RHIA, CDIP, CCS, CCS-P, CPC, COC, CPC-I - Coding & Billing for HIV & STI Testing and Preventative Services November 19, 2018 Presented by Dr. Lisa ...
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Coding & Billing for HIV & STI
Testing and Preventative Services
November 19, 2018
Presented by
Dr. Lisa L Campbell, PhD, MHA, MPH
RHIA, CDIP, CCS, CCS-P, CPC, COC, CPC-ISpeaker Biography
Certified Coding
26 Years Experience Medical Assistant Medical Biller Educator
Specialist
Clinical
Documentation Health Information Healthcare
Volunteer Consultant
Improvement Administrator Administrator
SpecialistThe information presented and responses to the questions
posed are not intended to serve as coding or legal advice.
Many variables affect coding decisions and any response to
the limited information provided in a question is intended
only to provide general information that might be considered
in resolving coding issues.
Disclaimer
All coding must be considered on a case-by-case basis and
must be supported by appropriate documentation in the
health record.
Therefore, we recommend consulting directly with payers to
determine specific payers’ guidance regarding appropriate
coding and claim submission.• CPT® copyright 2018 American Medical
Association
• The CPT codes that are utilized in
coding claims are produced and
copyrighted by the American Medical
CPT Disclaimer Association (AMA). Specific questions
regarding the use of CPT codes may be
directed to the AMA.
• CPT® is a registered trademark of the
American Medical AssociationObjectives • Understand how proper documentation and coding supports compliant billing practices and efficiencies. • Understand relevant ICD, CPT and modifier terminology and codes. • Become familiar with common HIV/STI ICD codes. • Apply knowledge learned by identifying which codes would be assigned to a patient scenario.
The Billing Process
Paint Identify Discuss Identify Follow
Paint a picture of Identify all services Discuss why you Identify any special Follow established
the visit by your you provided today– performed the circumstances– coding rules and
documentation CPT / HCPCS services–ICD-10-CM Modifiers regulationsDocumentation Basics
Improves clinical
Improves Improves patient
data for research
compliance care
and education
Protects the legal If it isn’t
Enables proper
interest of the documented – it
reimbursement for
patient, facility and can’t be coded and
services performed
clinician ultimately billed!Ensure your
Be careful to not cut and
documentation supports
paste documentation
the codes billed for More is not better – quality
without individualizing the
services and captures the vs. quantity
notes to the specific
essential elements needed
patient visit
by your payers
Documentation BasicsCPT/HCPCS Codes
New Patient Office Visit
99201 99202 99203 99204 99205
Level I Level II Level III Level IV Level V
Problem Focused Exp. Prob. Focused Detailed Comprehensive Comprehensive
HPI (1-3) HPI (1-3) HPI (4+) HPI (4+) HPI (4+)
History ROS (1) ROS (2-9) ROS (10+) ROS (10+)
PFSH (1-2) PFSH (3) PFSH (3)
Problem Focused Exp. Prob. Focused Detailed Comprehensive Comprehensive
Exam BA/OS (1) BA/OS (2-4) BA/OS (5-7) OS (8+) OS (8+)
Decision
Making Straightforward Straightforward Low Moderate HighEstablished Patient Office Visit
99211 99212 99213 99214 99215
Level I Level II Level III Level IV Level V
Nurse Visit Problem Focused Exp. Prob. Detailed Comprehensive
Focused
HPI (1-3) HPI (4+) HPI (4+)
History HPI (1-3) ROS (2-9) ROS (10+)
ROS (1) PFSH (1) PFSH (2)
Nurse Visit Problem Focused Exp. Prob. Detailed Comprehensive
Focused
BA/OS (1) BA/OS (5-7) OS (8+)
Exam BA/OS (2-4)
Decision
Making Nurse Visit Straightforward Low Moderate HighPreventative Medicine,
Individual Counseling
• Preventive medicine counseling and/or risk
factor reduction intervention(s) provided to an
individual (separate procedure);
• 99401 approximately 15 minutes
• 99402 approximately 30 minutes
• 99403 approximately 45 minutes
• 99404 approximately 60 minutesHIV Screening-Non-Medicare Patients
CPT Code Descriptor
86701 HIV-1
86702 HIV-2
86703 HIV-1 and HIV-2, single result
HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies,
87389
single resultHIV Screening-Medicare Part B
HCPCS Code Descriptor
Infectious agent antibody detection by enzyme Immune assay
G0432 (EIA) technique, qualitative or Semi-quantitative, multiple-step
method, HIV-1 or HIV-2, screening
Infectious agent antibody detection by enzyme-linked
G0433 immunosorbent assay (ELISA) technique, antibody, HIV-1 or HIV-
2, screening
Infectious agent antibody detection by rapid antibody test of oral
G0435
mucosa transudate, HIV-1 or HIV-2, screening.STI Screening-Chlamydia
CPT Code Descriptor
86631 Antibody; Chlamydia
86632 Antibody; Chlamydia, IgM
87110 Culture, chlamydia, any source
Infectious agent antigen detection by immunofluorescent technique;
87270 Chlamydia trachomatis
Infectious agent antigen detection by enzyme immunoassay technique, qualitative or
87320 semiquantitative, multiple-step method; Chlamydia trachomatisSTI Screening-Chlamydia
CPT Code Descriptor
Infectious agent detection by nucleic acid (DNA or RNA);
87490 Chlamydia trachomatis, direct probe technique
Infectious agent detection by nucleic acid (DNA or RNA);
87491 Chlamydia trachomatis, amplified probe technique
Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms;
87800 direct probe(s) technique
Infectious agent antigen detection by immunoassay with direct optical observation;
87810 Chlamydia trachomatisSTI Screening-Gonorrhea
CPT Code Descriptor
Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhea, direct probe
87590
technique
Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhea, amplified probe
87591
technique
Infectious agent antigen detection by immunoassay with direct optical observation; Neisseria
87850
gonorrhea
Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s)
87800
techniqueSTI Screening-Syphilis CPT Code Descriptor 86592 Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR, ART) 86593 Syphilis test, non-treponemal antibody; quantitative 86780 Antibody; Treponema pallidum
STI Screening-Hepatitis B
CPT Code Descriptor
Infectious agent antigen detection by enzyme immunoassay technique,
87340 qualitative or semiquantitative, multiple-step method;
hepatitis B surface antigen (HBsAg)
Infectious agent antigen detection by enzyme immunoassay technique,
87341 qualitative or semiquantitative, multiple-step method;
hepatitis B surface antigen (HBsAg) neutralizationModifiers
HIV Screening Modifiers
92: Alternative Laboratory Platform
Testing: When laboratory testing is being
33: Preventive Services: When the primary
performed using a kit or transportable
purpose of the service is the delivery of an
instrument that wholly or in part consists of a
evidence-based service in accordance with a
single use, disposable analytical chamber, the
US Preventive Services Task Force A or B
service may be identified by adding modifier
rating in effect and other preventive services
92 to the usual laboratory procedure code
identified in preventive services mandates
(HIV testing 86701-86703, and 87389). The
(legislative or regulatory), the service may be
test does not require permanent dedicated
identified by adding 33 to the procedure. For
space; hence by its design may be hand
separately reported services specifically
carried or transported to the vicinity of the
identified as preventive, the modifier should
patient for immediate testing at that site,
not be used.
although location of the testing is not in itself
determinative of the use of this modifier.ICD-10-CM Codes
Z11.3-Sexual mode of
Transmission
(other than HIV/HPV)
Z11.4-
Z11.8-Chlaymida
HIV
Z11.59-Other viral Z11.51-
diseases HPV
Diagnosis Codes-Screenings• Z20.2-Infections sexual mode of
transmission
Diagnosis • Z20.5-Viral Hepatitis
Codes-Contact • Z20.6-HIV
(Suspected) • Z20.828-Other viral communicable
diseases
Exposure • Z77.21-potentially hazardous body
fluidsDiagnosis Codes-Counseling
Z71.7-HIV
Z71.890-Other specified counselingDiagnosis Codes-HIV
Z21, Asymptomatic
B20, Human R75, Inconclusive
human
immunodeficiency virus laboratory evidence of
immunodeficiency virus
(HIV) disease HIV
(HIV) infection status
Includes AIDS, ARC, or
Inconclusive HIV test
symptomatic HIV No HIV-related illness
finding
infectionDiagnosis • Requires a minimum of two codes
Codes-HIV o Code B20 to identify the HIV
disease
Related o Additional codes to identify all
manifestations of HIV infection
Illnesses• During pregnancy, childbirth, or
Diagnosis Codes- puerperium
HIV-Related oCode O98.7- listed first
oAdditional code to identify the
Illness in type of HIV disease
Pregnancy oB20 or Z71Diagnosis Codes
HIV-Related Illness and Unrelated Conditions
• When a patient with HIV disease is admitted for an
unrelated condition, such as a traumatic injury or a
disease that was not caused by the HIV disease
o Code first the unrelated condition
o Other diagnoses would be B20 followed by
additional diagnosis codes for all reportable HIV-
related conditionsAsymptomatic HIV Infection Status • Code Z21 is used when the patient has the HIV virus in the blood but does not have any documented symptoms of the infection • Diagnosis may be HIV positive • Code Z21 is not used if the patient is treated for any HIV-related illnesses
A51.0-Genital Syphilis A51.1-Anal Syphilis A56.11-Chlamydial infection (PID) A56.3-Chlamydial infection (Anus and rectum) A59.9-Trichamonus A63.0-Condolyma A74.9-Chlamydia, NOS Diagnosis Codes-STI’s
Diagnosis Codes-High Risk Sexual Behavior
Z72.51- Z72.52-
Heterosexual Homosexual
Z72.89-Other
Z72.53-Bisexual problems related
to lifestyleDiagnosis Codes-Social Determinants of Health
Z59-
Z55-Education and Z56-Employment Z57-Occupational
Housing/economic
literacy status exposure
situations
Z64-Certifain
Z60-Social Z63-Primary
Z62-Upbringing psychosocial
environment support, family
situations
Z65-Other
psychosocial
situationsLet’s Practice
Case #1 A 26-year-old female presents to the health department with sores around her mouth. Her social history indicates multiple heterosexual risk factors for STIs and HIV, categorizing her as high risk. The physician orders a rapid HIV 1/2 screen, immunoassay screens for chlamydia and gonorrhea, and a qualitative syphilis screen.
Case #2 A male Medicare beneficiary presents to the health department with penile warts and requests an STI screen. The physician provides counseling, prescribes medications, and orders chlamydia and gonorrhea screens by polymerase chain reaction, a rapid HIV test, and a qualitative syphilis test.
Case #3 This HIV-positive established patient was seen in the office today with skin lesions on the chest and back. Excisional biopsies were taken, and the pathological diagnosis was Kaposi's sarcoma.
Case #4 The HIV-infected patient was suffering from an acute lymphadenitis due to his HIV infection. The glands in the neck area were most affected. Antibiotics were prescribed, but the patient refused antiretroviral treatment at this time. He believed his religion would eventually make antiretroviral medication unnecessary. Another consideration was his narcotic dependency. He was encouraged to continue participation in support groups for people with narcotic addiction and HIV.
Case #5 A 19-year old male who is new to the health department presents for STI screening. No symptoms, has had 3 male partners in past 6 months, inconsistent condom use. Reports receptive and insertive oral sex, occasional receptive anal sex, occasional anonymous partners. No complaints, good health, gonorrhea approx. 2 years ago, tested and treated by private provider. Recent HIV test negative 6 weeks ago - declines testing. Is tested for GC, CT (for reported sites of exposure) and has blood drawn for Syphilis RPR test.
Case #6 A 24-year-old woman retuning to the health department, is seeking testing after learning her male partner was diagnosed with gonorrhea. Asymptomatic, oral and vaginal exposure. Using NuvaRing as contraceptive method. No abnormalities on pelvic exam. Diagnostic tests for gonorrhea and chlamydia obtained and sent to lab. Dispensed: Ceftriaxone 250 mg IM injection and Azithromycin 1 gm PO.
Case #7 A 27-year-old patient presents to her primary care physician’s office concerned about recently having unprotected sex and requests an HIV test. The physician notices that the patient is also due for a well visit this year and performs it. Dr. Attending decides to perform a preventive medicine visit exam, spends 35 minutes counseling the patient and performs a rapid HIV test. This is an established patient.
Case #8 The patient (from case study #7) returns for their HIV test results. The physician advises the patient that the results are negative and counsels the patient for 30 minutes on the importance of safe sex and contraceptive methods. The physician also distributes contraception and advises the patient to return in 3 months for a retest.
Case #9 The patient returns for their HIV test results. The physician advises the patient that they are HIV+ (asymptomatic HIV). The physician counsels the patient and explains what it means to have a diagnosis of HIV+ vs. HIV infection, the proper use of medications, implements a treatment plan and advises the patient to return in 3 months for a retest. This is an established patient visit.
Case #10 The patient returns for their HIV test results. The physician advises the patient that they have the HIV infection (symptomatic HIV/AIDS). The physician counsels the patient and explains in detail what HIV infection is. The physician implements a treatment plan, discusses the importance of taking medications and the importance of practicing safe sex at all times. This is an established patient visit.
Case #11 A 17-year-old patient presents to the health department to discuss contraception options and safe sex. Patient is counsels by the provider, the patient on the various methods and suggests and HIV test. The patient agrees, but then minutes later declined to the HIV screening test. The billing provider spends 45 minutes counseling the patient and asked her to reconsider the HIV test at a later date.
Case #12 An HIV+ mom presents to the health department for antiretroviral therapy follow for her 2 month old baby. The physician documents an expanded problem focused history and performs a brief exam. Upon review of the lab results, the physician makes the decision to modify the antiretroviral medication. A revised treatment plan is discussed and the physician advises the patient to return in 1 month.
Case #13 A HIV positive patient presents to the health department with complaints of fever and extreme fatigue due to possible pneumonia. The final diagnoses are Pneumocystis carinii pneumonia (PCP) and AIDS.
Case #14 A 5 month (20 weeks) pregnant patient with a history of AIDS presents to her OB appointment complaining of severe cramping and heavy bleeding. She was put on IV meds and the bleeding stopped The patient was sent to Labor and Delivery.
Case #15 A medical assistant accidentally punctures finger with needle after drawing bloods from an AIDS patient. The office manager completes the workplace injury forms while the medical assistant is treated by physician in your office. The physician performs a detailed history and problem focused exam. Medical decision making includes blood work, a supply 48-hour PEP medication and counsels the medical assistant regarding transmission prevention. Bloodwork sent to lab for processing
Coding Manuals • 2018 Current Procedural Terminology • 2019 International Classification of Diseases, 10th version, Clinical Modification (ICD-10-CM) • 2018 Health Care Common Procedural Coding System (HCPCS) Professional Organizations • American Academy of Professional Coders (AAPC) • American Health Information Management Association (AHIMA) • American Hospital Association (AHA) Payers • Centers for Medicare and Medicaid Services (CMS) References
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