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Provided by Coventry Health Care ©2011 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission.

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Presentation on theme: "Provided by Coventry Health Care ©2011 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission."— Presentation transcript:

1 Provided by Coventry Health Care ©2011 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care. Usual and Customary Medical Bill Reviewer Training Program Unit 1: Professional Services Module 2: Evaluation and Management

2 Usual & Customary Training – E&MJuly 2011 Overview Classification of Evaluation and Management Services New and Established Patients Hospital Visits Emergency Department Services Consultations and Referrals Same Day E & M Services Lets start by discussing how E & M services are classified...

3 Usual & Customary Training – E&MJuly 2011 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. Lets continue The E & M section ranges from 99201- 99499.

4 Usual & Customary Training – E&MJuly 2011 Classification of Services Evaluation and management services are classified differently depending on the type of service, as well as where the service is rendered. Now lets take a look Evaluation and Management can be classified as: Evaluation and management services can also be classified by intensity. Office visits Hospital visits Consultations

5 Usual & Customary Training – E&MJuly 2011 Classification of Services Evaluation and Management services that have different intensities are considered different levels of service. Increasing Intensity The following levels of service can be assigned: Comprehensive Detailed Expanded Problem Focused Problem Focused

6 Usual & Customary Training – E&MJuly 2011 Classification of Services Different levels of services are determined primarily by three key components. Increasing Intensity The following levels of service can be assigned: Comprehensive Detailed Expanded Problem Focused Problem Focused Levels of services are determined primarily by: History Examination Complexity of Medical Decision-making Each component of an evaluation is assigned a level of service.

7 Usual & Customary Training – E&MJuly 2011 New vs. Established Patients Now that you understand how Evaluation and Management services are classified, we can discuss how patients are classified.

8 Usual & Customary Training – E&MJuly 2011 New vs. Established Patients There are two types of patients within evaluation and management office visits: New Patients Established Patients Lets take a look…

9 Usual & Customary Training – E&MJuly 2011 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

10 Usual & Customary Training – E&MJuly 2011 New Patients Seen By Multiple Physicians Lets continue….. 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. 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.

11 Usual & Customary Training – E&MJuly 2011 Established Patients An established patient is one who has been seen for the same injury or illness. Established Patients

12 Usual & Customary Training – E&MJuly 2011 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.

13 Usual & Customary Training – E&MJuly 2011 Hospital Visits Classification of Evaluation and Management Services New and Established Patients Hospital Visits Emergency Department Services Consultations and Referrals Same Day E & M Services Now that you are familiar with the basics of E & M services, lets discuss how hospital visits are reimbursed.

14 Usual & Customary Training – E&MJuly 2011 Hospital Visits Similar to office visits, there are two categories of patients within hospital visits: Initial Visits Subsequent Visits Lets take a look…

15 Usual & Customary Training – E&MJuly 2011 Initial Hospital Visits 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. The other services are not to be billed separately.

16 Usual & Customary Training – E&MJuly 2011 Initial Hospital Visits 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.

17 Usual & Customary Training – E&MJuly 2011 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.

18 Usual & Customary Training – E&MJuly 2011 Subsequent Hospital Visits Subsequent visits occur when the physician visits a hospitalized patient on subsequent days Reimbursement for subsequent visits differs depending on who provides the subsequent visit. Hi Mr. Jones, you are looking better today. If the same physician, or a physician from the same specialty group visits the patient, the visit should be billed as a subsequent visit.

19 Usual & Customary Training – E&MJuly 2011 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.

20 Usual & Customary Training – E&MJuly 2011 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…

21 Usual & Customary Training – E&MJuly 2011 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.

22 Usual & Customary Training – E&MJuly 2011 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 99218- 99220.

23 Usual & Customary Training – E&MJuly 2011 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.

24 Usual & Customary Training – E&MJuly 2011 Prolonged Service Code Characteristics: Prolonged Service Codes Prolonged Service Codes are codes used when a physician provides a service beyond the typical service time for a specific E & M code. The service provided and the length of time required must be identified and documented.

25 Usual & Customary Training – E&MJuly 2011 Prolonged Service Codes There are two types of prolonged service codes: Direct (Face to Face) Contact Without Direct Contact Lets take a look…

26 Usual & Customary Training – E&MJuly 2011 Direct (Face to Face) Contact Outpatient setting: CPT 99354: 31 to 74 minutes. CPT 99355: Each additional 30 minute increment. Inpatient setting: CPT 99356: 31 to 74 minutes. CPT 99357: Each additional 30 minute increment. Direct (Face to Face) Contact

27 Usual & Customary Training – E&MJuly 2011 Without Direct Contact CPT 99358: used to report the first hour spent (30-74 minutes) reviewing records and tests, or communicating with other medical professionals, during or following direct contact with a patient.

28 Usual & Customary Training – E&MJuly 2011 Emergency Department Emergency department codes are reimbursed slightly differently than other E & M services. Lets take a look... Classification of Evaluation and Management Services New and Established Patients Hospital Visits Emergency Department Services Consultations and Referrals Same Day E & M Services Emergency Department Services

29 Usual & Customary Training – E&MJuly 2011 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.

30 Usual & Customary Training – E&MJuly 2011 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

31 Usual & Customary Training – E&MJuly 2011 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.

32 Usual & Customary Training – E&MJuly 2011 CPT 99285 CPT 99281 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.

33 Usual & Customary Training – E&MJuly 2011 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 ER 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 ER services, critical care services are paid by time rather than key components and the presenting problem.

34 Usual & Customary Training – E&MJuly 2011 Consultations and Referrals Lets take a look… Evaluation and Management services can be billed differently if the physician provides advice regarding a diagnosis, or facilitates the transfer of a patient to a different physician.

35 Usual & Customary Training – E&MJuly 2011 Consultations and Referrals Evaluation and Management services are distinguished by: ConsultationsReferrals Lets take a look…

36 Usual & Customary Training – E&MJuly 2011 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.

37 Usual & Customary Training – E&MJuly 2011 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

38 Usual & Customary Training – E&MJuly 2011 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

39 Usual & Customary Training – E&MJuly 2011 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.

40 Usual & Customary Training – E&MJuly 2011 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 (99201-99215), or subsequent hospital care codes.

41 Usual & Customary Training – E&MJuly 2011 Same Day E & M Services Lets take a look… Occasionally, the same patient receives multiple E & M services on the same day... Sam Boyd, MD Orthopedist Jane Smith, MD Internist

42 Usual & Customary Training – E&MJuly 2011 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.

43 Usual & Customary Training – E&MJuly 2011 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.

44 Usual & Customary Training – E&MJuly 2011 E&M Coding Accuracy 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 type and level of E/M 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.

45 Usual & Customary Training – E&MJuly 2011 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. New Patient seen by multiple physicians. Well Done. Youre a star!


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