality – quality of the symptom Severity – intensity of the symptom Duration – how long the symptoms occurred • Timing – onset of the symptoms ROS • The status of each body system • Defines the problem • Clarifies differential diagnoses • Identifies the need for diagnostic tests ROS – Body Systems • Constitutional systems • Eyes • Ears, nose, mouth, throat • Cardiovascular • Respiratory • Gastrointestinal • Genitourinary

• Context – what the patient was doing when symptoms began • Modifying factors – factors that improve or worsen the patient’s symptoms • Associated signs and symptoms – additional complaints that add to the symptoms • Serves as baseline data for other affected body systems that may impact management and treatment options

• • • • • • •

Musculoskeletal Integumentary Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergic/Immunologic

PMFSH consists of a review of 3 areas: past medical history (personal illnesses, injuries, major operations and medication); past family history (review of family medical illnesses); and past social history (age appropriate review of past and current activities). Documentation of all 3 areas is required for new patient encounters.

Physical Examination The second component of E&M documentation is the Physical Examination (PE). PE is an objective assessment of organ systems or body areas pertinent to the medical compliant, illness or injury. The extent of the exam performed depends on the physician’s clinical judgment and the patient’s reason for seeking medical attention.

Body Areas and Organ Systems possibly examined include: • Head, including face • • Neck • • Chest, including breast and axillae • • Abdomen • • Genitalia, groin, buttocks • • Back • • Each extremity • • Constitutional systems • • Eyes • • Ears, nose, mouth, throat • • Cardiovascular

Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergic/Immunologic

When conducting Physical Examination Documentation, the physician should examine the body systems/body areas related to the presenting problem and abnormal and relevant negative findings of the affected or symptomatic body areas or organ systems must be documented in detail. A statement of “normal” is sufficient. A statement of “abnormal” or “asymptomatic” without any explanation is not acceptable.

Examples include: Abnormal skin/positive for skin rashes or lesions should be documented as “discolored skin lesions on the left arm and face.”

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6 The AMA and Centers for Medicare and Medicaid Services (CMS) developed a set of physical examination documentation guidelines in 1995 and again in 1997: • The 1995 guidelines are ambiguous and somewhat subjective • The 1997 guidelines reflect clearly defined examination elements for physicians to understand • Physicians may chose to use either set of guidelines; but not both Medical Decision Making The third component of E&M Documentation is Medical Decision Making (MDM). MDM is the complexity of establishing final diagnoses, selection of management options, and/or preparation of the patient treatment plan. MDM is determined by the number of possible diagnoses and/or management options considered; the documentation of data reviewed, amount of data and/or complexity of data for review; the risks of significant complications, morbidity and/or mortality relevant to the reason for seeking healthcare.

The number of possible diagnoses and/or management options considered depends upon clinical impression, management plans, and/or further evaluation. If treatment is for an established condition, documentation should clearly reflect whether the problem is improving, well controlled, resolving, resolved, controlled, inadequately controlled, worsening or failing to change as expected. The initiation of, or change in treatment or medication must be clearly documented. Referrals to specialists must clearly reflect the type of specialist and reason for the referral.

The documentation of data reviewed and/or complexity of data for review includes review of diagnostic tests such as labs, radiology or procedures which are ordered, discussions with health care professionals who performed labs, radiology or procedures, direct visualization and independent interpretation of image tracings or lab specimens that were previously interpreted by other physicians, and relevant findings from old medical records, history obtained from family members, caretakers or other sources.

The risks of significant complications, morbidity and/or mortality relevant to the reason for seeking healthcare are based on the risks associated with presenting the problems, diagnostic tests, procedures and specialty referrals, and the risks related to the disease process anticipated between the present encounter and the next encounter.

The following E&M Table of Risk is used to help determine whether the risk of significant complications, morbidity, and/or mortality is minimal, low, moderate, or high. Because the determination of risk is complex and not readily quantifiable, the table includes common clinical examples rather than absolute measures of risk. The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one. The assessment of risk in selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment. The highest level of risk in any one category (presenting problem(s), diagnostic procedure(s), or management options) determines the overall risk.

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E&M Table of Risk Presenting Problem •

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One self-limited or minor problem (e.g., cold, insect bite, tinea corporis)

Two/more self-limited minor prob.

One stable chronic illness Acute uncomplicated illness or injury

Diag. Procedures Ordered • • • • • • •

•

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• •

•

• •

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One/more chronic illnesses w/mild progression-side effect treatment Two/more stable chronic illnesses Undiagnosed new problem w/uncertain prognosis Acute illness with systemic symptoms (e.g. pneumonia, colitis) Acute uncomplicated injury One/more chronic illness w/severe progression – side effect of treatment Acute/chronic illnesses/injuries threat to life Abrupt neurologic change

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Management Options

Lab tests – venipuncture Chest X-ray EKG/EEG Urinalysis Ultrasound KOH Preparation Physiologic tests not under stress (e.g., pulmonary function) Non-cardio imaging with contrast (e.g., barium enema) Superficial needle/skin biopsy Clinical lab tests (i.e. arterial puncture) Physiologic tests under stress Dx endoscopies w/o risk factor Deep needle biopsy Refer patient for consult Cardio imaging studies w/contrast, w/o risk factors Obtain body cavity fluid

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Rest Gargle Elastic bandages Superficial dressings

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Over-the-counter drugs Minor surgery/no risk factors PT OT IV fluids w/o additive

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Minor surgery w/risk factor Elective major surgery w/o risk factor Prescription management Treatment nuclear medicine Closed fracture treatment/dislocation w/o reduction IV fluids w/additives

Cardio imaging studies w/contrast, w/risk factor Cardiac electrophysiologic tests Dx endoscopies w/risk factor Discography

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Elective major surgery w/risk factor Emergency major surgery Parenteral controlled substances Drug treatment with intense monitoring for toxicity Decision not to resuscitate or to deescalate care due to poor prognosis

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Evaluation and Management Services Documentation Requirements There are general principles of medical record documentation that are applicable to health care services in all settings: The medical record should be complete and legible. The documentation of each patient encounter should include the reason for the encounter and relevant history, physical examination finding, prior diagnostic test results, assessment, clinical impression or diagnosis, medical plan of care, and the date and legible identity of the observer. The past and present diagnoses should be accessible to the treating and/or consulting physician.

The appropriate health risk factors should be identified. The patient’s progress, response to and changes in treatment, and revision of diagnosis should be clearly documented. The diagnoses and treatment codes reported on the health insurance claim form should be supported by the documentation in the medical record.

The code sets used to bill for E&M services are organized into various categories and levels. In general, the more complex the visit, the higher the level of code reported. In order to report any code, the services furnished must meet the definition of the code. The code definition includes Three (3) Key Components: • • •

History – chief complaint, history of present illness, review of systems and past medical, family and social history Physical Examination – a general multi-system or single system examination of the body areas/organ systems pertinent to the chief complaint Medical decision making – establishing final diagnoses and management of treatment options

All new patient/initial visits require documentation of all 3 components. Established patient/subsequent visits require clear and concise documentation of 2 of the 3 components. Medical decision-making should always be 1 of the components of an established patient visit. In order to maintain an accurate medical record, services should be documented during the encounter or as soon as practical after the encounter.

Documentation is the key to ensuring that the level of service provided justifies the E&M visits code.

When ordering diagnostic ancillary services on your patients (i.e. lab work, radiology, physical therapy, etc), be sure to properly document the medical condition, on any requisition forms and on medical claims, that establishes the reason for ordering these services in the medical record.

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Preventive Medicine Visits Documentation Requirements Preventive/well visit services are comprehensive in nature and include: • A comprehensive health and developmental history, review of systems, past family and social history and assessment and history of pertinent risk factors • An age and gender appropriate multi-system physical examination which should include a Body Mass Index (BMI) assessment • Anticipatory guidance, health education, risk factor reduction and/or interventions and age appropriate counseling. Counseling should include: sexual health, nutrition, exercise, depression/mental health, tobacco, alcohol and substance abuse.

• The ordering of appropriate immunizations and/or the need for laboratory/diagnostic screening exams • Management of insignificant problems or the status of previously diagnosed stable conditions (SEE NOTE) The comprehensive history and examination performed during a preventive medicine visit are not the same as the comprehensive history and exam that are required for a problem-oriented Evaluation and Management (E&M) sick visit.

If a significant amount of additional work or effort is necessary to treat an abnormality or illness which results in a problem oriented sick visit during the preventive medicine visit encounter, both services should be reported with the applicable CPT code. The sick visit service should be reported with a problem oriented E&M sick visit CPT code and all of the sick visit ICD-9-CM codes should be reported. The well visit service should be reported with the preventive medicine visit E&M CPT code and the well visit ICD-9-CM code. Append modifier 25 to the preventive medicine visit E&M service code.

Documentation is the key to whether or not the additional work performed during the preventive medicine visit justifies the reason for assigning an additional E&M visits code.

NOTE: The Preventive Medicine Services CPT guidelines state, “An insignificant/trivial problem or abnormality that is encountered during a preventive medicine evaluation and management service which does not require additional work and does not require the performance of the key components of a problem-oriented E&M service should not be reported”.

Please refer to the Evaluation & Management Services section of the CPT codebook for specific reporting instructions.

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HIV Testing Documentation The HIV Testing Documentation is split into the first visit, second visit and HIV counseling. The first visit documentation consists of the signed HIV consent form, HIV test results, and notation that the test results were communicated to the patient. The second visit documentation consists of written justification for the rationale of the second of subsequent HIV test visit (i.e. risks identified during the first visit requiring further counseling). The HIV counseling with testing visit documentation consists of written justification that counseling was provided, the reason why the patient declined testing, and the follow up care plan, including indications for further counseling and testing.

The initial visit for confirmed results consists of preliminary or confirmatory positive test results, referrals for medical care and supportive services, follow up to confirm continuum of care, prevention/risk reduction counseling and follow up care plan, partner counseling and assistance including domestic violence screening, and the Medical Provider HIV/AIDS Report and Partner Contact Form*.

The following annual assessments consist of prevention/risk reduction counseling and follow up care plan and partner counseling and assistance including domestic violence screening.

While various state Medicaid agencies suggest the use of the rapid HIV test, it is the health care provider’s discretion to order a rapid HIV screen or the conventional HIV screening test. Contact your local Medicaid agency for specific guidance.

HIV Antibody – tests for the presence of antibodies that are produced in response to the presence of the HIV infection • CPT 86701 – HIV-1; single result • HCPCS G0435 – HIV-1 and/or HIV-2; single result • CPT 86702 – HIV-2, single result • CPT 86703 – HIV-1 & HIV-2; single result • CPT 86689 – HIV confirmatory (Western Blot) Rapid HIV tests – G0435, 86701, 86702 and 86703 • Orasure Technology • Trinity Biotech Uni-Gold • One test payable every 6 months Venipuncture – blood sample or urine sample collection • CPT 36415 – routine venipuncture • If HIV blood screening performed, must also report code 36415 *HIV is an infectious disease designated as notifiable at the national level.

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Modifiers What are Modifiers?

Modifiers are two digit (numeric or alpha numeric) codes that indicate that a procedure or service has been altered by a specific circumstance, but has not changed the code’s definition. There are CPT modifiers and Healthcare Common Procedures Coding System (HCPCS) modifiers. Some modifiers impact reimbursement and some modifiers are never reported alone. Each state Medicaid agency determines the approved modifiers. Contact your local Medicaid agency for specific guidance.

Modifiers commonly reported with HIV Services Modifier 25 - Significant, Separately, Identifiable E&M Service by Same MD on the Same Day of a Procedure, Service or Other E&M Service • Only report with E&M service codes (99201-99499) • Do NOT report on any other CPT code type • Do NOT report with HCPCS codes

Modifier 92 - Alternative Laboratory Platform Testing With current CDC recommendations on routine testing and the move toward HIV testing as a routine part of care, more providers may use rapid test kits. Several of these are Clinical Laboratory Improvement Administration (CLIA)-waived and suitable for use in physician offices. The following is the CPT guidance for use of this modifier: “When laboratory testing is being performed using a kit or transportable instrument that wholly or in part consists of a single use, disposable analytical chamber, the service may be identified by adding modifier 92 to the usual laboratory procedure code (HIV testing 86701-86703).”

• Only report with Path/Lab test codes (86701-86703) • Do NOT report on any other code type • Contact your local Medicaid agency for specific guidance Modifier QW - CLIA waived test In accordance with the Clinical Laboratory Improvement Amendments of 1988 (CLIA '88), a laboratory provider must have: a Certificate of Compliance, a Certificate of Accreditation or a Certificate of Registration in order to perform clinical diagnostic laboratory procedures of high or moderate complexity.

Waived tests include test systems cleared by the FDA designated as simple, have a low risk for error and are approved for waiver under the CLIA criteria.

• Only report with Path/Lab test codes (86701-86703) • Do NOT report on any other code type • If combinations of waived and non-waived tests are performed, modifier QW should not be used.

• Contact your local Medicaid agency for specific guidance

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International Classification of Diseases, 9 Revision Clinical Modification (ICD-9-CM) Coding The World Health Organization developed ICD-9 codes in 1948. The ICD-9-CM was revised and published for use in 1979. In October 1988 CMS mandated the use of ICD-9-CM codes on all claims. CMS revised these mandates to reflect “mandatory” correct reporting of ICD-9-CM codes on all claims. ICD-9-CM codes describe medical conditions (diseases), and injuries and poisoning. The codes are updated annually. They are reported on all claim types (physician, institutional, pharmacy, durable medical equipment (DME), etc.). There is also a list of supplementary classification codes that describe medical care rendered to patients whom are not sick but require medical attention, how injuries and poison occur, where injuries and poison occur, and misadventure during surgery.

The ICD-9 Coding System may be phased out no later than October 1, 2015 and replaced with two new Coding Systems.

The ICD-9-CM coding system has been in existence since 1966. It is outdated and does not reflect emerging technology. The ICD-10 Coding System is consistent with changes in health care and provides more codes that reflect emerging technology. The ICD-10-CM codes are used to report medical conditions. The ICD-10-PCS codes are reported on inpatient hospital (institutional) claims only to reflect the facility bill. The CPT & HCPCS codes should be continued for reporting services rendered by physicians. The ICD-9-CM codes should be continued for reporting services rendered through September 30, 2015. Claims submitted with ICD-10 codes for services rendered now through September 30, 2015 will be denied. ICD-10-CM codes should begin to be used for services rendered on or after October 1, 2015. Claims submitted with ICD-9-CM codes for services rendered on or after October 1, 2015 will be denied.

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HIV/AIDS Diagnosis Coding According to the ICD-9-CM coding guidelines, ICD-9-CM code 042 includes the following terms: • Acquired immune deficiency syndrome • Acquired immunodeficiency syndrome • AIDS • AIDS-like syndrome • AIDS-related complex • HIV infection, symptomatic • HIV-1 Use additional code(s) to identify all manifestations of HIV Use additional code to identify HIV-2 infection (079.53) EXCLUDES: § Asymptomatic HIV infection status (V08) § Exposure to HIV virus (V01.79) § Nonspecific serologic evidence of HIV (795.71) According to the ICD-9-CM coding guidelines, report code 079.53 for Human immunodeficiency virus, type 2 [HIV-2] Code Book Excerpts: Category code 079 Instructional Notes State: This category is provided to be used as an additional code to identify the viral agent in diseases classifiable elsewhere. This category will also be used to classify virus infection of unspecified nature or site § To locate this note, refer back to (category) code 079 - Viral and chlamydial infection in conditions classified elsewhere and of unspecified site Inconclusive HIV Diagnosis Coding Newborn babies born to HIV+ mothers often have a diagnosis of HIV+ as a result of the mother’s antibody status instead of the newborn. The diagnosis of HIV+ in newborns lasts up to 18 months without the newborn ever becoming infected. This is known as a “False Positive” result. Another term for “False Positive” is inconclusive HIV test results. Inconclusive test results are reported with ICD-9-CM code 795.71. People with healthy immune systems can be exposed to certain viruses, bacteria, or parasites and have no reaction to them.

People living with HIV/AIDS face serious health threats known as “opportunistic infections” (OI’s).

HIV/AIDS related OI’s take advantage of the weakened immune system resulting in life threatening illnesses.

The most severe OI’s occur when the CD4 count is below 200 cells/mm3. OI’s are common in people with HIV/AIDS and is the most common cause of death in people living with HIV/AIDS. The CDC has a comprehensive list of OI’s located on their web page.

Most common OI’s: • Candidiasis (Thrush) • Cytomegalovirus (CMV) • Herpes simplex viruses (chronic) • Kaposi Sarcoma • Pneumocystis pneumonia (PCP) • Mycobacterium avium complex (MAC or MAI)

• • • • •

Toxoplasmosis (Toxo) Tuberculosis (TB) Recurrent severe bacterial pneumonia Wasting Syndrome Malaria

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ICD-9-CM Code Tips Only confirmed cases of AIDS or HIV infection should be coded. Chart documentation that states “possible”, “probably”, “rule out”, “suspected” or “suspicion of” are never reported as AIDS (Dx 042). A diagnosis of HIV+ and asymptomatic HIV (V08) is not the same as a diagnosis of HIV infection, symptomatic HIV/AIDS and AIDS (042). Patients may test positive for HIV but may not become sick for many years. Once a diagnosis of HIV infection, symptomatic HIV/AIDS or AIDS is documented in the health record, report ICD-9-CM code 042. Symptomatic HIV (code V08) and inconclusive HIV (code 795.71) are never reported once a patient has a confirmed diagnosis of AIDS (code 042). If present for HIV testing and counseling; assign codes V73.89 + V65.44. Once medical record documentation states any of the common OI’s, assign ICD-9-CM code 042 as the principal diagnosis and the OI condition as the secondary diagnosis. Some opportunistic infections (OI’s), are inherent to HIV, such as pneumocystis carinii pneumonia (136.3) and Kaposi’s sarcoma (176.x).

• Health record documentation which states that the patient has: § HIV+, has not been diagnosed with an HIV-related illness (past or present), they are considered to be asymptomatic; assign code is V08 § HIV asymptomatic but is currently being treated for any HIV-related illness or is described as having any condition(s) resulting from HIV+ status; assign code 042 § HIV 2 infection; assign code 042 and code 079.53 § Inconclusive or nonspecific HIV test results; assign code 795.71* § Exposure to or contact with someone who has HIV/AIDS; assign code *V01.79 (note that this code is reported as an SDx; never as the PDx) § Engaged in unsafe sex practices that increases their risk; assign code V69.8* § Present for a well visit encounter that includes HIV testing and counseling; assign codes V70.0 and V65.44

ICD-9-CM Code Sequencing * When it is necessary to report multiple diagnoses codes, accurate interpretation of coding guidelines ensures proper code sequencing. Coding guidelines that only denote “principle diagnosis” vs. “secondary diagnosis” must be adhered to. OI infections codes are always assigned as the secondary diagnoses (when reported). The HIV-2 code is always assigned as the secondary diagnosis code (when reported).

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Modifiers E&M MODIFIER

NARRATIVE DESCRIPTION

25

Significant, separately, identifiable E&M service by same MD on same day as another procedure/service

MODIFIERS QW 92

NARRATIVE DESCRIPTION CLIA waived test Alternative laboratory platform testing

E&M CPT Codes E&M CPT CODES 99201-99205

NARRATIVE DESCRIPTION OFFICE/OUTPATIENT VISITS - NEW PATIENT • • • • •

99211-99215

OFFICE/OUTPATIENT VISITS - ESTABLISHED PATIENT • • • • •

99381-99387

99381 - Age Younger Than 1 Year 99382 - Early Childhood (Age 1 to 4 Years) 99383 - Late Childhood (Age 5 to 11 Years) 99384 - Adolescent (Age 12 to 17 Years) 99385 - Early Adult (Age 18 to 39 Years) 99386 - Adult (Age 40 to 64 Years) 99387 - Late Adult (65 Years of age and older)

• FOLLOW UP PREVENTIVE/WELL VISITS - ESTABLISHED PATIENT • • • • • •

99401-99404

99211 – Level 1 99212 – Level 2 99213 – Level 3 99214 – Level 4 99215 – Level 5

INITIAL PREVENTIVE/WELL VISITS - NEW PATIENT • • • • • •

99391-99397

99201 – Level 1 99202 – Level 2 99203 – Level 3 99204 – Level 4 99205 – Level 5

99391 - Age Younger Than 1 Year 99392 - Early Childhood (Age 1 to 4 Years) 99393 - Late Childhood (Age 5 to 11 Years) 99394 - Adolescent (Age 12 to 17 Years) 99395 - Early Adult (Age 18 to 39 Years) 99396 - Adult (Age 40 to 64 Years) 99397 - Late Adult (65 Years of age and older)

• PREVENTIVE MEDICINE COUNSELING AND/OR RISK FACTOR REDUCTION (WITHOUT HISTORY AND PHYSICAL EXAM) PROVIDED TO AN INDIVIDUAL • • • •

Approximately 15 minutes Approximately 30 minutes Approximately 45 minutes Approximately 60 minutes

NOTE: Well/preventive visit services are comprehensive in nature and include counseling and anticipatory guidance. These services can be reported by physicians and other qualified physician practitioners (i.e. Nurse Practitioners, Physician Assistants). Refer to page #9 for preventive services documentation requirements.

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HIV/AIDS ICD-9-CM Codes ICD-9-CM CODES V08

V01.79 V69.2 V65.44 042

079.53 795.71

V69.8 V73.89

NARRATIVE DESCRIPTION Asymptomatic HIV Includes: • HIV+ • HIV+ status Exposure to HIV/AIDS Includes: • Pre-exposure to HIV/AIDS High risk sexual behavior HIV Counseling HIV Disease Includes: • AIDS • AIDS like syndrome • AIDS related complex (ARC) • Symptomatic HIV infection • HIV 1 HIV 2 Report as secondary diagnosis code ONLY (when applicable) Nonspecific Evidence of HIV Includes: • Inconclusive HIV test • False positive results • False + Other Problems Related to Lifestyle Includes: • Asymptomatic high risk Report as secondary diagnosis code (when applicable) Special Screening for Other Specified Viral Diseases Includes: • HIV/AIDS

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AIDS Related Condition ICD-9-CM Codes ICD-9-CM CODES 112.84 112.4 112.0 078.5 054.9 176.9 031.2 136.3 130.0 011.9 348.30 799.40

NARRATIVE DESCRIPTION Candidiasis - Esophageal Candidiasis – Lungs, Bronchi & Trachea Candidiasis – Oral (Thrush) Cytomegalovirus Herpes Simplex Virus – Chronic (HSV) Kaposi Sarcoma Mycobacterium avium complex or M. kansasii, disseminated or Extrapulmonary (DMAC, MAC, MAI) Pneumocystis pneumonia (PCP) Toxoplasmosis of brain Pulmonary Tuberculosis (TB) Bacterial Pneumonia (PNA) HIV related Encephalopathy Wasting Syndrome (Cachexia)

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HIV/AIDS Screening Codes CPT CODES 36415

CPT/HCPCS CODES 86701* G0435* 86702* 86703* 86689 CPT/HCPCS CODES 87389 G0432 87390 87391 G0433 87534 87535 87536 87537 87538 87539

NARRATIVE DESCRIPTION Venipuncture Includes: • Includes collection of blood by venipuncture • Phlebotomy NARRATIVE DESCRIPTION (ANTIBODY) HIV 1; single result HIV 1 and/or HIV 2; single result HIV 2, single result HIV 1 & HIV 2; single result HIV confirmatory (Western Blot) NARRATIVE DESCRIPTION (ANTIGEN) Enzyme Immunoassay (EIA) HIV 1 antibody with HIV 1 & HIV2 antigens; qualitative or semi-quantitative; single step EIA; HIV 1 and/or HIV 2 EIA HIV 1; qualitative or semi-quantitative; multi-step EIA HIV 2; qualitative or semi-quantitative; multi-step Enzyme Linked Immunosorbent Assay (ELISA); HIV 1 and/or HIV 2 DNA/RNA; HIV 1; direct probe DNA/RNA; HIV 1; amplified probe DNA/RNA; HIV 1; quantification DNA/RNA; HIV 2; direct probe DNA/RNA; HIV 2; amplified probe DNA/RNA; HIV 2 quantification

NOTE: * Describes Quick/Rapid HIV Test performed in an office or clinic setting. Must possess a valid CLIA Certificate of Waiver issued by CMS and must append modifier QW to CPT code 87880. Please go to CMS’ website for a list of CLIA waived tests that require a CLIA Certificate. These codes can only be reported by an Internist, Family Practitioner, etc. that possess a valid CLIA license.

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Well Visit ICD-9-CM Codes ICD-9-CM CODES

NARRATIVE DESCRIPTION

V20.2 V20.31 V20.32 V70.0 V70.3

Routine infant, child or adolescent check up/exam – Ages 29 days to – 17 years old Routine newborn check up/exam – Newborn 0 to 7 days old Routine newborn check up/exam – Newborn 8 days to 28 days old Routine adolescent or adult check up/exam – Ages 18 years and older General medical exam for: • Camp • School admission • Sports competition General exam for pre-school age children Health examination in population surveys Other specified general medical examinations Unspecified general medical examination

V70.5 V70.6 V70.8 V70.9

NOTE: When assigning ICD-9-CM codes V20.2, V20.31, V20.32, V70.0 V70.3 and V70.5 as the principal diagnosis code, an additional code may be required (as a secondary diagnosis code) to identify special screening examinations for: • • • • • • • • • •

Viral and chlamydial diseases (V73.0-V73.9) Bacterial and spirochetal diseases (V74.0-V74.9) Other specified infectious diseases (V75.0-V75.9) Malignant neoplasms/cancer conditions (V76.0-V76.9) Endocrine, nutritional, metabolic & immunity disorders (V77.0-V77.99) Blood & blood forming organs (V78.0-V78.9) Mental disorders and developmental handicaps (V79.0-V79.9) Neurologic, eye and ear diseases (V80.0-V80.3) Cardiovascular, respiratory, and genitourinary diseases (V81.0-V81.6) Other conditions (V82.0-V82.9)

Miscellaneous Visit Codes ICD-9-CM CODES

NARRATIVE DESCRIPTION

V15.81

Noncompliance with medical treatment Against medical advice Long term (current) use of medication Long term (current) use of other specified medication such as: • High risk medication • Methadone • Opiate analgesic Prescription refill • •

V58.61-V58.67 V58.69

V68.1*

NOTE: Disclaimer: Please refer to the latest coding reference books to verify all codes contained in this packet. Where applicable, some ICD-9-CM codes must be assigned to the highest level of specificity (5th digit classification). CPT codes and some HCPCS codes may require add-on codes to accurately report services rendered. Reporting services with invalid codes could result in payment denial or delay in payment.

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Coding Resources •

CPT® 2014 Professional Edition. Publisher: American Medical Association.

•

Pocket Guide to E&M Coding and Documentation. Publisher: Healthcare Quality Consultants.

•

HCPCS Level II 2014. Publisher: Ingenix Optum.

•

ICD-9-CM, Volumes 1 & 2, Professional. Publisher: Ingenix optum.

•

Faye Brown’s ICD-9-CM Coding Handbook 2014 (with Answers). Publisher: American Hospital Association.

•

ICD-9-CM Fast Finder Sheets. Publisher: Ingenix Optum.

Note: Coding resources are updated annually. Please be sure to update coding resources each year.

PROPRIETARY INFORMATION PREPARED BY STACEY L. MURPHY FOR USE BY HEALTHHIV’S NATIONAL CENTER FOR HEALTHCARE CAPACITY BUILDING © 2014

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WEB RESOURCES •

Centers for Medicare and Medicaid Services (CMS) http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/index.html http://www.cms.gov/center/coverage.asp

•

Food and Drug Administration (FDA) http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/IVDRegulatory Assistance/ucm124105.htm

•

American Medical Association (AMA) http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-yourpractice/coding-billing-insurance/cpt.page

•

National Center for Health Statistics (NCHS) http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/index.html

•

Centers for Disease Control (CDC) http://www.cdc.gov/mmrw/preview/mmwr.html

•

American Academy of Professional Coders (AAPC) http://www.aapc.com/resources/index.aspx

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American Health Information Management Association (AHIMA) http://www.ahima.org/resources/default.aspx

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The American Academy of Family Physicians (AAFP) www.aafp.org/online/en/home/practicemgt/codingresources.html

•

American Hospital Association (AHA) http://www.aha.org/advocacy-issues/medicare/ipps/coding.shtml

PROPRIETARY INFORMATION PREPARED BY STACEY L. MURPHY FOR USE BY HEALTHHIV’S NATIONAL CENTER FOR HEALTHCARE CAPACITY BUILDING © 2014

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State Medicaid Agencies The Medicaid website has a webpage of Medicaid Agency updates and policy for the United States and the surrounding territories. Complete mailing address, telephone number, fax number, email address and web page information is available for your convenience by clicking on the name of your state. To access the web page, go to: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-State/By-State.html To narrow your search, type any of the following to: Medicaid Billing Provider Billing HIV Coding Guidelines

State Health Departments Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas

Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina

North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Territorial Health Departments American Samoa Guam

Northern Mariana Islands Puerto Rico

U.S. Virgin Islands

PROPRIETARY INFORMATION PREPARED BY STACEY L. MURPHY FOR USE BY HEALTHHIV’S NATIONAL CENTER FOR HEALTHCARE CAPACITY BUILDING © 2014

National Center for Health Care Capacity Building Syncing Innovative Appraoches with Successful Outcomes

E-mail: training@healthhiv.org Telephone: 202.507.6749 Fax : 202.232.6750

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