Question
Can you give an overview of CPT Codes, ICD9 Codes and the basics of documentation?
Answer
This is a very common question and so let me provide a general overview.
CPT Codes
It's important to remember that the CPT codes were created for and are owned by physicians. They are copyrighted by the American Medical Association (www.ama-assn.org/), and all use of CPT codes comes through the authority and auspices of the AMA. They've been around since the mid-1960s and serve as the primary purpose of standardizing the language of what is done to and for a patient.
We (audiology) were a recent afterthought as far as the CPT system, and really since only around 2000-2001 have we been given a voice in the process and authority to influence the process. So we are a fairly recent entrant, but we do have a voice, and that's what's important.
CPT Modifiers
One of the key things about modifiers is that when you do something, and the basic protocol doesn't change but something changes around the circumstances under which you do it, there is a modifier to help to explain what the circumstances were.
Case in point: all of our codes are valued on the basis of two ears. And if you did tympanometry for both ears, you would bill 95267. If you did tympanometry, however, on just one ear, then there's a modifier, -52, to say that you did not change the basic protocol of the procedure but you did not do all that you typically do with the procedure, and so what you would report would be a 95267-52.
If you're doing the same thing, again, on the same date of service, such as with a glycerol or a urea test, for example, then a -76 could be a modifier that is entertained for repeating a procedure on the same date of service.
And then, if you do something that's unusually long--not routinely long, but unusually long--for a particular patient, then a -22 is extended procedure. And with that, you would have to submit a report to justify why you're billing a -22, how much extra time it took, what all you did, etcetera.
So, the CPT coding system, as well as the modifiers, are contained within the CPT manual. And if you don't have one, I highly recommend that you do purchase a CPT manual (catalog.ama-assn.org/Catalog/cpt/cpt_home.jsp?checkXwho=done), and that you not just purchase one but you purchase one every year, simply because codes are deleted, new codes are added, and you need the authoritative book, in order to know how to code and what each code represents.
CPT is a system where you have to have an exact fit between what you did and the code that you choose. If it doesn't fit then you must not choose that code, and it goes under the unspecified otolaryngological procedure code, 92700.
ICD-9
In contrast, ICD-9 does not have that same level of specificity. The ICD-9 code list that we use had not been updated since 1971, until last year, which, for the first time, we had some new codes and some modifications of current codes placed into the book.
There are some additional new codes that will appear in the October 1st edition of the new ICD-9 manual; they have been approved. So we're just now starting to update all the coding diagnosis codes in ICD-9, for the first time in more than 30 years. And boy, has it been necessary.
But the moral of the story is that ICD-9 does not carry the precision as does CPT. With ICD-9, you have to choose a diagnosis code that will come as close as possible to the exact truth. And sometimes, you can't come to the exact truth, so you have to come as close as you can in order to be able to say, "This is what I found."
There are also some rules to selecting an ICD-9 code when things turn out to be normal, and we'll discuss that a little bit later on in the Q & A because some questions did pop up specific to that issue.
Documentation
Documentation is another area. When audiologists and, well, when anyone has been audited, whether it be physician, physical therapist, audiologist, SLP, it doesn't matter who, when anyone has been audited, the primary area where they have fallen down and become susceptible to penalty has been based upon the lack of appropriate documentation. And there are six elements to documentation that must be adhered to consistently.
- The first element is a history - Why is a person there? This must include the chief complaint, the presenting complaint, elements of the prior occupational or personal history, family history, enough background information to justify what you are about to do to the patient and for the patient. Without this information there really is no justification for why you saw the patient, and that documentation is absolutely essential to meet the requirement, the fundamental requirement of medical necessity.
- The second element is - What did you do? This is a description of all the diagnostic tests that we engaged in, and not just a description of the tests but also what we found. For example, "Hearing sensitivity was evaluated using standard audiometric techniques with supra-aural earphones. Pure-tone thresholds indicated a moderate to severe sloping sensorineural hearing loss in the right ear and a mild to moderate sensorineural hearing loss in the left ear." So you're describing what you're doing and also what you're finding at the same time in this particular section.
- The next element - What does it mean? This is your clinical interpretation. Sometimes it's a repeat of what you found. "These results are consistent with moderate to severe sensorineural hearing loss." Many times, though, you want to embellish that just a little bit to have a practical implication. In the case of unilateral hearing loss, for example, that may mean that the person needs a medical evaluation to ensure that there is no treatable active disease or medical issue involved with that unilateral hearing loss. The same can be for unilateral tinnitus, just use these two examples. So what's your interpretation of what you found?
Other times you may want to have some information in there regarding the practical functional limitations that the hearing loss will pose upon the individual. Physicians tend to be pretty smart when it comes to overall education, but they are not real smart when it comes to interpreting our results. They know what hearing loss means, but they don't always know what it means - if you know what I mean. Hearing loss - "yeah, you don't hear well." But what does it mean to that person's everyday function? Many times physicians really don't know that, and so it's up to us to explain it to them as appropriate to that instance, and this would be the section to do it. - Number four, based on the results, what do we recommend? The results have to be a logical flow from everything that happened before. What you recommend has to be supported by the history, by what you did, what you found, and also your clinical interpretation. It's a logical conclusion to everything that was written prior to that section in the report.
- Number five - You have to have an original signature. Do not, do not, do not use a name stamp or a facsimile signature. The one exception to that is if you are in a facility that uses electronic medical records. Then your signature is your login, and the working assumption there is that you, and only you, have access to that patient's medical record - and nobody but you. And by the way, there are some penalties involved should you share your access code with anyone else. And so by logging in under your name in an EMR, the computer does indeed assume that it is you.
- And number six - The date. The date must be the date of evaluation, the date the patient was seen.
Because if there is a mismatch between the date of service on the voucher that goes in for reimbursement, and the date of the evaluation on the report, if there's a mismatch between the two, you did not see that patient. That patient never came into your office, nothing ever happened, and you billed inappropriately.
So you must make sure that the date on the report is the date of the evaluation, and the date of service on the voucher that goes in for payment, is indeed the date that matches the date of the report.
Your recommendations now come under some specific guidelines, all under the heading of "Medical Necessity." Every one of us, me included, when we went through our professional training for audiology, were taught that when you find sensorineural hearing loss, you do an annual follow-up re-check to monitor the status of the hearing loss. That is no longer true under acceptable medical guidelines for medical necessity.
There are three broad areas, by which we are justified in recommending that the patient return to see us. One is if we can document that the patient has a dynamic condition. One illustration of a dynamic condition would be Endolymphatic Hydrops, in which case, you may have a change in hearing status that is unpredictable.
A perceived or a real change in status as reported by the patient, would be the second justification for the patient coming back to see you for a repeat visit—a repeat audiogram. Under that scenario you would tell the patient, "Now if you have a change in your status, or something new appears like ringing in the ears, or if you find that you're not hearing as well as what you are now, then I want to see you again to see what's going on."
Then you document that in that way in the chart, so that you fall under the heading of, "If the patient has a change in status, real or perceived, then a return visit should occur."
The third category is that if there's a risk of change in status due to a related diagnosis. I'm a pediatric audiologist, and one of the most common things that we encounter is the diagnosis of Cytomegalovirus (CMV). The child may have normal hearing sensitivity as predicted by ABR, and OAE, and VRA, and all of these other tests that we use in pediatric audiology. But, that related diagnosis of CMV places that child at great risk for a change in status. That would justify a return visit, again under the heading of "Medical Necessity." What is not acceptable any more is simply to tell the patient to come back for an annual re-check to see what's going on.
Now you can do make that recommendation, but if you do, it would not be appropriate to bill Medicare, Medicaid, or any other third-party payor because that is your desire as a provider, and not based upon a dynamic condition, or a risk of change, or anything else that would fall under the categories listed above.
"It's simply because I was taught that when you find Sensorineural Hearing Loss, you bring them back every year for a re-check." That's well and good, but that does not fall under the heading of "Medical Necessity" anymore.
Now let me digress just a second, and let you have some insight as to how this came about. When the cost of health care was much less than what it is now, we could make that recommendation and get away with it, simply because it was not a burden to the system.
But, again this comment is not just for audiology. It is for all of health care in general. The cost of healthcare has gone up so much that arbitrarily having the patient come back for repeat visits, when there's no risk of dynamic change or no risk of change due to related diagnosis, is no longer acceptable. It's simply that the healthcare system simply cannot afford it anymore. If there is a change, or if there's a documented risk for change, then you're justified.
If you do an evaluation, and there's a cautionary follow up, there must be a risk for change in status. An example here would be otitis media. One of the questions coming up later on is, "When I saw a child about four weeks ago, I documented a conductive hearing loss. The child has been under treatment, and is now coming back." That would qualify under medical necessity, because you are looking for a change, aka, improvement in status in that child. Hopefully you're going to find normal results at the end of this evaluation. Your documentation and your diagnosis code must reflect what you found on this follow-up visit.
Can you go over the most recent updates in CPT codes?
With regard to the updates for this year, a number of you participated in surveys to convert some of our CPT codes from practice expense to work RVUs. I do appreciate your efforts and your contribution very much in that effort. You need to know that we did present them. I cannot tell you what the outcome was because I don't know what the outcome was.
I know that we had a hard time because the American Academy of Otorlaryngology Leadership is very much opposed to our effort to convert our reimbursement formula from practice expense only to work RVUs. They came in with their own work survey that was much lower than ours. We were basically in a locked room for the better part of 8 hours trying to negotiate. We presented our positions to the AMA panel.
CMS now has the information, the Center for Medicare and Medicaid Services. We do not know if, number one, they will accept the work survey. Number two, we do not know what the assignment of the work RVU will be, because they have complete laterality to accept, reject, or modify what the AMA sends. We also don't know what the final value will be for the codes, probably not until the Physician Fee Schedule is released on November 1st.
We're not going to submit any more new codes for conversion until we see what transpired with these codes. For 92557 and 92579, in particular, we are told preliminarily by CMS that their draft run, their rough run on the calculation, the value should not change that much. But we don't know at this moment what that means. On some of the codes that we submitted, if CMS does accept them, and if everything holds true, we're hopeful that the value will increase substantially, in particular for some of the cochlear implant codes.
New codes have come out; again on those codes we really don't know what's going to happen, though, until November 1st. On the new codes coming out we have auditory brainstem implant programming. That will affect just a very small handful of you who work primarily in large neuro-otology centers.
The other code, the team conference code, will be appearing in the book next year. It has been surveyed, and that information has been turned in to CMS. We'll find out what they do with it. That will allow you to account for your time in a team conference with other individuals concerning a specific patient. That's something that we, and other professionals, don't have access to right now.
New codes in the pipeline will be a whole new balance family of codes. We're not going to delete the current balance diagnostic procedures, the 92541 through 92548. But we have to create a new family, in parallel, to account for the goggle recording of nystagmus and the associated protocols for analysis that come with that.
Canalith repositioning procedure, aka Epley. That'll be a proposal that's about ready to go. That'll be jointly presented by neurologists, ENTs, audiologists, and physical therapists, because all of those groups have vested interest in that procedure.
Cochlear implant diagnostics. This is a troubleshooting procedure for implants, and VEMP and the ASSR have now met all of the criteria for eligibility that AMA demands of a new code proposal. So we'll be preparing applications for that, for new codes.
Robert Fifer, Ph.D., is the Director of Audiology and Speech-Language Pathology for the Mailman Center for Child Development at the University of Miami School of Medicine. He is also an Audiology Online Contributing Editor in the area of Coding and Billing. He is the ASHA representative to the American Medical Association's Health Care Professions Advisory Committee for the Relative Value Utilization Committee in addition to being ASHA's representative to the AMA's Practice Expense Advisory Committee.
Editor's Note - The above is a partial transcript from the Coding and Billing QNA Live e-Seminar that was conducted on Audiology Online on June 27, 2007. (The recorded version is available here - Also the complete edited transcript is available here. The format of the session was different from most traditional presentations as we solicited questions ahead of time and also solicited questions during the event and had Dr. Fifer focus on answering those questions during the live session. We have published the transcript from the seminar in a semi-rough format to preserve the live feel from the session and to accelerate the publication timeline of this information to the Audiology Online readers. Submitted questions are bolded, followed by Dr. Fifer's response. Dr. Fifer is a frequent Contributing Editor for Audiology Online in this area, look for additional Coding and Billing QNA sessions on our home page in the near future. - Paul Dybala, Ph.D. - Editor
