The difference between ICD-9 and ICD-10 are significant. ICD-CM codes are used to document diagnoses. They are 3-7 characters in length and total 68,000 in contrast to the ICD-9 codes which are 3-5 digits in length and total over 14,000. The ICD-10 PCS are the procedure codes and they are alphanumeric, 7 characters, and total over 87,000. ICD-9 codes are 3-4 characters and total approximately 4,000. Outpatient procedures codes will not change so at least doctors in private practice will have somewhat of a break, even though these changes can represent a nightmare scenario for most physicians.
The changes required by Medicare mean updating software, training your staff, and managing to do all this without losing too many practice dollars to include these new requirements. Medical billing staff will need a good understanding of anatomy and physiology and will need to have an adequate medical record in order to bill correctly. Hopefully, in your role as Medical Director or Administrator, you have already spoken to your software vendor, prepared your billing staff for the new changes and have taken any available seminars and tele-conferences to prepare you for these changes.
It is expected that revenue cycles will suffer for the first few months, as practices come onboard with the changes. Hopefully, your practice can sustain these losses and quickly adapt your physicians and billers to the new world of healthcare.
One way to assure that your losses are minimal is to make certain that your physicians understand how to bill patients according to the acceptable limits approved by CMS and most private insurers.
As a Practice Administrator in Cardiology, I had the opportunity to assist in hiring new physicians for our group; several who had recently completed their fellowship program. Although they had treated patients in the hospital for some time, most of these physicians had never seen a billing sheet for private practice, let alone had any clue understanding how to bill for their services. This is probably not as amazing as it sounds, since most physicians, even those who have practiced for years really don't understand what a review of systems entails and how this review should translate into adequately billing for patient care. I decided that as part of my new physician integration, each doctor would be oriented to Review of Systems before they saw their first patient in our office.
The new changes that will occur starting in 2012 and the ICD-10 in October of 2013 will no doubt have some impact on each private practice and may affect your revenue for some period of time. You want to assure, however, that you do not lose revenue based on billing below par, so you may want to add a billing audit for each of your physicians as an addition to your preparation for new ICD changes.
Hopefully the information in todays' blog will give your doctors some valuable insights into understanding the three factors that determine a review of systems.
First let's understand some basic definitions:
New Patient - One who has not received services from the physician, or any doctor of the same specialty in the group within the past three years.
Established Patient - Once who as received services from the physician, or any doctor of the same specialty in the group within the past three years.
Note * There are no distinctions between New and Established patients for those seen in the Emergency Department.
Concurrent Care - Same or similar services provided by more than one physician on the same day.
Chief Complaint - A statement describing the symptoms reported by the patient, usually provided in the initial interview.
History of Present Illness - Description of the signs and symptoms presented by the patient including time from onset to visit date.
Review of Systems - An inventory of body systems that can help define the symptoms presented by the patient. The system review will help the physician ascertain diagnosis and the need for testing or treatment. For informational purposes, they include some of the following: Eyes, ears, nose, mouth, throat, cardiovascular, respiratory, gastrointestinal, musculoskeletal, neurological, endocrine... etc.
Past History - A review of the patients experience with illness or treatment that will include, prior surgeries, current medications, allergies, immunization status, dietary status.
Family History - A review of the medical evens in the patient's family that may or may not have contributed to their present illness.
Social History - Age appropriate information regarding: marital status, employment, use of drugs, alcohol or tobacco, education, sexual history, etc.
There are 3 major factors that are involved in Evaluation and Management services:
1. History - Four Major History Levels :
Problem Focused - Chief complaint, brief history of present illness or problem.
Expanded Focused - Chief complaint, brief history of present illness or problem, a review
of the relevant body system.
Detailed - Chief complaint, extended history of present illness, review of relevant body
systems, expanded review of other systems, related past, family and social history as to
chief complaint.
Comprehensive - Chief complaint, extended history of present illness, review of all body
systems, complete past, family, and social history.
2. Examination- Four Levels
Problem Focused - Concentration on affected body part or system.
Expanded Focused - Concentration on affected body part of system, with other related
reviews of systems that may be affected or affect the outcome of the disease.
Detailed Focused- An extended examination of the affected body part of system,and other symptomatic or related body systems.
Comprehensive - Multi-system examination or a complete comprehensive examination of a single body system.
3. Medical Decision Making - Refers to the complexity of establishing a diagnosis for the patient's symptoms and the management options that may have to be considered to treat this diagnosis. It also includes the amount of medical records that will need to be reviewed and considered and the risk of complications that the diagnosis presents.
4. Time - Amount of time spent with the patient and/or the patients family has been included to give the physician an additional tool in selecting a level of E/M services. These time recommendations are meant to serve as an average and may slightly differ depending on the circumstances of the visit.
When we correlate this information to use in coding we may use it as follows:
New Patient:
99201 - Problem Focused History / Problem Focused Exam / Straightforward Medical Decision/ 10
minutes spent face to face with patient or family.
99202 - Expanded Problem Focused History / Expanded Problem Examination / Straightforward Medical Decision / 20 minutes.
99203 - Detailed History / Detailed Examination / Low Complexity Decision Making / 30 minutes.
99204 - Comprehensive History / Comprehensive Examination / Moderate Complexity Decision Making / 45 minutes.
99205 - Comprehensive History / Comprehensive Examination / High Complexity Decision Making /
60 minutes.
Established Patient
99211 - History / Examination / Decision Making / 5 minutes or less
99212 - Problem Focused History / Problem Focused Exam / Straightforward Decision / 10 minutes or less.
99213 - Expanded Focused History / Expanded Focused Exam / Low Complexity Decision / 15 minutes.
99214 - Detailed History / Detailed Exam / Moderate Decision / 25 minutes.
99215 - Comprehensive History / Comprehensive Exam / High Complexity Decision/ 40 minutes.
You may find it helpful in the initial stages of the ICD-10 implementation to provide your physicians with a paper billing sheet that lists the procedure code, along with several choices from the new ICD-10 as it relates to your specialty. Hopefully, we will refine our ICD-10 choices and limit them to the particular specialty so we do not have to memorize 10,000 codes for each of our visits. I would also recommend that you provide your doctors with a pre-cheat sheet that shows a variety of the most common ICD-10 codes as it pertains to your office. Let's not overcomplicate these new changes and soon enough they will become as commonplace as the old.
Tomorrow: Verify / Verify / Verify
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