1. ICD-9, CPT, E&M Coding Documentation and Compliance
…or the in-service for the
in-service!!

2. …You’ve just seen a patient in your office…
…and after the exam
You want to get paid
(After all, you need to pay mortgage, food, etc)
Insurance will pay you if…
You tell the company what you did…AND…
You tell the company why you did it

3. Types of “Codes” Procedure codes ICD
What I did during the visit
Two Types
CPT
Evaluation and Management
ICD
Why I did it
The actual diagnosis code
…and these must make sense together

4. ICD codes
ICD-9

5. ICD Codes
ICD = International Statistical Classification of Diseases and Related Health Problems
Provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease.
Every health condition can be assigned to a unique category and given a code, up to six characters long.
Easy to understand
Allows for global (international) understanding of information

6. ICD-9 (9th version- currently one in use)
: Infectious and parasitic diseases
: Neoplasms
: Endocrine, nutritional, metabolic and immunity disorders
: Blood ad blood-forming organs
: Mental disorders (used by primary care and psych for research. DSM codes are used for clinical billing by psych)
: Nervous system
: Sense organs
: Circulatory system
: Respiratory system
: Digestive system
: Genitourinary system
: Complications of pregnancy/childbirth
: Skin and subcutaneous tissues
: Musculoskeletal system and connective tissue
: Congenital anomalies
: Certain conditions originating in the perinatal period
: Symptoms, signs and ill-defined conditions
: Injury and poisoning
E and V codes: External causes of injury and supplemental classification

7. ICD-9 Can list by disease or symptom
Get better reimbursement for more detail
Some insurances will only pay for a certain number of visits per diagnosis
e.g., diabetes
Large book with diagnostic codes or can get on line

8. More detail the better…. Break these down further!
ICD-9 codes
More detail the better….
Break these down further!

9. Diseases of the circulatory system (390-459)
Hypertensive disease ( )
(401) Essential Hypertension
(401.0) Hypertension, malignant
(401.1) Hypertension, benign
(402) Hypertensive heart disease
(403) Hypertensive renal disease
(403.91) Hypertensive renal disease, unspec., w/ renal failure
(404) Hypertensive heart and renal disease
(405.01) Hypertension, renovascular, malignant
(405.11) Hypertension, renovascular, benign

10. Endocrine, nutritional and metabolic diseases, and immunity disorders (240-279)
diseases of other endocrine glands ( )
Note: for , the following fifth digit can be added:
(250.x0) Diabetes mellitus type 2
(250.x1) Diabetes mellitus type 1
(250.x2) Diabetes mellitus type 2, uncontrolled
(250.x3) Diabetes mellitus type 1, uncontrolled
(250) Diabetes mellitus
(250.0) Diabetes mellitus without mention of complication
(250.1) Diabetes with ketoacidosis
(250.2) Diabetes with hyperosmolarity
(250.3) Diabetes with other coma
(250.4) Diabetes with renal manifestations
(250.5) Diabetes with ophthalmic manifestations
(250.6) Diabetes with neurological manifestations
(250.7) Diabetes with peripheral circulatory disorder
(250.8) Diabetes with other nonspecified manifestations
(250.9) Diabetes with unspecified complication

11. 780-799: Symptoms, signs and ill-defined conditions
(780) General symptoms
(780.0) Alteration of consciousness
(780.01) Coma, nondiabetic, nonhepatic
(780.02) Mental status changes
(780.09) Semicoma, stupor
(780.1) Hallucinations
(780.2) Syncope
(780.3) Convulsions
(780.31) Seizures, convulsions, febrile
(780.39) Seizures, convulsions, other
(780.4) Dizziness/vertigo, NOS
(780.5) Sleep disturbance, unspec.
(780.53) Hypersomnia, sleep apnea
(780.53) Sleep apnea w/ hypersomnia
(780.58) Movement disorder, sleep related
(780.6) Fever, nonperinatal
(780.7) Malaise and fatigue
(780.8) Sweating, excessive
(780.9) Other general symptoms
(780.92) Crying, infant, excessive
(780.93) Memory loss
(780.94) Early satiety

12. Current Procedural Terminology
CPT
Current Procedural Terminology

13. CPT CPT = Current Procedural Terminology
Code Set accurately describes medical, surgical, and diagnostic services
Designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes.
The current version is the CPT 2008.

14. CPT
A CPT code is a five digit numeric code that is used to describe medical, surgical, radiology, laboratory, anesthesiology, and evaluation/management services of physicians, hospitals, and other health care providers. 
There are approximately 7,800 CPT codes ranging from through  
Two digit modifiers may be added when appropriate to clarify or modify the description of the procedure.

15. Current Procedural Terminology
Chapter 1: Evaluation and Management Codes ( )
Chapter 2: Anesthesia Codes ( )
Chapter 3: Surgery Codes ( )
Chapter 4: Radiology Codes ( )
Chapter 5: Pathology/Laboratory Codes ( )
Chapter 6: Medicine Codes ( )
Appendices: Modifiers, Deleted codes

16. V codes: Supplemental classification
V01 Contact with or exposure to communicable diseases
V02 Carrier or suspected carrier of infectious diseases
V09 Infection with drug-resistant microorganisms
V10 Personal history of malignant neoplasm (i.e. cancer)
V16 Family history of malignant neoplasm
V17 Family history of certain chronic disabling diseases
V20 Health supervision of infant or child
V21 Constitutional states in development
V22 Normal pregnancy

17. V codes, cont V23 Supervision of high-risk pregnancy
V24 Postpartum care and examination
V25 Encounter for contraceptive management
V28 Encounter for [antenatal] screening of mother
V29 Observation and evaluation of newborns for suspected conditions not found
V30 Single liveborn
V31 Twin birth mate liveborn
V48 Problems with head neck and trunk
V49 Other conditions influencing health status
V50 Elective surgery for purposes other than remedying health states
V51 Aftercare involving the use of plastic surgery

18. V codes, cont V56 Encounter for dialysis and dialysis catheter care
V57 Care involving use of rehabilitation procedures
V58 Encounter for other and unspecified procedures and aftercare
V60 Housing, household and economic circumstances
V64 Persons encountering health services for specific procedures not carried out
V65 Other persons seeking consultation
V66 Convalescence and palliative care
V67 Follow-up examination
V68 Encounters for administrative purposes
V69 Problems related to lifestyle
V70 General medical examination
V71 Observation and evaluation for suspected conditions not found
V80 Special screening for neurological eye and ear diseases
V81 Special screening for cardiovascular respiratory and genitourinary diseases
V85 Body mass index

19. Relationship between CPT and ICD-9
The critical relationship between an ICD-9 code and a CPT code is that the diagnosis supports the medical necessity of the procedure.  
Since both ICD-9 and CPT are numeric codes, health care consulting firms, the government, and insurers have all designed software that compares the codes for a logical relationship. 
For example, a bill for CPT 31256, nasal/sinus endoscopy would not be supported by ICD , closed fracture of a phalanges of the foot.    
Such a claim would be quickly identified and rejected.

20. …trivia for boards… Health Care Financing Administration (HCFA)
Common Procedural Coding System (HCPCS)
Diagnosis Codes ICD – 9
Creates medical necessity
Level I CPT
Updated Annually
Level II (national) HCPCS (A-V)
Alphanumeric System
Level III (State) Local Codes (W-Z)

21. Evaluation and Management Most confusing for physicians
E & M Coding
Evaluation and Management
Most confusing for physicians

22. What are E&M Codes?
The Evaluation & Management (E&M) codes are a sub-set of the CPT codes.
Can be used by all privileged providers
Describes:
Complexity of care provided to a patient for non-procedural visits.
The place of service (inpatient or outpatient)
The type of service (new vs. established, consult, preventive, ER, critical care, etc)
Defined by 3 components
The patient history
The physical examination
Medical decision making

23. Why Code? REIMBURSEMENT Over coding = Fraud
Third Party Payers/Insurance Agencies
Prospective Payment Systems (PPS)
Over coding = Fraud
Under coding = Lost Revenue

24. What Do Coders Look For?
Professional Coders in your office or from insurance companies have been trained to match documentation in charts to the billing information
It is the Content, not the volume, of documentation that determines your E&M code!

25. What Do Coders Look For?
Every patient encounter should be legible and include:
Date of Encounter
Reason for the visit (chief complaint)
Appropriate history of present illness
An exam when necessary or appropriate; i.e. a new patient (consistency and problem pertinent)
Review of lab, x-ray, other ancillary services when appropriate
Assessment
Plan of care/Treatment options
Provider signature

26. Why is Documentation Important?
The documentation must support the E&M code you select.
Your documentation must also support the medical necessity of the services provided.
The first step is to clearly document the reason for every visit – the chief complaint.
The use of “Follow-up” is insufficient documentation as it does not indicate medical necessity.
However it is acceptable to document “Follow-up for _____”.
“If it isn’t documented, it wasn’t done!”

27. New vs. Established Consult Inpatient vs. Outpatient
Patient Type
New vs. Established
Consult
Inpatient vs. Outpatient

28. New vs. Established New patient
Any patient who has not received professional services, within the previous 36 months, from a provider within the same group, of the same specialty
Same group practice: One Federal Tax ID number for all providers, if more than one Federal Tax ID, can consider the patient new
e.g., current practice seen in OLBH ER and Outreach offices
Professional Services: Phone call, prescription, hospital or office visit, etc.
Specialty Issue: Optional if one federal Tax ID is shared by practitioners of other specialties (e.g., surgeon and FP)
** DO’s and MD’s of the same specialty DO NOT differ even if OMT is offered by the DO

29. Average and Recommended Code Distributions
The difference in the bell curves represents loss in physician income!!

30. Determining the Correct E&M Code
There are three key components to consider when selecting the appropriate E&M:
History
Exam
Medical Decision Making (MDM)
All three components must be documented for a new patient (new to clinic or not seen within the past three years). Indicate in CC if patient is new.
Only two of the three components must be documented for established patients (seen within the past three years).
E&M selection should never be based on the allotted time on the appointment schedule!

31. Determining the Correct E&M Code
To determine the correct level E&M code, consider the complexity of your patient’s condition and your medical decision making, then support that level of complexity with your documentation of history and/or exam.
Remember:
For a new clinic patient, initial consult, initial inpatient visit or ED encounter you must document all three key components
history, exam and your medical decision making.

32. Defining Levels of E&M Services
7 components
History
Examination
Medical Decision Making
Counseling
Coordination of care
Nature of Presenting Problem
Time

33. The Medical History

34. History
Also has several components to determine “complexity” or “type”
History of Present Illness (HPI)
Review of Systems (ROS)
Past Family and/or Social History (PFSH)
The extent of history is dependent on clinical judgment and the nature of the presenting problem.
The four types of History include: Problem focused, Expanded Problem Focused, Detailed and Comprehensive.

35. History of Present Illness

36. History – Chief Complaint
Chief Complaint Required
concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter.
The CC is usually stated in the patient’s own words.
For example, patient complains of upset stomach, aching joints, and fatigue
Cannot be the words “follow up” alone

37. History – History of Present Illness
Two types of HPI
Brief, which includes documentation of one to three HPI elements.
In the following example, three HPI elements – location, severity, and duration – are documented:
CC: A patient seen in the office complains of left ear pain.
Brief HPI: Patient complains of dull ache in left ear over the past 24 hours.

38. History – History of Present Illness
Extended, which includes documentation of at least four HPI elements or the status of at least three chronic or inactive conditions.
In the following example, five HPI elements – location, severity, duration, context, and modifying factors – are documented:
Extended HPI: Patient complains of dull ache in left ear over the past 24 hours. Patient states he went swimming two days ago. Symptoms somewhat relieved by warm compress and ibuprofen.

39. History Components Location Quality Severity Duration
Area of body, localized, unilateral, bilateral, fixed, migratory, radiation, referred
Quality
Specific pattern, sharp, dull, throbbing, stabbing, constant, intermittent, acute, chronic, stable, improving, worsening
Laceration as jagged or straight
Sore throat as scratchy
Severity
Pain scale, “compared to”, observation by physician (discomfort, wincing)
Duration

40. History Components Timing Context Modifying factors
Onset of problem or symptom and progression, recurrent, comes and goes, worsens or improves
Context
Associated with activity, improves with activity, etc
Modifying factors
Steps the patient has taken to alleviate symptoms, what exacerbates symptoms, is helped by, is hindered by
Associated signs/symptoms
Clinical impressions direct physician questioning
Specific symptoms (weakness, headache with injury)
Generalized symptoms, chills, fever, “pertinent positives and negatives”

41. History Guidelines HPI must be documented by the physician
ROS and/or PFSH can be recorded by ancillary staff
Physician must supplement or confirm the information
If obtained at a prior visit, do not need to re-record. Can review and update
Describe new information
Note date and location of earlier information

42. History Guidelines If unable to obtain a history
Describe patient’s medical condition or circumstance which precludes obtaining a history

43. Review of Systems

44. Review of Systems Definition The following “systems” are recognized:
An inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced
The following “systems” are recognized:
Constitutional (fever, weight loss) - Psychiatric
Eyes Endocrine
Ears, nose, mouth throat - Neurological
Cardiovascular - Allergic/Immunologic
Respiratory
Gastrointestinal
Musculoskeletal
Integumentary (skin and/or breast)
Hematologic/Lymphatic

45. Review of Systems Three categories of review Problem Pertinent
ROS inquires about the system directly related to the problem(s) identified in the HPI
Both positive responses and pertinent negatives should be documented
In the following example, one system – the ear – is reviewed:
CC: Earache.
ROS: Positive for left ear pain. Denies dizziness, tinnitus, fullness, or headache.

46. Review of Systems Extended
ROS inquires about the system directly related to HPI AND a limited number of additional systems
2-9 systems which are documented
In the following example, two systems – cardiovascular and respiratory – are reviewed:
CC: Follow up visit in office after cardiac catheterization. Patient states “I feel great.”
ROS: Patient states he feels great and denies chest pain, syncope, palpitations, and shortness of breath. Relates occasional unilateral, asymptomatic edema of left leg.

47. Review of Systems Complete
ROS inquires about the system directly related to the HPI AND all other body systems
At least 10 body systems must be documented
Those systems w/pertinent +or- responses must be individually documented, however for the remaining systems, “all other systems are negative” is permissible

48. Review of Systems
In the following example, 10 signs and symptoms are reviewed:
CC: Patient complains of “fainting spell.”
ROS:
Constitutional: weight stable, + fatigue.
Eyes: + loss of peripheral vision.
Ear, Nose, Mouth, Throat: no complaints.
Cardiovascular: + palpitations; denies chest pain; denies calf pain, pressure, or edema.
Respiratory: + shortness of breath on exertion.
Gastrointestinal: appetite good, denies heartburn and indigestion.
+ episodes of nausea. Bowel movement daily; denies constipation or loose stools.
Urinary: denies incontinence, frequency, urgency, nocturia, pain, or discomfort.
Skin: + clammy, moist skin.
Neurological: + fainting; denies numbness, tingling, and tremors.
Psychiatric: denies memory loss or depression. Mood pleasant.

49. Past Medical History
Medical
Family
Social

50. History - PFSH Past History Family History Social History
Past experience with illnesses, operations, injuries and treatments
Family History
Review of medical events in patients family, including hereditary disease
Social History
Age appropriate review of past and current activities

51. History - PFSH Pertinent
review of the history areas directly related to the problem(s) identified in the HPI.
Must document one item from any of the three history areas.
In the following example, the patient’s past surgical history is reviewed as it relates to the current HPI:
Patient returns to office for follow up of coronary artery bypass graft in Recent cardiac catheterization demonstrates 50 percent occlusion of vein graft to obtuse marginal artery.

52. History - PFSH Complete
A review of two or all three of the areas, depending on the category of E/M service.
Requires a review of all three history areas for services that, by their nature, include a comprehensive assessment or reassessment of the patient.
A review of two history areas is sufficient for other services.

53. History - PFSH
At least one specific item from each of the history areas must be documented for the following categories of E/M services:
Office or other outpatient services, new patient;
Hospital observation services;
Hospital inpatient services, initial care;
Consultations;
Comprehensive Nursing Facility assessments;
Domiciliary care, new patient; and
Home care, new patient.

54. History - PFSH Does NOT need to be re-recorded
Record new information only
“No change” PFSH can be documented

55. History Algorithm History Type HPI ROS PFSH Problem Focused (1 point)
Brief
None
Expanded Problem Focused (2 points)
Problem pertinent
Detailed (3 points)
Extended
Pertinent
Comprehensive (4 points)
Complete

56. Physical Examination

57. Physical Exam
Looked at either by
Body Areas
Organ Systems

58. Physical Exam Body areas recognized: Head (including face) Neck
Chest, including breast and axillae
Abdomen
Genitalia, groin, buttocks
Back (including spine)
Each extremity (separately)

59. Physical Exam Organ systems recognized
Constitutional
Eyes
ENT, Mouth
Cardiovascular
Respiratory GI GU
Musculoskeletal
Skin
Neurologic
Psychiatric
Hematologic; Lymphatic; Immunologic
The general multi-system exam should include findings of at least 8 of the above 12 organ systems

60. Documentation of Examination
Make sure you note specific abnormal or relevant findings of affected body areas or organ systems
Brief statement indicating negative or normal is sufficient for unaffected or asymptomatic systems
Describe abnormal or unexpected findings of asymptomatic areas or organs

61. > 6 Bulleted Elements
Physical Examination
Type
Either this
Or this
Problem Focused (1 point)
< 1 organ system/Body area
1-5 bulleted elements
Expanded Problem Focused (2 points)
2-4 Organ Systems/Body areas
> 6 Bulleted Elements
Detailed Exam (3 points)
5-7 Organ Systems/Body Areas
> 2 bulleted elements from 6 areas or
> 12 bullets from > 2 areas
Comprehensive Exam (4 points)
> 8 organ systems/body areas
Complete single system examination or
> 2 bulleted elements from 9 areas

62. Physical Examination Type of Examination Description Problem Focused
A limited examination of the affected body area or organ system.
Expanded Problem Focused
A limited examination of the affected body area or organ system and any other symptomatic or related body area(s) or organ system(s).
Detailed
An extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body areas(s) or organ system(s).
Comprehensive
A general multi-system examination OR complete examination of a single organ system and other symptomatic or related body area(s) or organ system(s).

63. Physical Examination General Multi-System Examinations
TYPE OF EXAMINATION
DESCRIPTION
Problem Focused
Include performance and documentation of elements identified by a bullet in 1 or more organ system(s) or body area(s)
Expanded Problem Focused
Include performance and documentation of at least 6 elements identified by a bullet in 1 or more organ system(s) or body area(s).

64. Physical Examination General Multi-System Examinations
TYPE OF EXAM
DESCRIPTION
Detailed
Include at least 6 organ systems or body areas. For each system/area selected, performance and documentation of at least 2 elements identified by a bullet is expected. Alternatively, may include performance and documentation of at least 12 elements identified by a bullet in 2 or more organ systems or body areas.
Comp.
1997 Documentation Guidelines for Evaluation and Management Services: Include at least 9 organ systems or body areas. For each system/area selected, all elements of the examination identified by a bullet should be performed, unless specific directions limit the content of the examination. For each area/system, documentation of at least 2 elements identified by bullet is expected.
1995 Documentation Guidelines for Evaluation and Management Services: Eight organ systems must be examined. If body areas are examined and counted, they must be over and above the 8 organ systems.

65. Exam Bullets Constitutional Eyes Ears, Nose, Mouth and Throat
3 vital signs
General appearance
Eyes
Inspection of Conjunctiva and Lids
Examination of Pupils and Iris (PERLA)
Ophthalmoscopic discs and posterior segments
Ears, Nose, Mouth and Throat
External appearance of Nose and Ears
Otoscopic Examination
Assessment of Hearing
Inspection of Nasal Mucosa/Septum
Examination of oropharynx

66. Exam Bullets Neck Respiratory Examination of Neck
Examination of Thyroid
Respiratory
Assessment of respiratory effort
Percussion of Chest
Palpation of Chest
Auscultation of Lungs

67. Exam Bullets Cardiovascular Chest (breasts) Palpation of PMI
Auscultation of the Heart
Assessment of Lower Extremity Edema
Examination of Carotid Artery
Examination of abdominal aorta
Examination of femoral pulse
Examination of pedal pulse
Chest (breasts)
Inspection of breasts
Palpation of breasts and axillae

68. Exam Bullets Gastrointestinal (abdomen) Genitourinary (male)
Examination with notation of masses or tenderness
Examination of liver and spleen
Examination for presence/absence of hernias
Examination of anus, perineum, rectum, including sphincter tone, hemorrhoids
Obtain stool for occult blood
Genitourinary (male)
Examination of scrotal contents
Examination of Penis
DRE prostate

69. Exam Bullets Genitourinary (female) Lymphatic
Examination of external genetalia
Examination of urethra
Examination of bladder
Examination of cervix
Examination of uterus
Examination of adenexa
Lymphatic
Palpation of lymph nodes in two or more areas
Neck, axillae, groin, other

70. Exam Bullets Musculoskeletal Examination of gait and station
Examination of joints, bones and muscles of one or more of the following 6 areas
Head and Neck
Spine, ribs and Pelvis
Right Upper Extremity
Left Upper Extremity
Right Lower Extremity
Left Lower Extremity
Examination includes…Inspection and/or palpation with notation of any misalignment, asymmetry, crepitation, etc; range of motion with notation of pain, crepitation; assessment of stability; assessment of muscle strength

71. Exam Bullets Skin Neurologic Psychiatric
Examination of skin and subcutaneous tissue
Palpation of skin and subcutaneous tissue
Neurologic
Test cranial nerves with notation of deficit
Examination of DTR
Examination of sensation
Psychiatric
Description of judgment and insight
Brief assessment of mental status

72. Medical Decision Making

73. Determination of Medical Decision Making
Based upon
Number of diagnoses or management options
Amount and complexity of data
Overall risk

74. Medical Decision Making
(MDM) refers to the complexity of determining a diagnosis and/or the selection of a treatment option.
Measured by documentation of the following:
Number of diagnoses and/or management options that must be considered.
Amount and/or complexity of data to be reviewed.
Risk of complications, morbidity and/or mortality, and co-morbidities.
Four types
Straightforward, Low Complexity, Moderate Complexity, and High Complexity.

75. Documentation to Support Complexity
Consider the following for risk
Chronic illness(es)
Well controlled
Mild exacerbation
Severe exacerbation
Acute illness
Uncomplicated like allergic rhinitis
With systemic symptoms like pneumonitis

76. Medical Decision Making Diagnoses/Management Options Max of 4 points
Problem Categories
Number of Problems
Possible Points
Score
Self Limited/minor
Max of 2 1
Established Problem – stable or improving
Established problem – worsening 2
New problem (no further work up)
Max of 1 3
New problem (work up needed) 4

77. Documentation to Support Complexity
Consider the following…
Did you order/review labs?
Did you order/review X-rays, US, MRI
Did you order/review any other testing
Did you visualize image, tracing, or specimen
Did you review or summarize old records
Must document this on the record
…old records reviewed which noted ….

78. Medical Decision Making Amount and Complexity of Data Max of 4 points
Type of Data
Check if Done
Possible Points
Score
Review/Order tests (8xxxx clinical) 1
Review/order tests (7xxxx radiology)
Review/order tests (9xxxx medicine)
Discuss test results with performing physician 2
Independent review of tracing, specimen, image
Decision to obtain medical records
Review, summarize old records and/or obtain history

79. Table of Risk Level of risk Presenting problem(s) Diagnostics ordered
Management options
Minimal (1 point)
One self-limited/minor problem (e.g., URI)
Lab tests requiring venipuncture
CXR
EKG
Urinalysis
Rest
Gargles
Ace wrap
Low (2 points)
2+self limited/minor problems
1 stable/chronic illness
Acute uncomplicated illness/injury
Physiologic tests not under stress (pulm. Function)
Non-cardiac imaging w/barium
Lab requiring arterial puncture
Skin biopsy
Over the counter drugs
Minor surgery w/no identified risk
PT/OT
IV fluids w/o additives
Moderate (3 points)
1+chronic illnesses with mild progression, or side effects of treatment
2+ stable chronic illnesses
Undiagnosed new problem w/uncertain prognosis
Acute illness with systematic symptoms
Acute uncomplicated injury
Physiologic test under stress
Diagnostic endoscopy w/no risk factors
Deep needle or incisional biopsy
Obtain fluid from body cavity
Minor surgery w/risk factors
Elective major surgery w/no risks
Prescription drug management
IV with additives
High (4 points)
1+ chronic illness with severe exacerbation or side effects of treatment
Acute/chronic illness that poses a threat to life/bodily function
Abrupt change in neurologic status
Cardiovascular imaging w/contrast w/risk factors
Cardiac electrophysiological tests
Diagnostic endoscopies w/identified risk factors
Elective major surgery w/risk factors
Emergency major surgery
Parenteral controlled substances
DNR due to poor prognosis

80. Medical Decision Making
The HIGHEST level of ANY ONE of the three aspects of a medical decision making will determine the overall level chosen

81. Medical Decision Making Final Medical Decision Making 2 of 3 rule
Straight Forward
Low
Moderate
High
Diagnosis &/or Management Options
Minimal (1)
Limited (2)
Multiple (3)
Extensive (> 4)
Amount of Data Reviewed
Table of Risk
Low (2)
Moderate (3)
High (4)

82. Defining Levels of E&M Services
7 components
History
Examination
Medical Decision Making
Counseling
Coordination of care
Nature of Presenting Problem
Time

83. Counseling and Coordination of Care
Discussion with patient or family concerning one or more of the following:
Diagnostic results
Prognosis
Risk & benefits of management options
Instruction for management
Compliance

84. Time…as another factor
Appropriate in cases where counseling and/or coordination of care dominates (>50%) of the patient and/or family encounter
Documentation requirements
Total face to face time or encounter
Total counseling/coordination time
Content of counseling/coordination

85. Time based billing…example
cc: Depression
Hx cc: 59 y/o female w/depression and anxiety. Denies suicidal ideations. Hx ativan use in past
Exam: vitals (list)
A/P: Depression. Had long discussion w/patient and counseled him on exacerbating factors and treatment options. Rx ordered (list)
Total visit time 25 minutes, counseling time 15 minutes

86. Summing Up Your Services
Billing the Correct Code…

87. The Constants of Coding
3 of 3 rule
Go to the lowest component
i.e., 2,3,4 = 2
3,3,4 = 3
Used for new patient, initial consults, initial hospital care and emergency department visits
2 of 3 rule
Go to the middle component
2,3,4 = 3
Used for established patient, subsequent hospital f/u, f/u consult

88. New vs. Established Patient
New Patient
All key components must meet or exceed the stated requirements to qualify for a particular level
Established Patient
Two key components must meet or exceed stated requirements to qualify for a particular level

89. Documentation Requirements New Patient Office Visit 3 of 3 rule
Level of Service
History
Examination
Medical Decision Making
99201
Problem focused
Straight forward complexity
99202
Expanded problem focused
99203
Detailed
Low complexity
99204
Comprehensive
Moderate complexity
99205
High complexity

90. Documentation Requirements New Patient Office Visit 3 of 3 rule
Level of Service
History
Examination
Medical Decision Making
99201
Problem focused
Straight forward complexity
99202
Expanded problem focused
99203
Detailed
Low complexity
99204
Comprehensive
Moderate complexity
99205
High complexity

91. Documentation Requirements New Patient Office Visit 3 of 3 rule
Level of Service
History
Examination
Medical Decision Making
99201
Problem focused
Straight forward complexity
99202
Expanded problem focused
99203
Detailed
Low complexity
99204
Comprehensive
Moderate complexity
99205
High complexity

92. Documentation Requirements New Patient Office Visit 3 of 3 rule
Level of Service
History
Examination
Medical Decision Making
99201
Problem focused
Straight forward complexity
99202
Expanded problem focused
99203
Detailed
Low complexity
99204
Comprehensive
Moderate complexity
99205
High complexity

93. Established Patient CPT E&M Guidelines 2 of 3 rule
Code
History
Physical Exam
Medical Decision making
Time
99211
Nursing service only
N/A
Nursing order 5
99212
Problem Focused (1)
Straight forward (1) 10
99213
Expanded Problem Focused (2)
Low Complexity (2) 15
99214
Detailed (3)
Moderate Complexity 25
99215
Comprehensive (4)
High Complexity (4) 40

94. Established Patient CPT E&M Guidelines 2 of 3 rule
Code
History
Physical Exam
Medical Decision making
Time
99211
Nursing service only
N/A
Nursing order 5
99212
Problem Focused (1)
Straight forward (1) 10
99213
Expanded Problem Focused (2)
Low Complexity (2) 15
99214
Detailed (3)
Moderate Complexity (3) 25
99215
Comprehensive (4)
High Complexity (4) 40

95. Established Patient CPT E&M Guidelines 2 of 3 rule
Code
History
Physical Exam
Medical Decision making
Time
99211
Nursing service only
N/A
Nursing order 5
99212
Problem Focused (1)
Straight forward (1) 10
99213
Expanded Problem Focused (2)
Low Complexity (2) 15
99214
Detailed (3)
Moderate Complexity (3) 25
99215
Comprehensive (4)
High Complexity (4) 40

96. Inpatient Codes Follow 3 of 3 rule Inpatient Services and Observation
Inpatient Consults
Inpatient follow ups follow the 2 of 3 rule

97. Other Medical Services
General Consultant
Pre/Post Operative Consults

98. Definition of Consultation
Type of service provided by a physician whose opinion ad advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.

99. Consultation Services
Documentation MUST include
Request for consultation documented in the medical record
Reason for consultation (medical necessity)
Report- Consultant’s opinion, advice and evaluation of the patient (this MUST be communicated back to the requesting physician)
Have separate initial coding
Follow up visits use established patient visits

100. Preoperative Consultation
Must request opinion or advice regarding a specific problem
Request and need for consult must be documented in the medical record
Any services ordered or performed must be documented
Consultant’s opinion, advice and evaluation of the patient must be communicated back to the requesting surgeon

101. Preoperative Clearance
ICD-9 diagnosis codes
V72.81 Preoperative cardiovascular examination
V72.82 Preoperative op respiratory examination
V72.83 Other specified preoperative examination
V72.84 Preoperative examination, unspecified
V72.85 Other specified examination
Must supplement with sigh/symptom/dx codes
Must also include surgical indication (eg, cataracts)

102. Rules for Consultation 99241-99275
Opinion or advise regarding E&M of a specific problem is requested
Documented request from appropriate source is required (if patient generated for )
Written report sent to referring provider (a letter for an outpatient)
Initiation of care at time of consult is acceptable
Post-op consult by provider performing pre-op clearance should use subsequent hospital codes or established office visit codes

103. New outpatient and consultative CPT E&M Guidelines 3 of 3 rule
Confirm
Consult
Initial consult
New patient
History
Physical Exam
Medical Decision Making
Time
99271
99241
99201
Problem Focused (1)
Straight forward (1) 10
99272
99242
99202
Expanded prob. focused (2)
Expanded prob.
focused (2) 20
99273
99243
99203
Detailed (3)
Low Complex (2) 30
99274
99244
99204
Comprehensive (4)
Moderate Complexity (3) 45
99275
99245
99205
High Complexity 60

104. Coding Examples

105. Documentation Requirements Established Patient Office Visit
Level of service
History
Examination
Medical decision making
99211
Nursing service only
Nursing order
99212
Problem focused
Straight forward complexity
99213
Expanded problem focused
Low complexity
99214
Detailed
Moderate complexity
99215
Comprehensive
High complexity

106. Example 99211 Non-physician visit
Patient Calls Advice Nurse with Possible UTI
Patient brings and drops-off UA
Nurse processes UA
You (Doctor/PA/NP) review and find UTI
Nurse calls in antibiotics and documents in Chart
Blood Pressure Check

107. Example 99212 4y/o female with fever and ear pain
Established Patient: 2 of 3 required
History: 1-2 HPI
Exam: 1-5 elements
Medical Decision Making: 1 self limited minor problem

108. Example 99212 4y/o female with fever and ear pain
History
Fever 101
Left ear 3 days
Exam
Injection with redness and drainage of tympanic membrane
Pharynx red, no exudates
+ anterior cervical nodes
Lungs clear
Heart rrr
Medical Decision Making
OM – Prescription Antibiotics
Fever control
Recheck in 2 weeks

109. Example 99213 4 y/o female with fever and ear pain
History:
1-3 HPI elements …AND
ROS
Exam: 6-11 elements
Medical Decision Making:
2 self-limited or minor problems …OR
1 new problem plus low risk

110. Example 99213 4 y/o female with fever and ear pain
History:
Fever and Ear pain for 3 days
ROS
Cough/sinus congestion, sore throat, vomiting and diarrhea
PFSH
NKA/Immunization/passive smoking/any chronic meds
Exam
3 vitals (weight, temp, BP)
Left TM red, pharynx red, tender nodes, neck supple, lungs clear, heart regular, abdomen non-tender
Medical Decision Making:
LOM
Antibiotics/Fever Control
Recheck in 2 weeks
Call if worse

111. Example 99214 58 y/o male at 3 month check up
Detailed history
Extended HPI
Extended ROS
One element PFSH
Detailed exam
12 exam elements from at least 2 systems
Moderate Complexity
2 of the following: Multiple dx; Moderate amount and complexity of data; Moderate risk

112. Example 99214 58 y/o male at 3 month check up
History
HTN; DM; DJD; vision exam UTD; (-) HA; (-) SOB; (-) CP; (-) NVDC; (-) Hematochezia; (-) Nocturia
PFSH
Unchanged from prior exam
Detailed exam
12 exam elements from at least 2 systems
Medical Decision Making
EKG, Pulse Oximetry; UA, Rapid Strep
Review of CXR
Prescriptions written
Document Procedures
Document OMM

113. OMT Billing

114. OMT codes These are nonallopathic lesions, not elsewhere classified.
CPT codes – 98929
ICD codes – depending on body region
Will be discussed at separate lecture in detail

115. Other Billable Services

116. Other Billable Services
Injections/Immunizations
Smoking Cessation
Visit and procedures

117. Injections/Immunizations
90471 is for first administration
90472 is for EACH additional administration
Cannot report if patient brings their own supply
Cannot bill (nursing service) if only injection given
Must provide separately identifiable service
e.g., get vital signs

118. Smoking Cessation Document that you told patient to stop smoking
99406 Greater than 3 minutes, up to 10 minutes
99407 Greater than 10 minutes

119. Other Billable Services
Digital Rectal Exam for Prostate Cancer Screening
G0102
Visual Acuity Exam (Snellen Chart)
99173
Needle Sticks!!
96150 – e.g., when an occupational health nurse sees a patient due to a needle stick he/she can code this encounter as E/M and CPT with the applicable ICD-9 primary for the wound and a secondary ICD-9 code of the External cause.

120. Billing an office Visit and a Procedure
Procedure must be a separate service from the evaluation and management service
Modifier 25 should be added to the evaluation and management service to identify that it is a separate service

121. Other Coding Opportunities
Modifiers
22 Unusual procedural service
25 significantly, separately identifiable E&M service by the same physician on the same day of the procedure or other service
e.g., patient comes in with sinus infection – you do OMT “cause it will help” vs. patient coming in specifically for OMT
32 Mandated by 3rd party (HMO)
51 Multiple Procedures

122. Other Miscellany

123. Other…
If you see a patient and admit directly to a hospital, you should submit only the hospital code.

124. Critical Care Codes Use appropriate E&M code if < 30 minutes 99291
First minutes of evaluation and management
99292
Each additional 30 minutes (can round up after 15 minutes)
e.g., minutes = x 1 and x 2

125. Prolonged Care Codes
Threshold time is 30 minutes over the time component allotted for the E&M code
Outpatient
Face to face time
Inpatient
Inpatient or outpatient office/floor/unit time without direct patient contact
e.g., IV running for rehydration in your office for 1 hour

126. Other Coding Opportunities
99050
After Hours
99052
Services Provided between 11pm and 8am
99054
Sundays/Holidays
99024
Post op follow up in Global Period
99058
Office services on Emergent basis
99082
Unusual Travel (transport/escort)
99090
Analysis of Data Stored on Computer

127. For Further Information
Evaluation and Management Services Guide - AMA