NUTS AND BOLTS OF CODING FOR AN ALLERGY PRACTICE

Diagnosis Coding

• The diagnoses need to be specific – ICD-10 is here in 2014
• Remember place the diagnosis with the most acuity first
• Acute precedes chronic
• Co-morbidities – you need to address how the comorbidity affect the allergy/asthma issues
• List the co-morbidities after your dx
• If you code it make sure it is in the documentation
• Medical necessity is defined with diagnosis codes

Chart Auditing –How to analyze your chart notes 

• Chief Complaint – make sure your note leads the reader down the appropriate path
• CC – “Patient is here for retesting for allergies”
• HPI – Make sure your HPI is for today’s encounter.
• HPI – Make sure it is clear what information is for today.

Previous information is ok but only for your information.

• HPI – The provider is required to obtain the information for the HPI.
• Past, family and social history – make sure it is applicable to the patient for your questions.
• ROS – if the patient is filling out the information or your staff, make sure there is documentation to support the providers review of the information obtained.

Chart Auditing –How to analyze your chart notes

• Exam – 2013 tell the reader what you see
• Normal is ok but describe – templates
• Make sure templates match the rest of the note for complaints
• You may use either the allergy specific or the general medical exam (1995 or 1997 guidelines)

Difference between a 99204 and a 99205

• 99204 99205
• Comprehensive hx Comprehensive hx
• Comprehensive exam Comprehensive exam

Moderate Medical Decision making (need two at same level or higher)

• Number of Diagnosis 3 or more
• Amount of Data 3 or more
• Lab
• Radiographs
• Medical records
• Medicine tests not billed
•  Risk
•  Moderate: Prescription drug management, undiagnosed new problem, one or more chronic conditions with mild exacerbation, progression or side effects of treatment

High Medical Decision Making need two at the same level or higher

• Number of diagnosis 4 or more
• Amount of data 4 or more
• Risk
• High:
•  Drug therapy requiring intensive monitoring for toxicity
•  One or more chronic illness with severe exacerbation, progression or side effects of treatment
•  Acute or chronic illness or injuries that pose a threat to life or bodily function

Ancillary services

• Allergy testing
• Interpret the test because the code includes interpretation and report as part of the code.
• Have name and/or initials of the supervising provider on the test
• Nebulizer treatments, MDI instruction
• Separate document
• CT Scans, radiographs
• If billing for it as a separate service, there should be a report as a separate document in the chart.
• Scopes
• Separate procedure note

Ancillary Services

• Immunotherapy – make sure billings for CMS are per cc – limit per billing are 10 cc’s
• Make sure there is documentation of the “recipes” for each patient.
• Document on the allergy injection record the beginning of a new vial.
• Document review of allergy injection record.
• If more than “normal” number of injections, make sure medical record supports the necessity of the higher number of vials manufactured.

Medical decision cheat sheet 99213

1. Two diagnosis doing well on RX – allergic rhinitis and asthma; allergic rhinitis and conjunctivitis

2. one diagnosis worse on RX – dermatitis not responding

Medical Decision making cheat sheet 99214

• Three diagnosis doing well – allergic rhinitis, asthma, anaphalysis to foods; or allergic rhinitis, asthma, dermatitis
• One new problem requiring an RX - urticaria requiring a RX
• One diagnosis doing well and one diagnosis not responding or worse. Both diagnoses are RX treatment – allergic rhinitis worse, asthma stable Medical decision making cheat sheet 99215
• New problem – pt acutely ill and needs labs, radiology studies, review of chart notes consultation with another health care provider. OR pt presents with additional workup planned and is high risk – 

Time

• Time is appropriate if more than 50% is counseling and coordination or care
• Document total face to face time
• Percentage is greater than 50% of the encounter
• Document the discussion with the patient.

CONSULT-HOSPITAL 99251 99252 99253 99254 99255

CONSULT-3 of 3 99241 99242 99243 99244 99245

NEW CPT- 3 of 3 99201 99202 99203 99204 99205