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©2010 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care.. Provided.

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Presentation on theme: "©2010 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care.. Provided."— Presentation transcript:

1 ©2010 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care.. Provided by Coventry Health Care® California Medical Bill Reviewer Re-Certification Unit 2: Official Medical Fee Schedule Module 3: Evaluation and Management

2 CA Regulations Training – E & M March 2010 Overview Hi! In this module, you will learn about evaluation and management services, how they are classified, and the difference between new and established patients. Then, you will learn about emergency department codes, the difference between consultations and referrals, and how same day E & M services are reimbursed. Lets start by discussing how E & M services are classified... Classification of Evaluation and Management Services New and Established Patients Hospital Visits Emergency Department Services Consultations and Referrals Same Day E & M Services Classification of Evaluation and Management Services

3 CA Regulations Training – E & M March 2010 Evaluation and Management Guidelines Evaluation and Management services focus on the initial understanding and diagnosis of an illness or injury, as well as facilitating the necessary treatment to cure the illness or injury. In the OMFS, the E & M section ranges from You might recall from the Physicians Services module that only physicians can bill for E & M services.

4 CA Regulations Training – E & M March 2010 Classification of Services Evaluation and management services are classified differently depending on the type of service as well as where the service is rendered. Evaluation and Management can be classified as: Office visits Hospital visits Consultations Evaluation and management services can also be classified by intensity. Lets take a look…

5 CA Regulations Training – E & M March 2010 Classification of Services There are seven different components that can be considered when differentiating levels of service. The following levels of service can be assigned: Comprehensive Detailed Expanded Problem focused Components include: History Examination Medical decision-making Counseling Coordination of Care Nature of Presenting Problem Time Increasing Intensity

6 CA Regulations Training – E & M March 2010 Classification of Services But different levels of service are determined primarily by three key components. The following levels of service can be assigned: Comprehensive Detailed Expanded Problem focused Levels of service are determined primarily by: History Examination Medical decision-making Increasing Intensity Each component of an evaluation is assigned a level of service.

7 CA Regulations Training – E & M March 2010 Classification of Services You should be aware that some E & M services only require two of the three key components to meet or exceed the requirements to qualify for a specific level of service. These services include: Established patient office visits Subsequent hospital care Follow-up inpatient consultations Subsequent nursing facility care Established patient home visits

8 CA Regulations Training – E & M March 2010 Example: Classification of Services In some instances, a provider spends the majority of the appointment counseling the patient or coordinating care. If at least 50% of the visit time is taken up in counseling or coordination of care, time becomes the criteria for service level. Documentation must note the time spent and a description of the counseling or care coordination.

9 CA Regulations Training – E & M March 2010 Classification of Services Providers are relied upon to code their visits accurately and fairly. However, during the review of a bill, any office visit on that bill may be evaluated for correctness of the assigned level of service. Also, utilization review departments working on behalf of the payors and 3 rd party administrators will look for patterns of abuse in provider coding.

10 CA Regulations Training – E & M March 2010 New vs. Established Patients There are two types of patients within evaluation and management office visits: New Patients Established Patients Lets take a look…

11 CA Regulations Training – E & M March 2010 New Patients A new patient is one who is new to the physician, or an established patient with a new injury or condition. New Patients

12 CA Regulations Training – E & M March 2010 New Patients Seen By Multiple Physicians If a patient sees different specialists within a multi- specialty medical group, each specialist is entitled to use a new patient code on the initial visit. However, per the fee schedule, only one physician per specialty may charge as a new patient visit for the same injury or condition. If a different physician within the same specialty is on call and sees a patient, the visit is billed as it would have been by the regular treating physician.

13 CA Regulations Training – E & M March 2010 Established Patients An established patient is one who has been seen for the same injury or illness. Established Patients

14 CA Regulations Training – E & M March 2010 Established Patients Established patients may return for a follow-up visit regarding the status of the initial illness or injury. Follow-up visits by established patients are automated in the bill review system. 1. If a second initial visit is billed, the bill review system suspends the bill and prompts the processor to evaluate whether the same provider is billing for a second initial visit. 2. If a second initial visit is billed, the processor should substitute with a comparable subsequent visit code.

15 CA Regulations Training – E & M March 2010 Hospital Visits Similar to office visits, there are two categories of patients within hospital visits: Initial Visits Subsequent Visits Lets take a look…

16 CA Regulations Training – E & M March 2010 Initial Hospital Visits The other services are not to be billed separately. If a patient is admitted to a hospital in the course of being seen elsewhere, including... Emergency department Observation Physicians office Nursing facility... all E/M services provided for that condition are included in the initial hospital visit.

17 CA Regulations Training – E & M March 2010 Example: Suppose Mr. Johnson is seen by Dr. Gade in the office for a possible back injury. The physician sends him to the hospital for x-rays, then sees Mr. Johnson in the ER. Mr. Johnson is admitted to the hospital for a vertebral fracture. Dr. Gade can charge for an initial hospital visit, but the office visit and the ER visit are included. The work and time involved in the first two encounters are considered as part of the initial visit service level. Initial Hospital Visits

18 CA Regulations Training – E & M March 2010 Initial Hospital Visits In some instances, physicians admit patients to the hospital by phone. If a physician admits a patient by phone, they report the initial hospital visit code on the day they actually see the patient.

19 CA Regulations Training – E & M March 2010 Subsequent Hospital Visits Subsequent visits occur when the physician visits a hospitalized patient on subsequent days. If the same physician, or a physician from the same specialty group visits the patient, the visit should be billed as a subsequent visit. Hi Mr. Jones, you are looking better today. Reimbursement for subsequent visits differs depending on who provides the subsequent visit.

20 CA Regulations Training – E & M March 2010 Subsequent Hospital Visits However, if a physician from a different specialty group visits the patient, the service may be billed with initial inpatient consultation codes or subsequent hospital care codes. Dr. Meyer says that your symptoms are improving. This means that only one initial hospital visit can be billed per patient.

21 CA Regulations Training – E & M March 2010 Observation Services Prior to being admitted to the hospital, a patient is occasionally placed under observation. In these cases, observation codes are used. There are two types of observation services: Initial Discharge Lets take a look…

22 CA Regulations Training – E & M March 2010 Initial Observation Codes Like other evaluation and management services, observation codes are not to be charged for post-operative care in connection with a surgical service. Initial observation services are reported per day. It is expected that a decision will be made within a day to send the patient home or admit him to the hospital.

23 CA Regulations Training – E & M March 2010 Example Initial Observation Codes If the patient is admitted to the hospital, the observation charges are rolled into the initial hospital visit. But, if the patient is admitted to observation and discharged on the same day, the only code used would be an initial admit code from

24 CA Regulations Training – E & M March 2010 Discharge Observation Services Discharge observation services are only reported when the patient is discharged from the hospital on a different day than they were admitted. Discharge observation services are indicated by CPT 99217: Observation care discharge.

25 CA Regulations Training – E & M March 2010 Emergency Department Services Emergency Department Services: services rendered in a 24- hour hospital-based facility designed to accommodate immediate medical care to patients requiring unscheduled treatments. There is no distinction between new or established patients in the emergency department. Emergency department (ED) codes are only to be billed for services in the ED. Services provided elsewhere, including an urgent care center, are not eligible for emergency room coding. In addition, for any single ED patient visit, only one physician can report an ED E/M code. If two physicians see the patient, one may code for an ED visit and the other for another appropriate visit.

26 CA Regulations Training – E & M March 2010 Emergency Department Services Like other types of evaluation and management services, emergency department visits tend to vary with intensity. Because of the extensive variability, time is not a descriptive component of an emergency department visit. Emergency department visits vary with: The number of patient encounters Time waiting for test results Medication Patient observation Care of other patients

27 CA Regulations Training – E & M March 2010 Emergency Department Codes Instead, emergency department visits are coded by key components and the nature of the presenting problem. Lets take a look… Emergency department codes vary by: The severity of the injury or illness. The extent of treatment. As a result, like evaluation and management codes, emergency department codes also vary.

28 CA Regulations Training – E & M March 2010 Example 2Example 1 CPT CPT Emergency Department Codes Corresponds to minor injuries or illnesses that require straightforward examination and treatment, such as: Emergency department visit for the treatment of poison ivy. Emergency department visit for the diagnosis and wrap of a sprained ankle. Corresponds to severe injuries or illnesses that pose an immediate threat to the patients life, such as: Emergency department visit for internal bleeding. Emergency department visit for severe chest pain.

29 CA Regulations Training – E & M March 2010 Critical Care Services If services provided in the emergency department are of a critical nature, and meet certain criteria, a critical service code may be billed in addition to the appropriate evaluation and management code(s). Critical care services may be billed for direct delivery of care in the ED to a critically ill or injured patient. Critical care service criteria: Total time delivering critical care services must be greater than 30 minutes. Physician must be in constant attendance, or involved in treatment directly. Separate documentation of critical care services must be included. Separate documentation is important because unlike other ED services, critical care services are paid by time rather than key components and the presenting problem.

30 CA Regulations Training – E & M March 2010 Consultations and Referrals Evaluation and Management services are also distinguished by: ConsultationsReferrals Lets take a look…

31 CA Regulations Training – E & M March 2010 Consultations A consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. Consultations The physician may order diagnostic tests in order to form an opinion regarding the patients diagnosis.

32 CA Regulations Training – E & M March 2010 Consultations In order for a visit to be classified as a consultation, the three ROs must be met. pinion equest for an pinion endering an pinion eport of an

33 CA Regulations Training – E & M March 2010 Referrals A referral constitutes the transfer of the total or specific care of a patient from one physician to another. Referrals do not constitute a consultation. Referrals

34 CA Regulations Training – E & M March 2010 Referrals If the referring physician writes eval and treat they are, in essence, referring the patient to the other physician and not asking for an opinion. This is true even if the specialist sends a report to the referring physician, which is considered only a professional courtesy.

35 CA Regulations Training – E & M March 2010 Where might you find documentation of the referral? Referrals Sometimes, a physician refers a patient to another physician without a written or verbal request for a consultation. The patient referral should be documented in the patients records. In these instances, the referral should be reported using office codes, outpatient codes ( ), or subsequent hospital care codes.

36 CA Regulations Training – E & M March 2010 Same Day E & M Services There are instances when a provider bills for an E&M twice on the same day. Lets take a look… Before denying the charge as a duplicate, you must check the providers documentation carefully. There are instances when the charges are allowable.

37 CA Regulations Training – E & M March 2010 Same Day E & M Visits I am glad he came in again…we should be able to repair the damage… You should be fine…come back in if you continue to experience symptoms… Subsequent E & M visits are allowable if: Charges are for different specialists in the same group. The patient experienced difficulties or complications that required a second trip to the office or emergency room.

38 CA Regulations Training – E & M March 2010 Same Day E & M Visits A modifier indicates subsequent E & M services on the same calendar day. Modifier –19: Subsequent E & M services within the same calendar day. This modifier must be used with the associated E & M code to bill for subsequent visits. An explanation that documents the circumstances must also be included with the bill.

39 CA Regulations Training – E & M March 2010 Summary How E & M services are classified and who can bill them. The difference between new and established patients. Emergency department service codes. Same day E & M services: What is allowable? The difference between consultations and referrals. Patients seen by multiple physicians.


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