Chicago Dermatological Society January 2011 Coding and Practice Management Seminar Saturday, January 22, 2011 Donald E. Stephens Convention Center Rosemont, IL . Table of Contents 5 ................Program 7 - 8 .............Continuing Medical Education Information and Accreditation Statement 9 - 40 ............Dermatology Coding 101: The Basics Boot Camp 41 - 65 ...........Coding and Health System Reform Update 67 - 104 ..........Coding Soup for Dermatology 105 - 118 .........Electronic Health Records and Meaningful Use 119 - 122 .........Additional Materials/Article . Chicago Dermatological Society 10 W. Phillip Rd., Suite 120 ˜ Vernon Hills, IL 60061-1730 (847) 680-1666 ˜ Fax: (847) 680-1682 Email: [email protected] ˜ Internet: www.ChicagoDerm.org 2011 CDS Coding Seminar Saturday, January 22, 2011 g Stephens Convention Center; Rosemont, IL PROGRAM 7:30 a.m. Registration, continental breakfast & visit with exhibitors Ballroom 21, Level 2 8:00 a.m. - 9:00 a.m. Coding 101 -- The Basics Boot Camp DANIEL SIEGEL, MD; PEG EIDEN & FAITH MCNICHOLAS Ballroom 21, Level 2 9:00 a.m. - 10:00 a.m. Alphabet Soup: CPT, ICD, PQRI, CMS and More! -- What's New and What You Need to Know to Comply With Medicare Rules DANIEL SIEGEL, MD, PEG EIDEN & FAITH MCNICHOLAS Ballroom 21, Level 2 10:00 a.m. - 10:20 a.m. Break Ballroom 21, Level 2 10:20 a.m. - 12:00 p.m. Coding Issues, continued Questions & Answers DANIEL SIEGEL, MD, PEG EIDEN & FAITH MCNICHOLAS Ballroom 21, Level 2 e-Prescribing and How EMR Will Affect a Clinical Practice RACHNA CHAUDHARI; AMERICAN ACADEMY OF DERMATOLOGY 12:00 p.m. Meeting Adjourns Mark the Date! Next CDS monthly meeting – Wednesday, March 2, 2011 at Stroger Hospital of Cook County; Timothy G. Berger, MD from the University of California-San Francisco Please note the following date change . The May monthly meeting sponsored by Rush University is now on Wednesday, May 11 at the Stephens Convention Center in Rosemont. Watch for details on the CDS website: www.ChicagoDerm.org . ____________________________________________________ Continuing Education Credit Chicago Dermatological Society “CCChhhiiicccaaagggooo DDDeeerrrmmmaaatttooolllooogggiiicccaaalll SSSoooccciiieeetttyyy MMMooonnnttthhhlllyyy CCCooonnnfffeeerrreeennnccceee” January 22, 2011 Rosemont, IL Participants must attend entire session to receive all types of credit. CFMC hosts an online evaluation system, certificate and outcomes measurement process. Following the conference, you must link to CFMC’s online site (link below) to complete an evaluation form, in order to receive your continuing education statement of hours (certificate). Once the evaluation form is complete, you will automatically be sent a copy of your certificate via email. Continuing Education evaluation and request for certificates will be accepted up to 60 days post activity date. The Colorado Foundation of Medical Care (CFMC) will keep a record of attendance on file for 6 years. CFMC contact information: 303-695-3300, ext. 3139. Link address to evaluation form: www.yourcesource.com/eval?act=473!01222011 JOINT SPONSOR STATEMENT This Continuing Educational activity is Joint-sponsored by the Colorado Foundation for Medical Care, Office of Continuing Education and the Chicago Dermatological Society. CFMC is accredited by the ACCME to provide continuing medical education for physicians. GOAL/PURPOSE To broaden the clinical knowledge of dermatologists with respect to diagnostic. SESSION OBJECTIVES Upon completion of sessions, participants will be able to apply new knowledge and skills in the area of physician learning. After participating in this program, physicians should be able to: 1. Describe the rules pertaining to proper coding for dermatological services. 2. Discuss the importance of accurate chart documentation so that it accurately reflects care provided to a patient. 3. Demonstrate how a dermatologist can effectively integrate e-prescribing and electronic medical records into his/her practice. CREDIT STATEMENTS CME CREDIT This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through joint sponsorship of the Colorado Foundation for Medical Care, Office of Continuing Education (CFMC OCE) and Chicago Dermatological Society. CFMC is accredited by the ACCME to provide continuing medical education for physicians. Colorado Foundation for Medical Care designates this educational activity for a maximum of 4 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. CFMC has no financial responsibility for this activity. OTHER HEALTH CARE PROFESSIONALS This educational activity has been planned and implemented following the administrative and educational design criteria required for certification of health care professions continuing education credits. Registrants attending this activity may submit their certificate along with a copy of the course content to their professional organizations or state licensing agencies for recognition for 4 hours. DISCLOSURE STATEMENTS All members of the faculty and planning team have nothing to disclose nor do they have any vested interests or affiliations. It is the policy of the Colorado Medical Society and Colorado Foundation for Medical Care (CFMC) that the faculty discloses real or apparent conflicts of interest relating to the topics of the educational activity, and also discloses discussions of off-label uses of drugs and devices before their presentation(s). Acknowledgment Grateful acknowledgement is given to Chicago Dermatological Society exhibitors for their participation and support of this educational activity. Page 2 of 2 Dermatology Coding 101: The Basics Boot Camp . 1/20/2011 Dermatology Coding 101 + Chicago Derma to log ica l S oci et y Saturday, January 22, 2011 Faith C. M. McNicholas, CPC, CPCD, PCS, CDC Manager – Coding & Reimbursement/Govt. Affairs Objective ¾ Introduction to ICD-9-CM, CPT, HCPCS ¾ Understanding ICD-9-CM, CPT, HCPCS codebooks organization ¾ Classification and use of specific codes ¾ Guidelines ¾ Appropriate use of codes 2 What is ICD-9- CM? 9 International Statistical Classification of Diseases and Related Health Problems - 9th Revision 9 Alphanumeric statistical system for coding every disease, description of symptom, abnormal finding, complaint, social circumstance, external cause and cause of injury, disease or death afflicting human beings, as classified by the World Health Organization 3 1 1/20/2011 ICD-9- CM? Cont… 9 Provides code titles and language that complement accepted clinical practice in the U.S. 9 Includes the level of detail needed for morbidity classification and diagnostic specificity in the United States ICD-9-CM is maintained by the U.S. National Center for Health Statistics (NCHS) 4 ICD-9-CM Organization ¾ Introduction ¾ Valid Three-digit Code ¾ Official ICD-9-CM Table Conventions ¾ Coding Guidelines ¾ Additional ¾ Disease Classification: Convention Alphabetic Index ¾ Summary of Code ¾ Disease Classification: Changes Tabular List 5 Basic steps to ICD-9-CM Coding ¾ Alphabetic Index – Volume 2 9Identify reason for the encounter 9Always consult Alphabetic Index – Volume 2 – first 9Locate main entry term 6 2 1/20/2011 Basic steps to ICD-9-CM Coding ¾Alphabetic Index – Volume 2 cont’d 9Read and understand any notes listed with main diagnostic term 9Review modifying terminology 9Interpret symbols, abbreviations 7 ICD‐9‐CM Alphabetic Index 8 Basic steps to ICD-9-CM Coding ¾ Tabular List - Volume 1 9Refer to Tabular List for code selection 9Codes listed as three, four, five and alpha- numeric digits 9Pay close attention to ‘inclusion’ and ‘exclusion’ notes when selecting codes 9Note instructions that direct you to use alternative/additional codes 9 3 1/20/2011 ICD-9-CM Symbols Denotes revised text Denotes new line Denotes revised code th 4th 4 digit required th 5th 5 digit required Denotes exclusion Excludes Denotes inclusion Includes 10 ICD‐9‐CM Tabular List 11 General ICD-9-CM Coding ¾ Diagnostic codes to be assigned at their highest level of specificity ¾ Assign principal code to report reason for encounter ¾ Do not assign three-digit codes when four- or five-digit codes available in same category ¾ When definitive diagnosis is established, it’s not appropriate to report signs and symptoms code 12 4 1/20/2011 General ICD-9-CM Coding ¾ NEC - “Not elsewhere classifiable” –use only when information available specifies a condition that has no distinctive code ¾ Other Code - use when available information provides detail for which a specific code does not exist. ¾ NOS –“Not otherwise specified”/ Unspecified -use only when inadequate information to allow specific code assignment ¾ Includes, Excludes notes – defines or clarifies content of the chapter, category etc 13 General ICD-9-CM Coding ¾ Use additional code – when directed additional code required when information is available ¾ Code first the underlying disease –is a sequencing rule ¾ Casual condition first – code may be assigned as principal diagnosis ¾ Omit code – denotes no code assignment ¾ See condition – refer to main term 14 Pitfalls in ICD-9-CM Usage ¾ Avoid code overuse ¾ Avoid using generic codes ¾ Overuse of codes can build profiles ¾ Never use code as primary diagnosis when documented as ‘probable’, ‘suspected’, ‘questionable’ or ‘rule out’ 15 5 1/20/2011 Correct ICD-9-CM coding ¾ Code and report treated chronic conditions ¾ List ancillary diagnostic/therapeutic