1) Coding is essential for physicians to get paid for the care they provide to patients. CPT and ICD codes are used to describe medical services and diagnoses. 2) RBRVUs and E/M codes determine payment amounts from insurers based on the complexity of care. Higher level E/M codes and procedural codes pay more than lower levels or well visits. 3) It is important for physicians to accurately code at high enough levels to reflect the full work being done, but not overcode and risk audits and penalties. Procedural codes often pay more than E/M visit codes alone.

1. Coding 100
Richard Lander MD FAAP

2. Why is coding important to me?

3. Coding tells the insurers & auditors
what the patient’s problems were and
what you did for them so that you can
get paid.

4. Coding is how you will
make your living.

5. What is a CPT and where do they
come from?

6. CPT codes stands for Current
Procedural Terminology. It is owned by
the AMA. It is revised yearly and it is
the standard for all medical billing.

7. What is a RBRVU?

8. RBRVU stands for Resource Based
Relative Value Units.

9. RBRVU
Developed at Harvard by Dr. Hsai to make Medicare
payments more equitable, it is now the standard of
payment for many private insurers.

10. What is an ICD?

11. ICD tells what
illness was
discovered in your
examinations

12. ICDs have “severity” scoring systems in
existence that look to see that
physicians are paid appropriately for
the work they deliver

13. Well visits

14. With well visits you only need to know if the
patient is “new” or “established. New patients –
one not seen by you or the practice in 3 years

15. Well visits
Age CPT Code New CPT Code Established
Under 1 year 99381 99391
1 – 4 years 99382 99392
5 – 11 years 99383 99393
12 – 17 years 99384 99394
18 – 39 years 99385 99395

16. Evaluation and Management Codes

17. E&M codes are for sick visits. They are
based on the severity of the illness and
work done.

18. Note: If more than 50% of visit is
counseling, then time is an
element

19. New patient
codes require
all 3 elements
New Patients
Patients only
Established require 2 out
of 3 elements
Doesn’t
require the
presence of a 99211
physician

20. 99212
Expanded problem focused history
Expanded problem focused exam
Straightforward medical decision making

21. 99213
Detailed history
Detailed examination
Medical Decision making of low complexity

22. 99214
Comprehensive history
Comprehensive examination
Medical decision making of moderate complexity

23. 99215
Comprehensive history
Comprehensive examination
Medical decision making of high complexity

24. Why is this important?

25. Most doctors (pediatricians, actually)
under code

26. What does this cost?

27. If you increase from 5% 99214 to 20% ,
you can increase your net income by
$20,000 without doing any more work

28. You don’t want to over code because
Medicaid and private health insurers can
and will audit you. If the documentation
doesn’t equal the code billed, they will
penalize you

29. Evaluation requested by an appropriate professional
with a report back to that person
99243 - Consult 99213 – E/M
3.17 x 36.79 1.39 x 36.79
$116.62 $51.14

30. Pediatricians do many procedures

31. If you don’t bill for the procedures you do, you cheat
yourself out of the many dollars

32. Subluxation of elbow
24640 99213
4.85x 36.79 1.39 x 36.79
$178.43 $51.14

33. What does this tell you?

34. It is critical to know the codes for all the procedures you do,
since obviously procedures pay better than E/M codes

35. Where can you learn more?

36. Decide if the practice you are
looking at has someone who
knows coding
The Academy offers coding
courses – at the NCE and as
stand alone courses

37. Other Steps

38. Be sure you have a current CPT and
ICD coding books in your office

39. USE
Them