Wilce Student Health Center CODING 101 Evaluation and

Wilce Student Health Center CODING 101 Evaluation and Management (E&M) and Procedure Coding for Office Encounters in a Student Health Center Michael Bower CPC

Wilce Student Health Center • Wilce Student Health Center at The Ohio State University • Autumn 2013 Enrollment 63, 964 (57, 466 Columbus Campus) • Student enrollment is a requirement to use Wilce SHS

Wilce Student Health Center • 2012 -2013 • 65, 605 Total Patient Visits • 28, 702 Primary Care • 9, 679 Preventive Medicine • 6, 401 Dental • 7, 460 Women’s • 13, 363 Other (Specialty, PT, Injection Therapy, Nutrition) • 118, 382 Pharmacy, Laboratory Tests, Radiology

Wilce Student Health Center Insurance Options • 22% covered under Student Health Insurance Plan • Student Health Insurance Office • Waiver Required to Opt out of SHIP • 61% covered under Contracted Carrier • Wilce Student Health Center in network status with four (4) major commercial carriers • Also in network status with OSU Employee Healthplan

Wilce Student Health Center Audience Survey • Role • Coders, Providers, Ancillary Staff, Administration • Current Billing Practice • Student Health Fee • Bill Student Health Insurance Plans • Bill Commercial Plans

Wilce Student Health Center Agenda • Evaluation and Management Codes • History • Exam • Medical Decision Making • Three Types of Encounters • Problem-oriented • Preventive medicine • Office based procedures • Coding obstacles and errors • Q & A

Wilce Student Health Center Scenario Disclaimers • Scenario documentation for this presentation is abbreviated. It should not be construed as a complete chart note. • E&M codes used in scenarios are for illustrative purposes. E&M codes selected must be supported by documentation in chart note. • Coding practices may vary between institutions. Work with your Compliance Office and Administration to ensure coding practices fall within applicable state and/or federal guidelines. • CMS guidelines offer a sound starting place. Commercial carriers generally follow CMS guidelines – although specific carrier rules may also apply.

Wilce Student Health Center Evaluation & Management Codes • Problem oriented – Physician work captured by Evaluation and Management Service codes (99201 -99205, 99211 -99215) • New vs Established patient • New patient – patient who has not received any professional services, i. e. , E/M service or other face to face service (e. g. , surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years. • Established patient – anyone not considered a new patient.

Wilce Student Health Center Evaluation & Management Code Selection Made Easy • Well, easier anyway…

Wilce Student Health Center Key Components of E&M Codes • Key Components of E&M • Chief Complaint (CC) • History (HPI, ROS, PFSH) • Exam • Medical Decision Making

Wilce Student Health Center Key Components – Chief Complaint • Concise statement of presenting problem. Often in patients words. Documented by the provider.

Wilce Student Health Center Key Components – History • History of Present Illness (HPI) • Chronological description of present illness from initial sign to • • the present Location - specific location of problem, e. g. right knee, throat Severity – description of severity or rating on pain scale, e. g. moderate, 6/10 Timing – when or frequency, e. g. persistent, intermittent, in the morning Modifying factors – what makes problem better or worse, e. g. OTC pain reliever, rest, exertion

Wilce Student Health Center Key Components – History • Quality – characteristic or description of sensation or pain, e. g. dull, sharp • Duration – length of time of symptoms, e. g. started this morning, three (3) days • Context – circumstances around or description of how symptoms began, e. g. while playing basketball, after eating week old leftovers • Associated signs and symptoms – additional symptoms offered by patient • HPI Levels - Brief HPI (1 -3 elements), Extended (4 or more elements)

Wilce Student Health Center Key Components – History • Review of Systems (ROS) • Inventory of body systems obtained through a series of questions seeking to identify signs and symptoms the patient may be experiencing. • Assist provider in narrowing the range of differential diagnoses. • While ancillary staff or patient may provide ROS in form of a questionnaire, the provider must review for accuracy, add to it when necessary and note the review in the chart. • ROS Levels – None, Problem Pertinent (1 system usually related to HPI), Extended (2 -9 systems), Complete (10 or more systems)

Wilce Student Health Center Key Components – History • Past, Family and Social History (PFSH) • Past - patient experiences with illness, injuries, operations and treatments. Includes current medications and known allergies. • Family – medical events in family including hereditary disease or those that present a risk to the patient • Social – age appropriate review of past and current activities • PFSH Levels – None, Pertinent (1 -2 new pat, 1 est pat), Complete (3 new pat, 2 -3 est pat)

Wilce Student Health Center Key Components – History • Left most element determines the level of history.

Wilce Student Health Center Key Components – Exam • Physical Exam • 1997 General Multisystem Exam – located on CMS website 1997 General Multisystem 1 -5 6 -11 bulleted elements 12+ 2+ elements bulleted for each of elements 9+ systems in 2+ systems Exam Type Problem- Expanded Focused Prob Focused Detailed Comprehen sive

Wilce Student Health Center Key Components – MDM • Medical Decision Making • Diagnosis / Management Options • Self Limited Problem (1), Established Diagnosis Stable (1), Established Diagnosis Worsening(2), New Problem No Additional Work Up(3), New Problem Additional Work Up Planned(4) • Type of Data • Order or Review Clinical Labs(1), Radiologic(1) or Other Diagnostic Tests(1) • Risk Assessment using Table of Risk • Presenting Problem, Diagnostic Procedure Ordered, Management Options Selected • MDM Levels – Straight forward, Low, Moderate, High

Wilce Student Health Center Key Components – MDM • Choose column with 2 or 3. Otherwise use the middle column. Dx Mgmt Options 1 - Minimal 2 - Limited 3 - Multiple 4 - Extensive Type of Data 1 - Minimal 2 - Limited 3 - Moderate 4 - Extensive Overall Risk Minimal Low Moderate High Level of MDM Straight Forward Low Moderate High

Wilce Student Health Center New Patient E&M code History Problem. Type Focused Expanded Prob Focused Detailed Comprehensive Exam Type Problem- Expanded Focused Prob Focused Detailed Comprehensive MDM Straight forward Low Moderate High Level 99201 99202 99203 99204 99205 Time 10 min 20 min 30 min 45 min 60 min

Wilce Student Health Center Established Patient E&M code History Type N/A Problem. Focused Expanded Prob Focused Detailed Comprehensive Exam Type N/A Problem. Focused Expanded Prob Focused Detailed Comprehensive MDM N/A Straight forward Low Moderate High Level 992011 99212 99213 99214 99215 Time 5 min 10 min 15 min 25 min 40 min

Wilce Student Health Center E&M Notes • 1995 Exam based on Body Areas or Systems • 1997 Exam based on General Multisystem Exam • Used at our facility to aid in consistency of provider documentation • Less ambiguity • HPI, Exam and Medical Decision Making cannot be performed/documented by ancillary staff (RN, LPN or MA). • These areas credit physician work and medical decision making by gathering appropriate information in relation to the chief complaint and therefore should be completed and documented by the provider.

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Wilce Student Health Center Problem Oriented Scenario #1 – Sore Throat • HPI: A 23 year old established male patient presents with a five (5) day history of sore throat. His symptoms are worsening over the last two (2) days. He rates his pain level 8/10 on the pain scale. He is having trouble eating due to the pain in swallowing. He also notes ear congestion. No current medications or drug allergies. • ROS: Review of systems reveals patient is positive for fever, chills , fatigue and body aches. Patient denies nasal congestion, rhinorrhea, sinus pain or pressure, cough or wheezing. • Exam: Vitals: 130/72, 88, 98. 6. Throat exam reveals moderate erythema, + bilateral white tonsillar exudates. Lungs are clear to auscultation and resonant to percussion. External auditory canals patent with pearly TMs.

Wilce Student Health Center Problem Oriented Scenario #1 – Sore Throat • Diagnostic Testing: Mono screen was negative. Direct strep was positive for group A beta strep. • Treatment Plan: Amoxicillin 500 mg is ordered for the patient. • Documented Dx: Streptococcal sore throat.

Wilce Student Health Center Problem Oriented Scenario #1 – Coding • CPT Procedure Coding: • 99214 – Evaluation & Management, established patient, level 4 • 86308 – Mono screen • 87880 – Direct Strep • 36415 – Venipuncture • ICD 9 Coding: • 034. 0 – Streptococcal sore throat • ICD 10 Coding: • J 02. 0 – Streptococcal pharyngitis (sore throat) • E&M Criteria - Detailed History, Expanded PF Exam, Moderate MDM

Wilce Student Health Center Established Patient E&M code History Type N/A Problem. Focused Expanded Prob Focused Detailed Comprehensive Exam Type N/A Problem. Focused Expanded Prob Focused Detailed Comprehensive MDM N/A Straight forward Low Moderate High Level 992011 99212 99213 99214 99215 Time 5 min 10 min 15 min 25 min 40 min

Wilce Student Health Center Problem Oriented Scenario #2 – Ankle Sprain • HPI: A 19 year old male presents with right ankle pain and swelling. He twisted his ankle while running this morning. He is unable to bear weight. His pain level is 7/10 on the pain scale. This is his first visit to our facility. • ROS: Patient denies numbness or tingling. • PFSH: He has no prior history of injury to the ankle or foot. • Exam: Vitals: 130/72, 88, 98. 6. Ankle exam reveals slight swelling and moderate tenderness to palpation over the lateral malleolus. Limited ROM. Posterior tibial pulse is normal. Light touch sensation of the foot is normal.

Wilce Student Health Center Problem Oriented Scenario #2 – Ankle Sprain • Diagnostic Testing: Radiologic exam of the right ankle is ordered. • Treatment Plan: Ankle brace and crutches are ordered. Patient is fitted with right ankle brace and instruction is given for use of crutches. Rx for pain management declined. OTC products reviewed for pain management. • Documented Dx: Results from radiology are pending and the provider documents ankle sprain.

Wilce Student Health Center Problem Oriented Scenario #2 – Coding • CPT Procedure Coding: • 99202 – Evaluation & Management, new patient, level 2 • 73610 – Radiologic examination, ankle; complete, minimum 3 views • L 4350 – Ankle control orthotic, stirrup style, rigid • E 0114 – Crutches, underarm, oth than wood, adjustable or fixed, pair

Wilce Student Health Center Problem Oriented Scenario #2 – Coding • ICD 9 Coding: • 845. 00 – Sprain and strain of ankle, unspecified site • E 001. 1 – Activities involving running • ICD 10 Coding: • S 93. 401 A – Sprain of unspecified ligament of right ankle, initial encounter • Y 93. 02 – Activity, running • E&M Criteria – Expanded PF History, Expanded PF Exam, Moderate MDM

Wilce Student Health Center New Patient E&M code History Problem. Type Focused Expanded Prob Focused Detailed Comprehensive Exam Type Problem- Expanded Focused Prob Focused Detailed Comprehensive MDM Straight forward Low Moderate High Level 99201 99202 99203 99204 99205 Time 10 min 20 min 30 min 45 min 60 min

Wilce Student Health Center Problem Oriented Scenario #3 – UTI • HPI: A 29 year old female presents with a two (2) day history of urinary frequency. Based on our UTI protocol, a UA is ordered (diagnosis code 788. 99 – Other symptoms urinary system) prior to being seen by the provider. • ROS: The patient denies hematuria, fever, or bilateral lower back pain. Patient denies any vaginitis or abnormal bleeding. • PFSH: The patient does have a history of UTIs with the most recent in 2012. • Exam: Vitals: 130/72, 88, 98. 6. External genitalia normal. Bladder & Urethra normal. Cervix and uterus normal. Abdomen non tender, no organomegaly.

Wilce Student Health Center Problem Oriented Scenario #3 – UTI • Diagnostic Testing: Urinalysis (gross and microscopic) results indicate a large amount of blood, RBCs 30 -49, bacteria, WBCs > 49/hpf and positive for nitrites. • Treatment Plan: Macrobid 100 mg is ordered for the patient. • Documented Dx: Acute cystitis. Hematuria.

Wilce Student Health Center Problem Oriented Scenario #3 – Coding • CPT Procedure Coding: • 99213 – Evaluation & Management, established patient, level 3 • 81003 – Urinalysis, automated without microscopy • 81015 – Urinalysis, qualitative, microscopic only

Wilce Student Health Center Problem Oriented Scenario #3 – Coding • ICD 9 Coding: • 595. 0 – Acute cystitis • 599. 72 – Microscopic hematuria • Note that dx 788. 99 is not coded as the symptoms are an integral part of the disease process in the first listed diagnosis code. • ICD 10 Coding: • N 30. 01 – Acute cystitis with hematuria • E&M Criteria – Expanded PF History, Expanded PF Exam, Moderate MDM

Wilce Student Health Center Established Patient E&M code History Type N/A Problem. Focused Expanded Prob Focused Detailed Comprehensive Exam Type N/A Problem. Focused Expanded Prob Focused Detailed Comprehensive MDM N/A Straight forward Low Moderate High Level 992011 99212 99213 99214 99215 Time 5 min 10 min 15 min 25 min 40 min

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Wilce Student Health Center Preventive Medicine Encounters • No Chief Complaint • Age and gender appropriate • History • Review of Systems (ROS) • Past Family and Social History (PFSH) • Exam • Counseling/guidance/risk factor reduction interventions and ordering of lab/diagnostic procedures

Wilce Student Health Center Preventive Medicine Encounters • Physician work captured by Preventive Medicine Visit codes (99381 -99397). • New vs Established Patient • Patient Age ( <1 yrs, 1 -4 yrs, 5 -11 yrs, 12 -17 yrs, 18 -39 yrs, 4064 yrs, 65+yrs) • Includes care for small problem that requires no extra physician work. • Code also immunization administration and products. • Code also significant, separately identifiable E&M services on the same date for substantial problems requiring additional work using modifier 25.

Wilce Student Health Center PM Scenario #1 – Annual Gynecological Exam • Scenario: A 21 year old female presents for her annual • • gynecological exam. She is an established patient for our practice. She is currently feeling well with no complaints. ROS: Patient denies breast concerns, urinary symptoms, vaginal discharge or itching. Her last LMP was 05/20/2014. PFSH: Past medical history, social history and family history reviewed. She is currently sexually active. Number of partners in last year is 2. The patient has not had a pap smear in the past. Exam: The exam revealed no abnormal findings. Diagnostic Testing: Cervical cytology. Urine specimen for gonorrhea and chlamydia screening.

Wilce Student Health Center PM Scenario #1 – Coding • CPT Procedure Coding: • 99395 – Periodic comprehensive preventive medicine evaluation • 88142 – Cytopathology, cervical • 87491 – Chlamydia trachomatis • 87591 – Neisseria gonorrhoeae • ICD 9 Coding: • V 72. 31 – Routine gynecological examination • V 74. 5 – Screening venereal disease • ICD 10 Coding: • Z 01. 419 – Encounter for gynecological examination (routine) without abnormal findings • Z 11. 3 – Encounter for screening infections with a predominantly sexual mode of transmission

Wilce Student Health Center Gynecological Exam Requirements • The requirements to bill for a routine gynecologic exam requires seven (7) of the eleven (11) elements listed below to be completed. • Inspection and palpation of breasts for masses or lumps, tenderness, symmetry, or nipple discharge. • Digital rectal exam including sphincter tone, presence of hemorrhoids, and rectal masses. • External genitalia (general appearance, hair distribution or lesions). • Urethral meatus (size, location, lesions or prolapse). • Urethra (masses, tenderness, or scarring). • Bladder (fullness, masses, or tenderness). • Vagina (appearance, estrogen effect, discharge, lesions, cystocele or rectocele).

Wilce Student Health Center Gynecological Exam Requirements • Cervix (appearance, lesions, or discharge). • Uterus (size, contour, position, mobility, tenderness, consistency, descent or support). • Adnexa (masses, tenderness, organomegaly, or nodularity). • Anus and perineum.

Wilce Student Health Center PM Scenario #2 – Annual Wellness Exam • Scenario: A 20 year old male presents for an annual wellness exam. He is new to our practice. He is currently feeling well with no complaints. He does request STI screening. • ROS: Patient denies any complaints. • PFSH: Past medical history, social history and family history reviewed. He is up to date on immunizations with the exception of HPV and would like to begin the series. He is currently sexually active. Number of partners in last year is 2. Method of STI prevention is none. • Exam: The exam revealed no abnormal findings.

Wilce Student Health Center PM Scenario #2 – Annual Wellness Exam • Diagnostic Testing: Urine specimen for gonorrhea and chlamydia, blood specimen for HIV and syphilis. • Treatment Plan: HPV immunization is ordered and given.

Wilce Student Health Center PM Scenario #2 – Coding • CPT Procedure Coding: • 99385 -25 – Initial comprehensive preventive medicine • • • evaluation 87491 – Chlamydia trachomatis 87591 – Neisseria gonorrhoeae 86703 – Testing for HIV antibodies; HIV-1 and HIV-2; single result 86780 – Treponema pallidum 90471 – Immunization administration; 1 vaccine 90649 – HPV vaccine, quadrivalent, 3 dose schedule

Wilce Student Health Center PM Scenario #2 – Coding • ICD 9 Coding: • V 70. 0 – Routine general medical examination • V 74. 5 – Screening venereal disease • V 04. 89 – Vaccination, other viral diseases • ICD 10 Coding: • Z 00. 00 – Encounter for general adult medical examination without abnormal findings • Z 11. 3 – Encounter for screening infections with a predominantly sexual mode of transmission • Z 11. 4 – Encounter for screening for human immunodeficiency virus [HIV] • Z 23 – Encounter for immunization

Wilce Student Health Center PM Scenario #3 – Travel Assessment • Scenario: A 22 year old male presents for a travel assessment. He will be traveling to Haiti in six (6) weeks with his church group. He will be staying in a hotel. He is up to date on his immunizations with the exception of influenza and typhoid. • Treatment Plan: Travel guidelines and handouts reviewed with patient. Immunizations for influenza and typhoid are ordered and given.

Wilce Student Health Center PM Scenario #3 – Coding • CPT Procedure Coding: • 99401 -25 – Preventive medicine counseling and/or risk • • factor reduction intervention; approx. 15 minutes 90471 – Immunization administration; 1 vaccine 90472 – Immunization administration; each additional vaccine 90658 – Influenza virus vaccine 90691 – Typhoid vaccine

Wilce Student Health Center PM Scenario #3 – Coding • ICD 9 Coding: • V 70. 3 – Other medical examination for administrative purposes • V 04. 81 – Immunization for influenza • V 03. 1 – Immunization for typhoid • ICD 10 Coding: • Z 02. 89 – Encounter for other administrative examinations • Z 23 – Encounter for immunization

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Wilce Student Health Center Office Based Procedure Encounters • Chief Complaint • History of Present Illness (HPI) • Review of Systems (ROS) • Past Family and Social History (PFSH) • Exam • Medical Decision Making • Diagnosis / Management Options

Wilce Student Health Center Office Based Procedure Encounters • Type of Data • Risk Assessment based on Presenting Problem, Diagnostic Procedure Ordered, Management Options Selected • Minor surgery with no identified risk factors – Low Management Options • Minor surgery with identified risk factors – Moderate Management Options • Skin biopsy – Low Diagnostic Procedure Ordered

Wilce Student Health Center Office Based Procedure Encounters • Physician work captured by procedure code • E&M service included in procedure code • Common office based procedure codes • Laceration repair • Incision and drainage of abscess • Biopsy of skin lesion • Wart treatment • Colposcopy • Excision of nail

Wilce Student Health Center Office Based Procedure Encounters • Code also immunization administration and products. • Code also therapeutic injection administration and products. • Code also significant, separately identifiable E&M services on the same date for substantial problems requiring additional work using modifier 25.

Wilce Student Health Center Office Based Procedure – Laceration Repair • Criteria for laceration repair code selection • Complexity – Superficial, Intermediate, Complex • Site • Size

Wilce Student Health Center Office Based Procedure – Laceration Repair • Superficial Wounds • CPT codes: 12001 -12018 • Local anesthesia • Routine debridement and decontamination • Simple one layer closure • Sutures, staples, tissue adhesives, cauterization without closure • Total length of several repairs in same code category

Wilce Student Health Center Office Based Procedure – Laceration Repair • Superficial Wound Sites • Scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet) • Face, ears, eyelids, nose, lips and/or mucous membrane • Superficial Wound Sizes • 2. 5 cm or less • 2. 6 cm to 7. 5 cm • 7. 6 cm to 12. 5 cm • 12. 6 cm to 20. 0 cm • 20. 1 cm to 30. 0 cm • > 30. 0 cm

Wilce Student Health Center Office Based Procedure – Laceration Repair • Intermediate Wounds • CPT codes: 12031 -12057 • Local anesthesia • Routine debridement and decontamination • Closure of contaminated single layer wound • Layer closure (e. g. subcutaneous tissue, superficial fascia) • Removal of foreign material (e. g. gravel, glass) • Total length of several repairs in same code category

Wilce Student Health Center Office Based Procedure – Laceration Repair • Intermediate Wound Sites • Scalp, axillae, trunk and/or extremities • Neck, hands, feet and/or external genitalia • Face, ears, eyelids, nose, lips and/or mucous membrane • Intermediate Wound Sizes • 2. 5 cm or less • 2. 6 cm to 7. 5 cm • 7. 6 cm to 12. 5 cm • 12. 6 cm to 20. 0 cm • 20. 1 cm to 30. 0 cm • > 30. 0 cm

Wilce Student Health Center Office Based Procedure – Laceration Repair • Complex Wounds – not performed at our facility • CPT codes: 13100 -13153 • More complicated than layered repair • Exploration of nerves, vessels, tendons • Vessel ligation

Wilce Student Health Center Procedure Scenario #1 – Laceration Repair • HPI: A 22 year old male presents with minor lacerations to his left hand. Patient states he broke a glass while washing dishes approximately 30 minutes ago. He was unable to control the bleeding at home and is here for treatment. • Exam: The exam of laceration #1 shows a 1 cm laceration on the palmar surface of the fourth finger. Laceration #2 shows a 1. 7 cm laceration on the palmar surface of the third finger. Both wounds were explored and no foreign bodies were found. • Treatment Plan: Wound #1 was closed using a skin adhesive. Wound #2 was closed with 3 Ethilon sutures. • Documented Dx: Open wound finger.

Wilce Student Health Center Procedure Scenario #1 – Coding • CPT Procedure Coding: • 12001 – Simple repair superficial wound; 2. 6 cm to 7. 5 cm • ICD 9 Coding: • 883. 0 – Open wound of finger without mention of complication • E 920. 8 – Accident caused by other cutting and piercing instruments or objects • ICD 10 Coding: • S 61. 213 A – Laceration w/o foreign body of left middle finger w/o damage to nail, initial encounter • S 61. 215 A – Laceration w/o foreign body of left ring finger w/o damage to nail, initial encounter • W 25. 000 A – Contact with sharp glass, initial encounter

Wilce Student Health Center Office Procedure – I&D of Abscess • Incision and Drainage of Abscess • Simple or single (10 day global period) • CPT code: 10060 • Carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle or paronychia • Complicated or multiple (10 day global period) • CPT code: 10061 • Carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle or paronychia

Wilce Student Health Center Office Procedure – I&D of Abscess • Incision and Drainage of Pilonidal Cyst • Simple (10 day global period) • CPT code: 10080 • Complicated (10 day global period) • CPT code: 10081

Wilce Student Health Center Procedure Scenario #2 – I&D of Abscess • HPI: A 24 year old female presents with pain in the left axillae. • • She has a history of staph infections of the axillae. This pain began about 3 months ago. Exam: The exam shows several raised evolving furuncles in the axillae. The largest being 1. 5 cm x 1. 5 cm in the mid posterior left axillae. Treatment Plan: The area is cleansed an incision and drainage is performed. A small amount of blood and pus is released. Diagnostic Testing: A culture is obtained. Documented Dx: Hidradenitis.

Wilce Student Health Center Office Procedure Scenario #2 – Coding • CPT Procedure Coding: • 10060 – Incision and drainage of abscess; simple • 87070 – Culture, bacterial; any other source except urine, blood or stool • ICD 9 Diagnosis Coding: • 705. 83 – Hidradenitis • ICD 10 Diagnosis Coding: • L 73. 2 – Hidradenitis suppurative

Wilce Student Health Center Office Procedure – Biopsy of Skin Lesion • Single lesion (0 day global period) • CPT code: 11100 • Skin, subcutaneous tissue and/or mucous membrane • Includes simple closure • Each additional lesion (0 day global period) • CPT code: 11101 • Skin, subcutaneous tissue and/or mucous membrane • Includes simple closure • List in addition to CPT code: 11100

Wilce Student Health Center Office Procedure – Biopsy of Skin Lesion • Biopsy is defined as a procedure to obtain tissue for a pathologic examination. These codes support a biopsy via means of provider choice, including shaving or punch methods. • Even when the entire lesion is removed, the intent of the procedure is to obtain tissue and so the biopsy code is appropriate.

Wilce Student Health Center Procedure Scenario #3 – Biopsy of Lesion • HPI: A 21 year old female presents with two slightly raised skin • • lesions of the left shoulder. Patient indicates these have changed in size and color over the last several months. Exam: The exam shows one 3 mm and one 4 mm raised lesions with variable brown color. Treatment Plan: After reviewing diagnosis and treatment options, a shave biopsy is performed on each lesion. Diagnostic Testing: Specimens are collected and sent to pathology. Documented Dx: Neoplasm unspecified behavior.

Wilce Student Health Center Office Procedure Scenario #3 – Coding • CPT Procedure Coding: • 11100 – Biopsy of skin, subcutaneous tissue; single lesion • 11101 – Biopsy of skin, subcutaneous tissue; each additional lesion • 99000 – Handling of specimen for transfer from office to laboratory • 88305 x 2 – Level IV – Surgical pathology, gross and microscopic examination

Wilce Student Health Center Office Procedure Scenario #3 – Coding • ICD 9 Diagnosis Coding: • 238. 2 – Neoplasm of uncertain behavior; skin • ICD 10 Diagnosis Coding: • D 48. 5 – Neoplasm of uncertain behavior; skin

Wilce Student Health Center Office Procedure – Destruction of Warts • Up to 14 lesions (10 day global period) • CPT code: 17110 • Benign lesions other than skin tags or cutaneous vascular proliferative lesions • Includes laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement. • 15 or more lesions (10 day global period) • CPT code: 17111 • Do NOT code 17110

Wilce Student Health Center Office Procedure – Destruction of Warts • Other site specific lesion destruction codes: • Anus 46900 -46917 • Penis 54050 -54057 • Vagina 57061, 57065 • Vulva 56501, 56515

Wilce Student Health Center Procedure Scenario #4 – Destruction Warts • HPI: A 19 year old male presents with concerns of several wart like lesions on the top of this left foot. They are aggravated by his shoe when walking or running. • Exam: The exam shows 3 small warts, each measuring approx. 3 mm, on the top of his left foot, just distal to the ankle. • Treatment Plan: Treatment options were reviewed and the patient elected to have these treated with liquid nitrogen. • Documented Dx: Viral warts.

Wilce Student Health Center Office Procedure Scenario #4 – Coding • CPT Procedure Coding: • 17110 – Destruction benign lesions, up to 14 lesions • ICD 9 Coding: • 078. 10 – Viral warts, unspecified • ICD 10 Coding: • B 07. 9 – Viral wart, unspecified

Wilce Student Health Center Coding Obstacles and Errors • E&M Code Selection • New vs established patient codes • Correct code level selection • Documentation to support level selected • Charge Capture • Bundled and Unbundled Services • Therapeutic Injections and Immunizations • Administration • Medication or Vaccine • DME supplies

Wilce Student Health Center Coding Obstacles and Errors • Diagnosis Selection • ICD-9 CM Guidelines • General Coding Guidelines • Chapter Specific Guidelines • Symptoms vs Definitive Diagnosis • Signs and symptoms routinely associated with a disease process should not be assigned as additional codes • Factors Influencing Health Status – V Codes • Immunization codes • Personal and Family History codes • Classification of External Causes – E Codes • E Codes are not used as first listed diagnosis codes • Dog bite, needle stick injury

Wilce Student Health Center Coding Obstacles and Errors • Diagnosis Links • Ensure services are correctly linked to all relevant diagnosis codes assigned • Carrier rules may apply

Wilce Student Health Center Questions and Answers