1. HCA Encounter Form Education May 2006
Office / Outpatient Visits
Documentation Requirements
Billable Time
99211 Services
Consultations
Preventative Medicine Visits
Screenings
Modifiers

2. Office Visits New vs. Established
    A “new” patient ( ) is someone who has not seen a provider (MD, PA, NP) within same
group; same specialty; same group payor ID number within the last 3 years.
An “established ( ) patient is someone that has seen a provider (MD, PA, NP) within same
group; same specialty; shared group payor ID # within the last 3 years.
New/Established designation is regardless of location of initial service. If a patient is seen in the
hospital by Dr. A and later continues care with Dr. A in his/her office, they are established.
If you are a new physician who has taken over patients from a retiring physician and the patient has
seen either that provider or another provider in the same group; same specialty; same payor ID
number within the last 3 years, they will be established to you.

3. Documentation The medical record is a “legal” document.
The medical record should be complete and legible
The reason for the visit should be clear
The date and legible identify of the observer clearly noted
The rationale for ordering diagnostic and other ancillary services
should be easily inferred.
The patient’s progress, response to and changes/revisions in
Treatment/diagnosis or need for continued treatment should be well documented.

4. Documentation
One of 2 things will happen when you provide an E&M office, outpatient
consultation or inpatient service to a patient.
Either:
You will spend 50% or more of the visit in a discussion; counseling; discussing mgmt options, coordinating care whereby then you need to document “time spent in these activities” or
You will spend 50% or more of the visit securing an HPI, Exam and determining the assessment and plan (eg. workup, treatment). If this occurs, a notation of time spent performing this review is NOT required. Instead elements of HPI, Exam and medical decision making will support your code selection.

5. Billable Time (>50% of the total visit time)
When the patient is present, counseling includes discussions on:  
Diagnostic results, impressions, and/or recommended studies; prognosis; risks and benefits of management (treatment) options;
Instructions for management (treatment) and/or follow-up;
Importance of compliance with chosen management (treatment) options;
Risk factor reduction; and patient and family education.
Coordination of Care w/other health care professionals
*Remember to “document time” spent in discussion.

6. The Documentation Process E&M Coding – when HPI, Exam and MDM predominant (>50% of total visit time)
A provider note is broken up into 3 key sections
History
Exam
Medical Decision Making

7. The Documentation Process E&M Coding
The HPI and Examination are described as:
Problem Focused
Expanded Problem Focused
Detailed
Comprehensive
The MDM (Medical Decision Making) is described as:
Straightforward/Minimal
Low
Moderate
High Complexity Mgmt

8. The Documentation Process E&M Coding - HPI
The HPI requires:
Reason for the Visit
Present Factors
(timing, location, modifying factors, signs/symptoms, duration, quality, context, and/or severity)
Review of Systems
Past, Family, Social History

9. The Documentation Process E&M Coding - Exam
The Exam requires:
1995 or
1997 guidelines

10. 1995 Exam Guidelines Body Areas (ea. are a count of 1) Head/Face Neck
Abdomen
Chest, including breast & Axillae
Genitalia, groin, buttocks
Back, including spine
“Each” extremity

11. 1995 Exam Guidelines Systems (ea. are a count of 1) Constitutional
Eyes
Ears, Nose, Mouth, Throat
Cardiovascular
Respiratory GI GU
Musculoskeletal
Skin
Neuro
Psych
Hematologic
Lymphatic
Immunologic

12. 1997 Exam Guidelines
In 1997 the AMA and CMS proposed a different set of guidelines for documentation of
the provider exam. 9 specialties participated and developed individual specialty
templates to represent what they believed incorporated elements of their exam.
Single System (S) Multi-Specialty (M)
Cardiovascular Anyone
ENT GI GU
Skin
Neuro
Muscloskeletal
Psych

13. Difference between 1995 & 1997 Exam
You could and still say: HEENT: Normal
1997
You would have to state the elements reviewed within a
system/body area – eg. Oropharnyx is clear, TM’s are normal

14. Medical Decision Making
1 of 3 Key Categories
Category 1:
Self-limiting/minor problem (stable, improved) 1 pt
Established problem (stable, improved) 1 pt
Established problem (worsening, not optimally responding) 2 pts
New Problem w/o workup 3 pts
New problem with workup 4 pts
1pt=minimal; 2pt=low risk; 3pt=moderate risk; 4+pts= high risk
Note: Please list all problems affecting your decision making on that visit.
Please indicate if problem is new; worsened; stable, mild/serious
exacerbation and/or life-threatening.

15. Medical Decision Making
2 of 3 Key Categories
Category 2:
Review/order labs (regardless of # ordered/reviewed) 1 pt
Review/order radiology tests (regardless of # ordered/reviewed) 1 pt
Review.order EEGs, EKGS (regardless of # ordered/reviewed) 1 pts
Discuss results w/interpreting provider 1 pt
Obtain old records other then from pt 1 pt
Review/Summarize old records and or obtain history from someone
Other then patient and/or discussion of case w/another healthcare
Provider pts
Independent Review of image/specimen/tracing 2 pts
1=minimal
2=low risk
3=moderate risk
4+= high risk

16. Medical Decision Making
3 of 3 Key Categories
Category 3:
Minimal (reassurance, no OTC, no medication mgmt)
Colds
URI w/o Fever
Bug bite
Low risk (1 stable Chronic problem, acute uncomplicated illness)
Sinusitis
Vaginitis
URI w/Fever
Bronchitis (not serious/pneumo)
Headache w/o nausea vomiting
Low back pain

17. Medical Decision Making
3 of 3 key areas continued
Moderate risk (2+ stable CI, 1 CI w/mild exacerbation; undiagnosed new problem)
Hard node in breast w/workup
Headache/migraine w/nausea/vomiting
Blood in stools
3+ stable chronic problems
Mild exacerbation of 1 chronic illness
High risk (significant exacerbation of a CI, threat to life/self)
Chest pain
Significant Shortness of Breath; COPD pt.
Multiple Chronics evaluated (HTN, Diabetes, Renal Failure, COPD, Hyperlipidemia)
Significant exacerbation of 1 chronic illness

18. New Patient Visit (99201-05) Consultations (99241-45)
HPI Exam MDM Code
1PF,0ROS,OPFS 1 body area/system (95) Straight (10 min)
Update 1 CI (97) 1 element (97) (15 min)
1PF;1ROS;OPFS 2-7 Ltd sys/areas (95) Straight (20 min)
Update 1 CI (97) 6-11 elements (97) (30 min)
4PF;2-9ROS;1PFS 2-7 Ext sys/areas (95) Low (30 min)
Update 3 CI (97) 12 elements (97) (40 min)
4PF;10ROS;2PFS 8 sys/areas (95) Moderate (45 min)
Update 3 CI (97) All Boxed Areas (97) (60 min)
4PF;10ROS;2PFS 8 sys/areas (95) High (60 min)
All Boxed Areas (97) (80 min)

19. Established Office Visit (99211-99215)
HPI Exam MDM Code
Does not require the presence of a physician (5 min)
1PF,0ROS,OPFS 1 body area/system (95) Straight (10 min)
Update 1 CI (97) 1 element (97)
1PF;1ROS;OPFS 2-7 Ltd sys/areas (95) Low (15 min)
Update 1 CI (97) 6-11 elements (97)
4PF;2-9ROS;1PFS 2-7 Ext sys/areas (95) Moderate (25 min)
Update 3 CI (97) 12 elements (97)
4PF;10ROS;2PFS 8 sys/areas (95) High (40 min)
Update 3 CI (97) All Boxed Areas (97)

20. 99211 Billable Services
Examples of office/clinic visits generally billable using 99211:
A blood pressure eval for an est pt whose physician requested a f/u visit to ck blood pressure
Refilling medication for a patient whose prescription has run out to hold him over until her can get an appointment (pt must be present in office suite)
Discussion with patient in person following laboratory tests that indicate the need to adjust medications or repeat order of tests
Suture removal following placement by a different physician/physician group
Visit for instructions/patient education on how to use a peak flow meter
Diabetic counseling
Dressing change for an abrasion/injury

21. 99211 Non Billable Services
Examples of services generally not billable using 99211:
Blood draw - should be billed using CPT 36415
Laboratory tests - the lab performing the test should bill the appropriate codes
Monitoring of cardiology tests, such as thallium stress tests, where such monitoring is inherent in the performance of the test
Injection of medication - use CPT drug administration code and drug code 
Influenza vaccination - use vaccination code and administration code only

22. Consultations (99241-45) Place of Service: office/outpt/ER
Documentation Criteria:
Document name of referring physician name
Indicate in HPI that the visit is a result of a “request for consultation”
Provide a written report to the requesting provider unless there is a shared record situation (aka inpatient; or same specialty consult)

23. Consultations CPT Codes 99241-99245
 If a provider requests (verbal or written) a consultation.
  If you are a specialist and you hold a particular expertise a member of your group can refer a
patient for consultation to you.
If you see a patient in the “outpatient” setting of a hospital per the request of a provider of
another specialty or same specialty and your expertise is required.
Code for a consultation in the ER, if the ER physician calls you in to evaluate whether or not a
patient should be admitted. If they are not admitted by the provider or a member of his/her
specialty group then submit code If they are admitted and you are the admitting
provider then you can only code for the admission ( ).

24. Preventative Medicine Visits CPT Code 99381-87 (new) 99291-97 (est)
Preventative Medicine Visit Codes include payment for:
The review of “stable” chronic problems
Routine Screenings (eg. Pap smear, breast & pelvic, manual rectal exam)
Risk Factor Counseling
Billable Separately When Billed on Same Day as Physical are:
E&M Office Visit codes (for re-management of existing problems or new problems (need mod 25)
Do not bill 2 new E&M’s in same day
Injections, Immunizations
Procedures Performed (exception Medicaid – they will only pay for procedure)
Some Screenings
Labs (Indicate signs/symptoms or diagnosis to support testing)

25. Physicals - Medicare
MC does not pay for physicals ( ; ) other then new mc beneficiaries (next slide)
They will pay for services (eg. medically necessary follow-up or new problems addressed during a physical.
They will pay for problems addressed during a physical when a modifier 25 is affixed.
MC will pay for screenings performed during a physical if the service is performed during a covered period. (eg. paps covered every 2 yrs).

26. Physicals Medicare “New MC Beneficiary”
G0344: Effective 1/1/05 MC will pay physical / new MC enrollee / within 6 mths
G0366: EKG (global)
G0367 (EKG tracking only)
G0368 (EKG Inter & Rep Only)
Medicare does not pay for routine annual physicals ( ; )
Medicare will pay for services (eg. medically necessary follow- up or new problems) billed w/physicals. Mod 25 needs to be affixed to codes.

27. Medicare – “New MC Beneficiary” Required Documentation
Initial Exam includes review of:
HPI
Attention to risk factors for disease detection
Past medical, Social & Surgical history
Experiences w/illnesses
Hospital stays
Operations
Allergies
Injuries & treatments
Current medication & supplements
FH (hereditary or place the individual at risk) History of alcohol, tobacco,
illicit drug use
Diet
Physical activities
Psych Eval - Depression
Individual’s potential (risk factors) for depression including current or past experiences w/depression or other mood disorders.
Refer to appropriate screening instrument for persons without a current diagnosis of depression recognized by a National Professional Medical Organizations.

28. Medicare – “New MC Beneficiary” Required Documentation
EKG
Performance and interpretation of an EKG.
Functional Abilities / Level of Safety
Mininum review must include assessment of:
Hearing impairment
Activities of daily living
Falls risk
Home safety
Examination
Measurement of individual’s height, weight, blood pressure
Visual acuity screen
Other age-appropriate factors as deemed appropriate by the provider based on the individual’s med/social history and current clinical standards.

29. Medicare – “New MC Beneficiary” Required Documentation
Risk Factor Counseling
Education, counseling and referral as deemed appropriate by the provider based on results of the review
Provide Brief Written Plan
A checklist or alternative provided to the individual for obtaining the appropriate screening and other preventive services which are covered separately under Medicare Part B.
11 points checklist:
Immunizations (pneumococcal, Influenza, Hep B and their administration.
Mammography screening
Pap smear & pelvic examination screening
Prostate cancer screening tests
Colorectal cancer screening tests
Diabetes outpatient self-mgmt training services
Bone mass measurements
Glaucoma screening
Medical nutrition therapy for individuals with diabetes or renal disease
Cardiovascular screening blood tests
Diabetes screening tests

30. Physicals - Medicaid Will pay for physicals if pt ONLY has Medicaid
Will not pay for physical if billed AFTER Medicare denial.
Will not pay for physicals billed with screenings on same day.
They do not recognize modifier 25 at all.

31. Physicals – HMO’s “Managed Care Plans” Tufts/HPHC/HMOBlue
Will pay for physicals
Will also pay for problems addressed during a physical (eg. UTI dx billed with )
They will not pay for screenings if billed in conjunction with an annual physical unless high risk or abnormal dx submitted.
They will however pay for screenings if billed with an E&M office visit code ( or ) vs. a physical cpt code.

32. Screenings – Pap Smear
Code a Q0091 for the collection of the pap smear.
Code diagnosis code V76.2 (low risk of malignant neoplasm) or V15.89 (high risk)
Coverage every 2 yrs.

33. Screenings – Breast & Pelvic
Code G0101 if “both” the breast & pelvic exam are performed.
Code Dx. code V76.10
If G0101 is billed with a Physical it will reject as a “bundled” service for Tufts, HPHC (blues pays)
It is reimburseable when it is billed by itself as the “sole” service or with an E&M office visit code.
Coverage every 2 years.
G0101 requires the review and documentation of 7 out of 11 areas in GU system.

34. Screening – Breast & Pelvic Documentation Requirements G0101 requires documentation of 7/11 elements:
Inspection and palpation of breasts for masses or lumps, tenderness, symmetry or nipple discharge.
Digital rectal examination including sphincter tone, presence of hemorrhoids, and rectal masses.
Pelvic examination (w/or w/out specimen collection for smears and cultures) including:
· External genitalia (general appearance, hair distribution, or lesions) · Urethral meatus (size, location, lesions, or prolapse) · Urethra (masses, tenderness, or scarring). · Bladder (fullness, masses, or tenderness). · Vagina (general appearance, estrogen effect, discharge, lesions, pelvic support,
cystocele, or rectocele) · Cervix (general appearance, lesions, or discharge). · Uterus (size, contour, position, mobility, tenderness, consistency,
descent, or support) · Adnexa/parametria (masses, tenderness, organomegaly, or nodularity)
Anus and perineum.

35. Screenings – Blood Occult Routine
Code G0107 with diagnosis code V76.51
Annual benefit
Do not use “82270” in the absence of signs/symptoms or it will reject.

36. Screenings – Digital Rectal Exam
Code G0102 with diagnosis code V76.44
Annual benefit. Note: not covered when billed with annual physical
(eg. preventive medicine code)
It is reimburseable if billed with an office visit.

37. Screenings – Routine Labs
(eg , 81000, 82270)
In the absence of signs/symptoms these services will reject.
It is critical that you link a diagnosis code (eg. definitive or signs/symptoms)
when ordering a lab test when applies.

38. Modifiers
Modifiers are 2 digit codes which accompany a 5 digit CPT code in
order to further describe a situation to support additional payment
when more then one service is being reported in the same session
on the same day.
Primary Care Modifiers 25

39. Modifier 25
Modifier –25
Should only be appended to evaluation and management (E/M)
service codes HCPCS codes G0101(Breast & Pelvic Screening)
and Procedures
You do not need a modifier 25 when billing an office visit and
also billing for:
1) Diagnostics (eg. EKG)
2) Immunizations
3) Screenings

40. Modifier 25 Examples Modifier 25 Examples
When the patient presents for a planned procedure and has a different problem that requires an E/M service (two different diagnoses would be used to distinguish the services)
the patient presents with a "minor" problem and after evaluation the decision is made to perform a procedure. In the second example –25 is used if the procedure is minor in nature, meaning that the post-operative period is less than 90 days and the primary diagnosis would be the same for both.