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ACA Success Story in Southern Illinois


Laura Olmsted, a Certified Application Counselor (CAC), from Shawnee Health Services, had the great pleasure of helping Bill*, a 53 year old from Marion, Illinois, understand what the Affordable Care Act is all about.

Bill is a hardworking self-employed contractor -- making $23,000/year -- who works independent construction jobs, and has not been able to afford health insurance. However, health insurance is something that Bill desperately requires. In the past year and a half, he has suffered not one, but three heart attacks and a broken femur. Mounting medical bills are causing him incredible financial burden, and preventing him from accessing care that he needs.

Luckily, Bill recently met Laura, who helped him to complete an application on Healthcare.gov once he went through the Get Covered Illinois screener. Bill received great news: not only was he eligible for insurance, but he had options, ranging from the low end of paying nothing for a Bronze level or lower end Silver plan, to only $180 per month for a high-end Silver plan after the premium tax credit was factored in.

Laura’s client considered his choices and selected a Silver Multi-State plan through Blue Cross Blue Shield of Illinois where he pays only pocket change - $4.53 per month - for his premium. The plan has a $250 deductible and an out of pocket max of only $2,000 per year. Bill plans to pay for the premiums up front since the price was so affordable.

Should Bill have looked into buying health insurance prior to the enactment of Obamacare (the Affordable Care Act), he would have encountered a very different situation:

  • No certified enrollment specialist would have helped him find and understand his health insurance options;
  • Unless he was connected with an insurance broker, Bill would have had to shop for plans on his own, rather than being able to compare them all in one place;
  • No tax credits or subsidies would be available to help him afford his premium;
  • Bill may have been denied coverage based upon pre-existing conditions; and
  • If Bill did find coverage, prior to Oct. 1 of this year, he likely would have found a plan with higher premiums and without the requisite 10 essential health benefits like the qualified health plan that he recently purchased.
Because of his new options through the Illinois Health Insurance Marketplace, Bill will now be able to receive the health care necessary to get well, and continue living a healthy, productive life in Illinois.
 
(*Bill is a fictional name to protect the client's anonymity)

99205 CPT® Code Description, Progress Notes, RVU, Distribution.

This 99205 CPT® lecture reviews the procedure code definition, progress note examples, RVU values, national distribution data and explains when this code should be used in the clinic and hospital setting. CPT stands for Current Procedural Terminology. This code is part of a family of medical billing codes described by the numbers 99201-99205.  CPT® 99205 represents the high (level 5) office or other outpatient new patient visit and is part of the Healthcare Common Procedure Coding System (HCPCS). After you're done studying this lecture, make sure to also review the lectures on level three  and level four new patient office visits.  A patient is considered outpatient until inpatient admission to a healthcare facility occurs.  This procedure code lecture for new office patient visits is part of a complete series of CPT® lectures written by myself, a board certified internal medicine physician with over ten years of clinical hospitalist experience in a large community hospitalist program. I have written my collection of evaluation and management (E/M) lectures over the years to help physicians and non-physician practitioners (nurse practitioners, clinical nurse specialists, certified nurse midwives and physician assistants) understand the complex criteria needed to stay compliant with the Centers for Medicare & Medicaid Services (CMS) and other third party insurance companies.

You can find my entire collection of  medical billing and coding CPT® lectures together in one place on my Pinterest site (CPT® lectures here and other associated E/M lectures here).  You don't need to be a Pinterest member to get access to any of my CPT® procedure lectures. As you gain understanding of these E/M procedure codes, remember you have an obligation to make sure your documentation supports the level of service you are submitting for payment. The volume of your documentation should not be used to determine your level of service. The details of your documentation are what matter most. In addition, the E/M services guide says the care you provide must be "reasonable and necessary" and all entries should be dated and contain a CMS defined legible signature or signature attestation, if necessary.

99205 MEDICAL CODE DESCRIPTION


My interpretations discussed below are based on my review of the 1995 and 1997 E&M guidelines, the CMS E&M guide and the Marshfield Clinic audit point system for medical decision making.  These resources can be found in my hospitalist resources section.  The Marshfield Clinic point system is voluntary for Medicare carriers but has become the standard audit compliance tool in many parts of the country.  You should check with your own Medicare carrier in your state to verify whether or not they use a different criteria standard than that for which I have presented here in my free educational discussion.  I recommend all readers obtain their own updated CPT® reference book as the definitive authority on CPT® coding.  I have provided access through Amazon to the 2015 CPT® standard edition pictured below and to the right. CPT® 99205 is an office or other outpatient procedure code and can be used by any qualified healthcare practitioner to get paid for their office or other outpatient new patient services.  The American Medical Association (AMA) describes the 99205 CPT® procedure code as follows:
Office or other outpatient visit for the evaluation and management of a new patient, which requires these three components: A comprehensive history; A comprehensive examination;  Medical decision making of high complexity.  Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.  Usually, the presenting problem(s) are of moderate severity.  Physicians typically spend 60 minutes face-to-face with the patient and/or family.
A new patient is defined as a patient who has not received professional services from a doctor or another doctor of the exact same specialty and subspecialty who belonged to the same group practice within the past three years.  This definition of a new patient was updated in 2012.

This medical billing code can be used for time based billing when certain requirements are met.  However, documentation of time is not required to remain compliant with CMS regulations.  If billed without time as a consideration, CPT® 99205 documentation should comply with the rules established  by the 1995 or 1997 guidelines referenced above. The three important coding components for an new patient office or other outpatient visit are the:
  1. History
  2. Physical Exam
  3. Medical Decision Making Complexity (MDM)
For all new patient office or other outpatient visit codes (99201-99205), the highest documented three out of three above components determines the correct level of service code.    Stated another way, the lowest level of documentation from history, physical or medical decision making complexity will determine the overall appropriate level of E/M service in this code group.   This is different from the established patient (99211-99215) rules, which require just the  highest documented two out of three above components.

In order to appropriately code a level 5 (99205) new patient office visit, all three components (history, physical and MDM complexity) must achieve level five status.  What are the absolute minimum requirements for this level five visit?  These requirements are discussed below.  In addition, as with all E/M encounters, a face-to-face encounter is always required.  However, in the case of outpatient clinic codes, Medicare does allow incident to billing, where the the service is provided by someone other than the physician.  If certain requirements are met, the physician may collect 100% of allowable charges in these situations.  Services billed incident to are billed under the physician's provider number.
  • Comprehensive history:  Requires four or more elements of  the history of present illness (HPI) OR documentation of the status of three chronic medical conditions.  It also requires least one item each from past history (illnesses, operations, injuries, treatments), social history and family history.  In addition, a complete review of systems is also required (10 or more organ systems) as well. 
  • Comprehensive examination:  The CMS E&M services guide on pages 31 and 32 describes the acceptable body areas and organ systems for physical exam.  Either a general multi-system examination or complete examination of a single organ system (with other symptomatic or related body area(s) or organ system(s) --1997 guidelines) is acceptable.  For a general multi-system examination,  1997 guidelines require documentation of at least two bullets each in at least nine organs systems or body areas (described on pages 52-55 in E/M services guide) while 1995 guidelines require findings from about 8 or more of the 12 organ systems, not otherwise specified.  Requirements for a complete single organ exam are discussed in the  E/M services guide from pages 57-82. 
  • Medical decision making of high complexity (MDM):  This is split into three components. The 2 out of 3 highest levels in MDM are used to determine the overall level of MDM. The level is determined by a complex system of points and risk. What are the three components of MDM and what are the the minimum required number of points and risk level as defined by the Marshfield Clinic audit tool? 
    • Diagnosis (4 points) 
    • Data (4 points) 
    • Risk (high); The risk table can be found on page 37.
    The medical decision making point system is highly complex. I have referenced it in detail on my E/M pocket cards described below. These cards help me understand what level of service my documentation supports. I carry these cheat sheet cards with me at all times and reference them all day long.  As a hospitalist who performs E/M services almost exclusively, these cards have prevented me from under and over billing thousands of times over the last decade.

    CLINICAL EXAMPLES OF CPT® 99205


    What are some progress note documentation examples for a CPT® 99205, the level 5 new patient visit in an office or other outpatient setting?  Although not required, many doctors use the subject, objective, assessment and plan (SOAP) note format for their documentation.  A CPT® 99205 note could  look like this:
    Subjective:  Abdominal pain.  RLQ.  Started yesterday.  Constant.  3/10.  Associated fever yesterday now resolved  (at least 4 HPI).  No nausea, chest pain, dizziness, shortness of breath.  In the absence of these pertinent positives and negatives, all other ROS were reviewed and were otherwise negative (at least 10 ROS ).  Nonsmoker.  No personal history of colitis.  No family history of colitis.   (at least one element each from 3 of 3 past history, social and family)
    Objective:   120/80   80    Tmax 98.9 (three vital signs = one bullet)  alert, memory intact, no acute distress, no icterus, pupils symmetric, poor dentition, oropharynx normal, no thyroid masses, trachea midline, no neck adenopathy, no groin adenopathy, normal respiratory effort, normal breath sounds, normal heart tones without murmur or JVD, no leg edema, positive bowel tones, no guarding RLQ, no palpable masses or organomegally, no skin rashes, no induration.  (at least 2 bullets each in nine areas/systems)
    Assessment:   1) Abdominal Pain RLQ (4 points for diagnosis, new problem, more work-up planned)
    Plan:    Check CBC, CT scan abdomen today.  (2 points for data, one point each for ordering lab and radiology).  I discussed case details personally with Dr XYZ regarding the potential need for surgical consultation.  They will evaluate in their office after the CT is performed. (2 points for data).
    In this example, the  history (subjective), physical (objective) and MDM (assessment and plan) components all meet the minimum requirements to get paid for a 99205 new patient outpatient clinic visit based on the definition of this CPT® code detailed above.  Both the history and physical are comprehensive.  Medical decision making is high complexity because two of the three components in MDM meet the threshold for overall high complexity.  Diagnosis is 4 points (high complexity), data is 4 points (high complexity) and risk is moderate based on an undiagnosed new problem with uncertain prognosis or acute illness with uncertain prognosis.    Since two out of three are at least high, the overall MDM is high.  Choosing high risk is appropriate because two out of three components of MDM did reach high complexity status based in the E/M rules. 

    Remember, the code group (99201-99205) requires all three elements (history, physical, MDM) to meet the minimum level of service as opposed to the outpatient established code group (99211-99215) which has the two out of three requirement.  Stated another way, the lowest level of documentation from history, physical and MDM will determine the overall appropriate level of service for new clinic patient evaluations.    If the MDM and physical meet criteria for 99205 but the history only meets the criteria for a 99203 visit,  then 99203 is the correct code to choose for the visit.  Taken to the extreme, if the MDM and the physical exam both meet criteria for 99205 but the history only meets the criteria for a 99201 evaluation, then the correct code to choose is 99201.  Here is another example of an appropriately coded 99205 new patient office visit:
    History:  Cough resolved last week after stopping ACE inhibitor.  No SOB.  No CP.  Complains of headache 7/10 started yesterday.  All other systems reviewed and negative. (10 ROS allowed due to this notation)   History of COPD present.  Smoking, no interest in quitting.  No FH of lung cancer. (one element each from past history, family and social)
    Physical Exam:   210/90  90  Tmax 98.9 (three vital signs = one bullet)  alert, memory intact, no acute distress, no icterus, pupils symmetric, poor dentition, oropharynx normal, no thyroid masses, trachea midline, no neck adenopathy, no groin adenopathy, normal respiratory effort, normal breath sounds, no crackles or wheezes, normal heart tones without murmur, no JVD, no leg edema, positive bowel tones, no guarding, no palpable masses or organomegally, no skin rashes, no induration, no weakness on  neurological exam.  (at least 2 bullets each in nine areas/systems)
    Assessment:  HTN-worse with numbness and headache. Suspect malignant HTN. See med changes.
         DM-stable, no changes planned.     
         COPD with resolved cough-stable, no changes planned.  (the status of three chronic medical conditions in place of HPI) (4 points for diagnosis-  see discussion below)
    Plan:  Give dose of clonidine now.  Start ARB for HTN. (moderate risk for prescription drug management).  Go to the ER to rule out head bleed.  Consider admission to hospital. 
    As you know, documenting the status of three chronic medical conditions can substitute for the HPI.  Add in at least 10 additional review of systems and one element each from past history, family and social elements and the minimum history documentation required for CPT® 99205 has been met.  The physical exam meets the comprehensive requirement with at least two bullets in each of nine areas or systems.  All physical exam components offer value to the encounter to exclude potential complications of therapy or to search for evidence of decompensated disease.

    The MDM is high complexity.  This progress note documentation gets four diagnosis points for a new problem (headache) with more work up planned.  In addition,  this represents high risk on the risk table for chronic illness (HTN) with severe exacerbation, progression or side effects.  The data component of medical decision making is irrelevant as only two out of three components for MDM require high complexity status within MDM. These complexities are displayed on my bedside E/M reference card shown below.  The highest two out of three components for MDM are of  high complexity and therefore this overall documentation supports CPT® 99205.  Below is another example of a new patient 99205 office visit:
    S:   HA present 3/10,  for 3 days and constant.  Associated with double vision (at least 4 HPI)   No fever, no neck stiffness, no nausea/vomiting. No chest pain or SOB.  All other systems reviewed and negative. (at least 10 ROS based on this notation) No history of migraines.  Nonsmoker.  No FH brain cancer. (one element each from past history, social and family elements)
    O: 120/80  90  Tmax 98.9 (three vital signs = one bullet), no head trauma, alert, memory intact, no acute distress, no icterus, pupils symmetric, EOMI, poor dentition, oropharynx normal, no thyroid masses, trachea midline, no neck adenopathy, no groin adenopathy, normal respiratory effort, normal breath sounds, no crackles or wheezes, normal heart tones without murmur, no JVD, no leg edema, positive bowel tones, no guarding, no palpable masses or organomegally, no skin rashes, no induration, normal neurological exam.  (at least 2 bullets each in nine areas/systems)
    A:  Acute HA wit double vision.    No history of chronic headaches (one new problem with more work up planned and of uncertain prognosis is 4 points on MDM for diagnosis)
    P: Check CBC/BMP.  I called the neurologist and personally discussed case details with them today.  They recommended an MRI today and to follow up in their office after it's done in the next day or two.  (4 points for date with 1 point for lab, 1 point for MRI and 2 points for discussing case with another healthcare provider).
    This new patient outpatient evaluation is appropriate for CPT® 99205 as the history, physical and MDM all contain the necessary documentation based on the Marshfield Clinic audit tool.  Medical decision making is high because the diagnosis element is high complexity (4 points for new diagnosis with more work-up planned) and the data element is high complexity (4 points for ordering lab, MRI and discussing the case).  A risk table assessment is not necessary as high complexity is already defined.  Therefore, the highest two out of three elements in MDM are high. Here is another progress note example of a level 5 new patient office visit:
    S:   48 year old male here to establish care.  /SOB/N/V/HA.  No neuropathy. No polyuria or polydypsia.  Average blood sugar reading 145.  Occasional chest pain with exertion.  Better with rest.  Good exercise tolerance. All other systems reviewed and negative. (at least 10 ROS based on this notation) Nonsmoker.  No family history of CAD.  Diabetes type II for 10 years. (one element each from past history, family and social elements)
    O:  120/80  90  Tmax 98.9 (three vital signs = one bullet), no head trauma, alert, memory intact, no acute distress, no icterus, pupils symmetric, poor dentition, oropharynx normal, no thyroid masses, trachea midline, no neck adenopathy, no groin adenopathy, normal respiratory effort, normal breath sounds, no crackles or wheezes, normal heart tones without murmur, no JVD, no leg edema, positive bowel tones, no guarding, no palpable masses or organomegally, no skin rashes, no induration, normal neurological exam.  (at least 2 bullets each in nine areas/systems)
    A: 1) HTN, controlled, no changes planned.  2) DM II, uncontrolled. 3) CAD, with stable angina. 4)  COPD stable no changes planned.  (4 points on MDM for diagnosis and substituting three chronic medical conditions for HPI)
    P:  Increase Metformin from daily to BID dosing. (moderate risk for prescription drug management).  Order Echo (1 point in data for ordering echo). Check CBC (1 point in data for ordering lab).  EKG done.  Tracing personally reviewed.  No ST or TW changes at rest.  Sinus rhythm ( 2 points in data for independent visualization of tracing).
    Both the history and physical meet minimum criteria for CPT® 99205 with comprehensive requirements documented for both.  Medical decision making is high based on a 4 points for both the diagnosis and data components.  The moderate risk table assessment does not apply.  Remember, the highest two out of three elements from data, diagnosis and risk determines the overall level of MDM complexity.  

    USING NEW PATIENT CLINIC CODES IN THE HOSPITAL SETTING


    The CPT® medical billing code group 99201-99205 should used by Hospitalists and other physicians or non-physician practitioners in the hospital setting under certain circumstances.  I have previously discussed all the possible initial encounter codes that could be used in the hospital setting.  These new patient clinic and other outpatient visit codes are included as possibilities.  I have provided a detailed discussion of  that decision tree analysis at the link provided just above.  However, I will discuss the pertinent portions of that analysis here.

    For patients admitted observation status, the attending physician should choose from the observation group of medical codes 99218-99220 for the initial encounter, 99224-99226 for observation status follow-up codes, and 99217 for observation discharge.  Under certain situations, same day admit and discharge billing codes 99234-99236 or critical care procedure codes may also apply too.  This is not the case for consultants taking care of observation status patients.  What codes should a consultant use in an observation status situation?  This is where the correct code decision can get very complicated.  Medicare no longer recognizes consult procedure codes.  Consultants should pick the appropriate level of service from the new outpatient clinic code group 99201-99205 as their initial encounter, but only IF the patient has NOT been seen previously  by the physician or a physician partner of theirs in the same group and exact same specialty and subspecialty within the previous three years.  Alternatively, critical care codes can be used instead if documentation supports their use.

    If the patient HAS been seen in the last three years by the same physician or partner physician in the same group and exact same specialty and subspecialty, the consultant should use the established patient clinic code group 99211-99215 on their initial date of service and continue to use that code group for all subsequent observation services, including the day of discharge.  Remember, all hospital observation CPT® code groups are reserved only for the attending physician.  If a patient qualifies as a new patient but clinician documentation does not support any code from the code group 99201-99205 (usually because of the three out of three documentation requirement), then it is appropriate to instead choose a code from the established patient code group (99211-99215) that meets documentation requirements.  This guidance has previously been confirmed by Medicare carriers. 

    The above discussion relates to Medicare because Medicare does not accept consult codes.  Other insurances may still accept consultation codes.  In those cases, the consultant should chose a level of service from medical code group 99241-99245 (outpatient consult codes) as the initial encounter and then pick a billing code from the established patient clinic codes 99211-99215 for all subsequent care visits, including the day of discharge,  while the patient is hospitalized for observation services.  If the patient is formally admitted inpatient, the consultant should use the inpatient subsequent care codes 99231-99233 for all subsequent face-to-face encounters.


    DISTRIBUTION OF NEW PATIENT OFFICE OR OTHER OUTPATIENT VISIT CODES (99201-99205)


    What is the distribution of CPT® code 99205 relative to other levels of service in this medical code group? The chart below was published in May, 2012 by the OIG in a report titled Coding Trends of Medicare Evaluation and Management Services on page 21.  As you can see, between 2001 and 2010, the distribution of new patient office visits 99204 and 99205 has shifted higher (an increase of 12% and 4% respectively) while the  proportion of level three 99203 has remained constant with no change from 2001-2010.  In 2010, CPT® code 99205 represented 13% of all services from code group 99201-99205.

    CPT 99201-99205 services distribution chart 2001-2010

    Here is data from the most recent 2011 CMS Part B National Procedure Summary Files data (2011 zip file) showing how many CPT® 99205 encounters were billed and the dollar value of their services for Part B Medicare.    As you can see in the image below, E/M code 99205 was billed 3,146,795 times in 2011 with allowed charges of $613,063,429.79 and payments of $455,593,105.78.   

    2011 National Part B Summary File 99201-99205 CMS 2011


    RVU VALUE


    How much money does a CPT® 99205 pay in 2016?  That depends on what part of the country you live in and what insurance company you are billing.  E/M procedure codes, like all CPT® billing codes, are paid in relative value units (RVUs).  This complex RVU discussion has been had elsewhere on The Happy Hospitalist.  For raw RVU values, a CPT® 99205 is worth 4.77 total RVUs for facility services and 5.82 total RVUs for non-facility.  The work RVU for 99205 is valued at 3.17.  A complete list of RVU values on common hospitalist E/M codes is provided at the provided link.  What is the Medicare reimbursement for CPT® code 99205?  In my state, a CPT® 99205 pays just under $160 (facility) and just over $193 (non-facility) in 2016. The dollar conversion factor for one RVU in 2014 is $35.8043.

    My coding card taught me that I should be billing for the work I'm providing and it has taught me how to document appropriately. You can see many more of my E/M lectures by clicking through on the provided link. If you need bedside help determining what level of care you have provided, I recommend reviewing the pocket card described below.


    		LINK TO E/M BEDSIDE POCKET REFERENCE CARD POST

    EM Pocket Reference Cards Using Marshfield Clinic Point Audit

    Click image for high definition view




    DOI Moves to Allow Consumers to Continue Current Coverage into 2014

    Get Coverage Illinois℠ The Official Health Marketplace

    The Illinois Department of Insurance (DOI) announced on November 22 that it will follow President Obama’s November 14 recommendation and allow insurance companies to renew a number of health plans in the individual and small group markets that do not meet certain Affordable Care Act (ACA) requirements without being penalized. Illinois joins Florida, North Carolina, Ohio, Kentucky, Kansas, Oregon, South Carolina, Colorado, Hawaii and Texas in giving insurance companies the choice to renew existing health insurance policies with current policyholders.

    “DOI came to this decision based on the concerns raised by Illinois consumers and the guidance from the U.S. Department of Health and Human Services,” Andrew Boron, Director of the Illinois Department of Insurance said. “Allowing companies to renew current plans gives consumers more time to evaluate their options and will provide a smoother transition into the health care coverage system envisioned by the ACA.”

    DOI will immediately work with insurance companies who choose to extend the terminated or cancelled coverage to quickly renew such policies. In step with President Obama’s announcement, policies in effect on Oct. 1, 2013, in the individual or small group market, can be renewed for a policy year starting between Jan. 1, 2014, and Oct. 1, 2014.

    According to notifications received by DOI, approximately 185,340 people in Illinois have been advised by insurers so far in 2013 that their coverage has been cancelled or terminated. DOI’s most recent data indicate that more than 476,000 Illinois residents were insured by private individual policies in 2012.

    Today’s announcement was made on the same day that federal authorities pushed back the deadline for enrolling in a plan that begins on Jan. 1, from Dec. 15 to Dec. 23. The change gives people eight additional days in which to consider their options.

    For Illinois consumers, the ability to renew plans will depend on their insurance company’s decision of whether or not to exercise this option. Consumers should contact their local insurance agent to discuss what options are available to them.

    In addition, according to the federal government, any insurance company choosing to renew a non-compliant plan in 2014 should notify consumers that they can purchase coverage through the Health Insurance Marketplace where they may qualify for federal financial assistance, which may include premium tax credits for small employers and other subsidies for individual consumers. This notice should also advise consumers about the protections under the ACA they are foregoing by renewing their current plans including certain Essential Health Benefits that may not be offered through existing plans. Such protections will be required in plans being sold in the Health Insurance Marketplace.

    Insurance companies will not be permitted to sell any new plans after December 31, 2013 that do not meet ACA standards. Consumers seeking healthcare coverage should continue to visit http://getcoveredillinois.gov to learn about new health insurance options available through the Marketplace. Those who may consider keeping their current policy should compare it with new plans offered through the Marketplace which cover more benefits, sometimes at a lower cost. DOI is also recommending consumers that have questions regarding differences between a continuation of their current coverage and benefits afforded to them through a plan on the Health Insurance Marketplace to call DOI’s Office of Consumer Health Information at (877) 527-9431.

    The following insurers have received approval to offer coverage through the Illinois Health Insurance Marketplace:

    Aetna Life Insurance Company
    Coventry Health and Life Insurance Company
    Coventry Health Care of Illinois, Inc.
    Health Alliance Medical Plans, Inc.
    Health Care Service Corporation, a Mutual Legal Reserve Company (Blue Cross)
    Humana Health Plan, Inc.
    Humana Insurance Company
    Land of Lincoln Mutual Health Insurance Company

    “Making certain that Illinois residents have access to quality affordable health care remains one of our top priorities,” continued Boron. “Today’s actions reinforce our commitment to a culture of coverage.”

    Republished from Get Covered Illinois News

    An Illinois Navigator's Experience Finding Lower Premiums in the Marketplace

    I decided I might as well enroll myself with a Qualified Health Plan on the Marketplace before I sat down as an In Person Counselor (with a client) so I tried for a few days right after Oct. 1.

    Since the site was so slow, I decided to wait until some of the excitement wore off and tried again in mid-October. I sat down after dinner and put in an hour on the computer. I quickly verified my identity, similar to the online process for requesting your free credit report. I answered simple questions about what streets I have lived on, former cities I lived in, etc. They were all multiple choice questions, and I got them all right!

    Then I was able to compare the plans for my county and sort them based on certain features: metal, HSA eligible, out-of-pocket costs, etc. At that point there are fewer plans to choose from and I checked off the "compare box" on three that I thought seemed to be a good fit. After looking at the plans, side by side I was able to click on a link with each that took me to the website for each plan so I could do a provider search. I entered my current doctor and to see if my doctor was in-network. This made it pretty easy for me to decide. The pages did load slowly so I folded laundry while they loaded.

    Once I enrolled in health coverage, I had to decide to elect or not to elect to access dental. I went through the same process with the dental coverage, but did find that the links did not work for all the dental plans. I eventually decided on a plan and enrolled. Then I put the laundry away while it loaded and waited.

    At the end, I got the page where it said my application was complete. I printed out the page along with my application ID# and am excited to let people know that my premiums are going down!

    I self-pay for insurance now and will still do so in 2014. I currently pay just over $340 a month for health and dental. Starting in January, I will only pay $185.10 for health and dental. I make too much money for any tax subsidy, so even without assistance I am seeing a huge benefit. I still get to see the same doctor and dentist that I have had since I was a kid and really cannot complain too much. Buying insurance before privately took more time as I would have to research and deal with the insurance brokers and then the underwriters questioning of any of my possible health issues.

    I look forward to helping my clients find affordable options on the Marketplace, too.

    Joann Boblick
    Certified In Person Counselor
    La Grange, IL

    Clearing up the Facts

    There has been a lot of confusion about some recent notices to consumers from insurance companies that sell coverage in the individual insurance market, and I’d like to clear up the facts.

    Today, more than 3 out of every 4 Americans get insurance from an employer, Medicare, Medicaid, or the Veterans Benefits Administration. Americans who purchase insurance on their own, however, generally buy coverage in the individual insurance market.

    Before the Affordable Care Act, coverage in the individual market often was unaffordable, had high co-pays or deductibles, or lacked basic benefits like maternity care, mental health services, and prescription drug coverage. These plans also had high turnover rates, and often were not renewed at the end of a plan year. One study showed that more than half of enrollees in the individual market left their plan within a year.

    The health care law is creating new protections for people in the individual market, as well as strengthening employer-based coverage. In the Health Insurance Marketplace, consumers will no longer be charged more because of gender or a pre-existing condition, recommended preventive services will be covered with no additional out of pocket cost, there will be caps on out of pocket costs, and plans will have to offer a basic package of 10 categories of essential health benefits.

    Some insurance companies that sell products in the individual market are making changes to their plans. Plans that were in place before the Affordable Care Act passed, and that essentially have not changed - that is benefits have not been cut or additional costs imposed on consumers - are exempt or “grandfathered” out of these basic requirements that ensure quality coverage. Those grandfathered plans can stay the same. Nothing has changed this fact, and that coverage can continue into 2014, so long as both the insurance company and the consumer agree that it will continue.

    Some of less than 5 percent of Americans who currently get insurance on the individual insurance market have recently received notices from their insurance companies suggesting their plans may no longer exist. These Americans have a choice – they can choose a plan being offered by their insurer, or they can shop for coverage in the Marketplace. As insurers have made clear – they aren’t dropping consumers; they’re improving their coverage options, often offering plans that are more affordable.

    Today, consumers have a choice of an average of 53 qualified health plans in the states where the federal government runs the Marketplace, including those in which it does so in partnership with states. Nearly all consumers live in states with average premiums below earlier estimates. Moreover, half of the people in the individual market today qualify for lower costs on monthly premiums when signing up for coverage through the Marketplace.

    While the product is good, there is no denying the online experience on HealthCare.gov must be improved. We will not stop improving the site until every American that wants it has access to quality, affordable coverage.

    Importantly, while the team is improving the site, we have opened up new pathways for consumers to apply for coverage through the Marketplace. There are four basic ways to apply for coverage. Sign up by December 15 for coverage that starts January 1, 2014. Enrollment stays open until March 31.

    By Kathleen Sebelius, Secretary of Health and Human Services
    Posted     October 30, 2013 on the HHS.gov blog


    99204 CPT® Code Description, Progress Notes, RVU, Distribution.

    This 99204 CPT® lecture reviews the procedure code definition, progress note examples, RVU values, national distribution data and explains when this code should be used in the clinic and hospital setting. CPT stands for Current Procedural Terminology. This code is part of a family of medical billing codes described by the numbers 99201-99205.  CPT® 99204 represents the mid-high (level 4) office or other outpatient new patient visit and is part of the Healthcare Common Procedure Coding System (HCPCS). After you're done studying this lecture, make sure to also review the lecture on mid level office visits  (CPT® 99203).  A patient is considered outpatient until inpatient admission to a healthcare facility occurs.  This procedure code lecture for new office patient visits is part of a complete series of CPT® lectures written by myself, a board certified internal medicine physician with over ten years of clinical hospitalist experience in a large community hospitalist program. I have written my collection of evaluation and management (E/M) lectures over the years to help physicians and non-physician practitioners (nurse practitioners, clinical nurse specialists, certified nurse midwives and physician assistants) understand the complex criteria needed to stay compliant with the Centers for Medicare & Medicaid Services (CMS) and other third party insurance companies.

    You can find my entire collection of  medical billing and coding CPT® lectures together in one place on my Pinterest site (CPT® lectures here and other associated E/M lectures here).  You don't need to be a Pinterest member to get access to any of my CPT® procedure lectures. As you gain understanding of these E/M procedure codes, remember you have an obligation to make sure your documentation supports the level of service you are submitting for payment. The volume of your documentation should not be used to determine your level of service. The details of your documentation are what matter most. In addition, the E/M services guide says the care you provide must be "reasonable and necessary" and all entries should be dated and contain a CMS defined legible signature or signature attestation, if necessary.

    99204 MEDICAL CODE DESCRIPTION


    My interpretations discussed below are based on my review of the 1995 and 1997 E&M guidelines, the CMS E&M guide and the Marshfield Clinic audit point system for medical decision making.  These resources can be found in my hospitalist resources section.  The Marshfield Clinic point system is voluntary for Medicare carriers but has become the standard audit compliance tool in many parts of the country.  You should check with your own Medicare carrier in your state to verify whether or not they use a different criteria standard than that for which I have presented here in my free educational discussion.  I recommend all readers obtain their own updated CPT® reference book as the definitive authority on CPT® coding.  I have provided access through Amazon to the 2015 CPT® standard edition pictured below and to the right. CPT® 99204 is an office or other outpatient procedure code and can be used by any qualified healthcare practitioner to get paid for their office or other outpatient new patient services.  The American Medical Association (AMA) describes the 99204 CPT® procedure code as follows:
    Office or other outpatient visit for the evaluation and management of a new patient, which requires these three components: A comprehensive history; A comprehensive examination;  Medical decision making of moderate complexity.  Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.  Usually, the presenting problem(s) are of moderate severity.  Physicians typically spend 45 minutes face-to-face with the patient and/or family.
    A new patient is defined as a patient who has not received professional services from a doctor or another doctor of the exact same specialty and subspecialty who belonged to the same group practice within the past three years.  This definition of a new patient was updated in 2012.

    This medical billing code can be used for time based billing when certain requirements are met.  However, documentation of time is not required to remain compliant with CMS regulations.  If billed without time as a consideration, CPT® 99204 documentation should comply with the rules established  by the 1995 or 1997 guidelines referenced above. The three important coding components for an new patient office or other outpatient visit are the:
    1. History
    2. Physical Exam
    3. Medical Decision Making Complexity (MDM)
    For all new patient office or other outpatient visit codes (99201-99205), the highest documented three out of three above components determines the correct level of service code.    Stated another way, the lowest level of documentation from history, physical or medical decision making complexity will determine the overall appropriate level of E/M service in this code group.   This is different from the established patient (99211-99215) rules, which require just the  highest documented two out of three above components.

    In order to appropriately code a level 4 (99204) new patient office visit, all three components (history, physical and MDM complexity) must achieve level four status.  What are the absolute minimum requirements for this level four visit?  These requirements are discussed below.  In addition, as with all E/M encounters, a face-to-face encounter is always required.  However, in the case of outpatient clinic codes, Medicare does allow incident to billing, where the the service is provided by someone other than the physician.  If certain requirements are met, the physician may collect 100% of allowable charges in these situations.  Services billed incident to are billed under the physician's provider number.
    • Comprehensive history:  Requires four or more elements of  the history of present illness (HPI) OR documentation of the status of three chronic medical conditions.  It also requires least one item each from past history (illnesses, operations, injuries, treatments), social history and family history.  In addition, a complete review of systems is also required (10 or more organ systems) as well. 
    • Comprehensive examination:  The CMS E&M services guide on pages 31 and 32 describes the acceptable body areas and organ systems for physical exam.  Either a general multi-system examination or complete examination of a single organ system (with other symptomatic or related body area(s) or organ system(s) --1997 guidelines) is acceptable.  For a general multi-system examination,  1997 guidelines require documentation of at least two bullets each in at least nine organs systems or body areas (described on pages 52-55 in E/M services guide) while 1995 guidelines require findings from about 8 or more of the 12 organ systems, not otherwise specified.  Requirements for a complete single organ exam are discussed in the  E/M services guide from pages 57-82. 
    • Medical decision making of moderate complexity (MDM):  This is split into three components detailed below.  The two out of three highest levels in MDM are used to determine the overall level of MDM.  The individual levels are determined by a complex system of points and risk. What are the three components of MDM and what are the the absolute minimum required number of points and risk level as defined by the Marshfield Clinic audit tool? 
      • Diagnosis (3 points) 
      • Data (3 points) 
      • Risk (moderate); The risk table can be found on page 37. 
      The medical decision making point system is highly complex. I have referenced it in detail on my E/M pocket cards described below. These cards help me understand what level of service my documentation supports. I carry these cheat sheet cards with me at all times and reference them all day long.  As a hospitalist who performs E/M services almost exclusively, these cards have prevented me from under and over billing thousands of times over the last decade.

      CLINICAL EXAMPLES OF CPT® 99204


      What are some progress note documentation examples for a CPT® 99204, the level 4 new patient visit in an office or other outpatient setting?  Although not required, many doctors use the subject, objective, assessment and plan (SOAP) note format for their documentation.  A CPT® 99204 note could  look like this:
      Subjective:  Abdominal pain.  RLQ.  Started yesterday.  Constant.  3/10.  Associated fever yesterday now resolved  (at least 4 HPI).  No nausea, chest pain, dizziness, shortness of breath.  In the absence of these pertinent positives and negatives, all other ROS were reviewed and were otherwise negative (at least 10 ROS ).  Nonsmoker.  No personal history of colitis.  No family history of colitis.   (at least one element each from 3 of 3 past history, social and family)
      Objective:   120/80   80    Tmax 98.9 (three vital signs = one bullet)  alert, memory intact, no acute distress, no icterus, pupils symmetric, poor dentition, oropharynx normal, no thyroid masses, trachea midline, no neck adenopathy, no groin adenopathy, normal respiratory effort, normal breath sounds, normal heart tones without murmur or JVD, no leg edema, positive bowel tones, no guarding RLQ, no palpable masses or organomegally, no skin rashes, no induration.  (at least 2 bullets each in nine areas/systems)
      Assessment:   1) Abdominal Pain RLQ (4 points for diagnosis, new problem, more work-up planned)
      Plan:    Check CBC, CT scan abdomen today.  (2 points for data, one point each for ordering lab and radiology)
      In this example, the  history (subjective), physical (objective) and MDM (assessment and plan) components all meet the minimum requirements to get paid for a 99204 new patient outpatient clinic visit based on the definition of this CPT® code detailed above.  Both the history and physical are comprehensive.  Medical decision making is moderate complexity because two of the three components in MDM meet the threshold for overall moderate complexity.  Diagnosis is 4 points (high complexity), data is 2 points (low complexity) and risk is moderate based on an undiagnosed new problem with uncertain prognosis or acute illness with uncertain prognosis.    Since two out of three are at least moderate, the overall MDM is moderate.  Choosing high risk is not appropriate because two out of three components of MDM did not reach high complexity status based in the E/M rules.  Choosing low risk is not appropriate because at least two MDM elements were of moderate complexity or higher.

      Remember, the code group (99201-99205) requires all three elements (history, physical, MDM) to meet the minimum level of service as opposed to the outpatient established code group (99211-99215) which has the two out of three requirement.  Stated another way, the lowest level of documentation from history, physical and MDM will determine the overall appropriate level of service for new clinic patient evaluations.    If the MDM and physical meet criteria for 99204 but the history only meets the criteria for a 99202 visit,  then 99202 is the correct code to choose for the visit.  Taken to the extreme, if the MDM and the physical exam both meet criteria for 99205 but the history only meets the criteria for a 99201 evaluation, then the correct code to choose is 99201.  Here is another example of an appropriately coded 99204 new patient office visit:
      History:  Cough resolved last week after stopping ACE inhibitor.  No SOB.  No CP.  All other systems reviewed and negative. (10 ROS allowed due to this notation)   History of COPD present.  Smoking, no interest in quitting.  No FH of lung cancer. (one element each from past history, family and social)
      Physical Exam:   150/90  90  Tmax 98.9 (three vital signs = one bullet)  alert, memory intact, no acute distress, no icterus, pupils symmetric, poor dentition, oropharynx normal, no thyroid masses, trachea midline, no neck adenopathy, no groin adenopathy, normal respiratory effort, normal breath sounds, no crackles or wheezes, normal heart tones without murmur, no JVD, no leg edema, positive bowel tones, no guarding, no palpable masses or organomegally, no skin rashes, no induration, normal neurological exam.  (at least 2 bullets each in nine areas/systems)
      Assessment:  HTN-worse, see med changes.
           DM-stable, no changes planned.     
           COPD with resolved cough-stable, no changes planned.  (the status of three chronic medical conditions in place of HPI) (4 points for diagnosis-  see discussion below)
      Plan:  Start ARB for HTN. (moderate risk for prescription drug management)
      As you know, documenting the status of three chronic medical conditions can substitute for the HPI.  Add in at least 10 additional review of systems and one element each from past history, family and social elements and the minimum history documentation required for CPT® 99204 has been met.  The physical exam meets the comprehensive requirement with at least two bullets in each of nine areas or systems.  All physical exam components offer value to the encounter to exclude potential complications of therapy or to search for evidence of decompensated disease.

      The MDM is moderate complexity.  This progress note documentation gets four  diagnosis points for discussing two stable problems (two points total for DM and COPD)  with an established problem that is worsening and no more work up planned (two points for HTN).  In addition, zero points are earned for the data component, but risk is moderate based on prescription drug management.  Prescription drug management is considered moderate risk.  This is displayed on my bedside E/M reference card shown below.  The highest two out of three components for MDM are of moderate complexity and therefore this overall documentation supports CPT® 99204.  Below is another example of a new patient 99204 office visit:
      S:   HA present 4/10, global pain for 3 days and constant. No ringing in the ears. (at least 4 HPI)   No fever, no neck stiffness, no nausea/vomiting. No chest pain or SOB.  All other systems reviewed and negative. (at least 10 ROS based on this notation) No history of migraines.  Nonsmoker.  No FH brain cancer. (one element each from past history, social and family elements)
      O: 120/80  90  Tmax 98.9 (three vital signs = one bullet), no head trauma, alert, memory intact, no acute distress, no icterus, pupils symmetric, poor dentition, oropharynx normal, no thyroid masses, trachea midline, no neck adenopathy, no groin adenopathy, normal respiratory effort, normal breath sounds, no crackles or wheezes, normal heart tones without murmur, no JVD, no leg edema, positive bowel tones, no guarding, no palpable masses or organomegally, no skin rashes, no induration, normal neurological exam.  (at least 2 bullets each in nine areas/systems)
      A:  Acute HA, NOS.  Stable. (one new problem with more work up planned and of uncertain prognosis is 4 points on MDM for diagnosis and also moderate risk too)
      P: Check CBC/BMP.  Continue to observe.  
      This new patient outpatient evaluation is appropriate for CPT® 99204 as the history, physical and MDM all contain the necessary documentation based on the Marshfield Clinic audit tool.  Medical decision making is moderate because the diagnosis element is high complexity (4 points for new diagnosis with more work-up planned), the data element is low complexity (only one point for ordering lab), and the risk table is moderate for dealing with an undiagnosed new problem with uncertain prognosis.  Therefore, the highest two out of three elements in MDM are moderate. Here is another progress note example of a level 4 new patient office visit:
      S:   48 year old male here to establish care. No CP/SOB/N/V/HA.  No neuropathy. No polyuria or polydypsia.  Average blood sugar reading 145.  All other systems reviewed and negative. (at least 10 ROS based on this notation) Nonsmoker.  No family history of CAD.  Diabetes type II for 10 years. (one element each from past history, family and social elements)
      O:  120/80  90  Tmax 98.9 (three vital signs = one bullet), no head trauma, alert, memory intact, no acute distress, no icterus, pupils symmetric, poor dentition, oropharynx normal, no thyroid masses, trachea midline, no neck adenopathy, no groin adenopathy, normal respiratory effort, normal breath sounds, no crackles or wheezes, normal heart tones without murmur, no JVD, no leg edema, positive bowel tones, no guarding, no palpable masses or organomegally, no skin rashes, no induration, normal neurological exam.  (at least 2 bullets each in nine areas/systems)
      A: 1) HTN, controlled.  2) DM II, uncontrolled. 3) CAD, controlled.  (three points on MDM for diagnosis and substituting three chronic medical conditions for HPI)
      P:  Increase Metformin from daily to BID dosing. (moderate risk for prescription drug management) 
      Both the history and physical meet minimum criteria for CPT® 99204 with comprehensive requirements documented for both.  Medical decision making is moderate based on a moderate risk table assessment and three points in the diagnosis section.  No points are achieved in the data section of MDM, but none are necessary.  Remember, the highest two out of three elements from data, diagnosis and risk determines the overall level of MDM complexity.  

      USING NEW PATIENT CLINIC CODES IN THE HOSPITAL SETTING


      The CPT® medical billing code group 99201-99205 should used by hospitalists and other physicians or non-physician practitioners in the hospital setting under certain circumstances.  I have previously discussed all the possible initial encounter codes that could be used in the hospital setting.  These new patient clinic and other outpatient visit codes are included as possibilities.  I have provided a detailed discussion of  that decision tree analysis at the link provided just above.  However, I will discuss the pertinent portions of that analysis here.

      For patients admitted observation status, the attending physician should choose from the observation group of medical codes 99218-99220 for the initial encounter, 99224-99226 for observation status follow-up codes, and 99217 for observation discharge.  Under certain situations, same day admit and discharge billing codes 99234-99236 or critical care procedure codes may also apply too.  This is not the case for consultants taking care of observation status patients.  What codes should a consultant use in an observation status situation?  This is where the correct code decision can get very complicated.  Medicare no longer recognizes consult procedure codes.  Consultants should pick the appropriate level of service from the new outpatient clinic code group 99201-99205 as their initial encounter, but only IF the patient has NOT been seen previously  by the physician or a physician partner of theirs in the same group and exact same specialty and subspecialty within the previous three years.  Alternatively, critical care codes can be used instead if documentation supports their use.

      If the patient HAS been seen in the last three years by the same physician or partner physician in the same group and exact same specialty and subspecialty, the consultant should use the established patient clinic code group 99211-99215 on their initial date of service and continue to use that code group for all subsequent observation services, including the day of discharge.  Remember, all hospital observation CPT® code groups are reserved only for the attending physician.  If a patient qualifies as a new patient but clinician documentation does not support any code from the code group 99201-99205 (usually because of the three out of three documentation requirement), then it is appropriate to instead choose a code from the established patient code group (99211-99215) that meets documentation requirements.  This guidance has previously been confirmed by Medicare carriers. 

      The above discussion relates to Medicare because Medicare does not accept consult codes.  Other insurances may still accept consultation codes.  In those cases, the consultant should chose a level of service from medical code group 99241-99245 (outpatient consult codes) as the initial encounter and then pick a billing code from the established patient clinic codes 99211-99215 for all subsequent care visits, including the day of discharge,  while the patient is hospitalized for observation services.  If the patient is formally admitted inpatient, the consultant should use the inpatient subsequent care codes 99231-99233 for all subsequent face-to-face encounters.


      DISTRIBUTION OF NEW PATIENT OFFICE OR OTHER OUTPATIENT VISIT CODES (99201-99205)


      What is the distribution of CPT® code 99204 relative to other levels of service in this medical code group? The chart below was published in May, 2012 by the OIG in a report titled Coding Trends of Medicare Evaluation and Management Services on page 21.  As you can see, between 2001 and 2010, the distribution of new patient office visits 99204 and 99205 has shifted higher (an increase of 12% and 4% respectively) while the  proportion of level three 99203 has remained constant with no change from 2001-2010.  On an absolute basis, of all codes in the group 99201-99205, CPT® code 99204 represented 35% of all services from code group 99201-99205.

      CPT 99201-99205 services distribution chart 2001-2010

      Here is data from the most recent 2011 CMS Part B National Procedure Summary Files data (2011 zip file) showing how many CPT® 99204 encounters were billed and the dollar value of their services for Part B Medicare.    As you can see in the image below, E/M code 99204 was billed 8,570,728 times in 2011 with allowed charges of $1,339,686,101.09 and payments of $961,895,033.93.  Based on allowed charges and payments, CPT® 99204 was the seventh most common E/M code in 2011 for Medicare Part B.  

      2011 National Part B Summary File 99201-99205 CMS 2011


      RVU VALUE


      How much money does a CPT® 99204 pay in 2016?  That depends on what part of the country you live in and what insurance company you are billing.  E/M procedure codes, like all CPT® billing codes, are paid in relative value units (RVUs).  This complex RVU discussion has been had elsewhere on The Happy Hospitalist.  For raw RVU values, a CPT® 99204 is worth 3.67 total RVUs for facility services and 4.64 total RVUs for non-facility.  The work RVU for 99204 is valued at 2.43.  A complete list of RVU values on common hospitalist E/M codes is provided at the provided link.  What is the Medicare reimbursement for CPT® code 99204?  In my state, a CPT® 99204 pays just over $123 (facility) and just over $154 (non-facility) in 2016. The dollar conversion factor for one RVU in 2014 is $35.8043.

      My coding card taught me that I should be billing for the work I'm providing and it has taught me how to document appropriately. You can see many more of my E/M lectures by clicking through on the provided link. If you need bedside help determining what level of care you have provided, I recommend reviewing the pocket card described below.


      		LINK TO E/M BEDSIDE POCKET REFERENCE CARD POST

      EM Pocket Reference Cards Using Marshfield Clinic Point Audit

      Click image for high definition view




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