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

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Presentation on theme: "ICD-9, CPT, E&M Coding Documentation and Compliance …or the in-service for the in-service!!"— Presentation transcript:

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 …and after the exam You want to get paid You want to get paid (After all, you need to pay mortgage, food, etc) (After all, you need to pay mortgage, food, etc) Insurance will pay you if… Insurance will pay you if… You tell the company what you did…AND… You tell the company what you did…AND… You tell the company why you did it You tell the company why you did it

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

4 ICD codes ICD-9

5 ICD Codes ICD = International Statistical Classification of Diseases and Related Health Problems 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. 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. Every health condition can be assigned to a unique category and given a code, up to six characters long. Easy to understand Easy to understand Allows for global (international) understanding of information Allows for global (international) understanding of information

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

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

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

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

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

11 : Symptoms, signs and ill- defined conditions (780) General symptoms (780) General symptoms (780.0) Alteration of consciousness (780.0) Alteration of consciousness (780.01) Coma, nondiabetic, nonhepatic (780.01) Coma, nondiabetic, nonhepatic (780.02) Mental status changes (780.02) Mental status changes (780.09) Semicoma, stupor (780.09) Semicoma, stupor (780.1) Hallucinations (780.1) Hallucinations (780.2) Syncope (780.2) Syncope (780.3) Convulsions (780.3) Convulsions (780.31) Seizures, convulsions, febrile (780.31) Seizures, convulsions, febrile (780.39) Seizures, convulsions, other (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 CPT Current Procedural Terminology

13 CPT CPT = Current Procedural Terminology CPT = Current Procedural Terminology Code Set accurately describes medical, surgical, and diagnostic services 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. 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 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. 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 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. 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 1: Evaluation and Management Codes ( ) Chapter 2: Anesthesia Codes ( ) Chapter 2: Anesthesia Codes ( ) Chapter 3: Surgery Codes ( ) Chapter 3: Surgery Codes ( ) Chapter 4: Radiology Codes ( ) Chapter 4: Radiology Codes ( ) Chapter 5: Pathology/Laboratory Codes ( ) Chapter 5: Pathology/Laboratory Codes ( ) Chapter 6: Medicine Codes ( ) Chapter 6: Medicine Codes ( ) Appendices: Modifiers, Deleted codes Appendices: Modifiers, Deleted codes

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

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

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

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

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

23 Why Code? REIMBURSEMENT REIMBURSEMENT Third Party Payers/Insurance Agencies Third Party Payers/Insurance Agencies Prospective Payment Systems (PPS) Prospective Payment Systems (PPS) Over coding = Fraud Over coding = Fraud Under coding = Lost Revenue 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 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! 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: Every patient encounter should be legible and include: Date of Encounter Date of Encounter Reason for the visit (chief complaint) Reason for the visit (chief complaint) Appropriate history of present illness Appropriate history of present illness An exam when necessary or appropriate; i.e. a new patient (consistency and problem pertinent) 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 Review of lab, x-ray, other ancillary services when appropriate Assessment Assessment Plan of care/Treatment options Plan of care/Treatment options Provider signature Provider signature

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

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

28 New vs. Established New patient 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 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 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 e.g., current practice seen in OLBH ER and Outreach offices Professional Services: Phone call, prescription, hospital or office visit, etc. 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) 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 ** 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: There are three key components to consider when selecting the appropriate E&M: History History Exam Exam Medical Decision Making (MDM) 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. 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). 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! 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. 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: Remember: For a new clinic patient, initial consult, initial inpatient visit or ED encounter you must document all three key components 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. history, exam and your medical decision making.

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

33 The Medical History

34 History Also has several components to determine “complexity” or “type” Also has several components to determine “complexity” or “type” History of Present Illness (HPI) History of Present Illness (HPI) Review of Systems (ROS) Review of Systems (ROS) Past Family and/or Social History (PFSH) Past Family and/or Social History (PFSH) The extent of history is dependent on clinical judgment and the nature of the presenting problem. 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. 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 Chief Complaint Required concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter. 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. The CC is usually stated in the patient’s own words. For example, patient complains of upset stomach, aching joints, and fatigue For example, patient complains of upset stomach, aching joints, and fatigue Cannot be the words “follow up” alone Cannot be the words “follow up” alone

37 History – History of Present Illness Two types of HPI Two types of HPI Brief, which includes documentation of one to three HPI elements. Brief, which includes documentation of one to three HPI elements. In the following example, three HPI elements – location, severity, and duration – are documented: 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. 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. 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. 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: 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 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 Location Area of body, localized, unilateral, bilateral, fixed, migratory, radiation, referred Area of body, localized, unilateral, bilateral, fixed, migratory, radiation, referred Quality Quality Specific pattern, sharp, dull, throbbing, stabbing, constant, intermittent, acute, chronic, stable, improving, worsening Specific pattern, sharp, dull, throbbing, stabbing, constant, intermittent, acute, chronic, stable, improving, worsening Laceration as jagged or straight Laceration as jagged or straight Sore throat as scratchy Sore throat as scratchy Severity Severity Pain scale, “compared to”, observation by physician (discomfort, wincing) Pain scale, “compared to”, observation by physician (discomfort, wincing) Duration Duration

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

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

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

43 Review of Systems

44 Definition Definition 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 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: The following “systems” are recognized: Constitutional (fever, weight loss)- Psychiatric Constitutional (fever, weight loss)- Psychiatric Eyes- Endocrine Eyes- Endocrine Ears, nose, mouth throat- Neurological Ears, nose, mouth throat- Neurological Cardiovascular- Allergic/Immunologic Cardiovascular- Allergic/Immunologic Respiratory Respiratory Gastrointestinal Gastrointestinal Musculoskeletal Musculoskeletal Integumentary (skin and/or breast) Integumentary (skin and/or breast) Hematologic/Lymphatic Hematologic/Lymphatic

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

46 Review of Systems Extended Extended ROS inquires about the system directly related to HPI AND a limited number of additional systems ROS inquires about the system directly related to HPI AND a limited number of additional systems 2-9 systems which are documented 2-9 systems which are documented In the following example, two systems – cardiovascular and respiratory – are reviewed: 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.” 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. 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 Complete ROS inquires about the system directly related to the HPI AND all other body systems ROS inquires about the system directly related to the HPI AND all other body systems At least 10 body systems must be documented 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 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: In the following example, 10 signs and symptoms are reviewed: CC: Patient complains of “fainting spell.” CC: Patient complains of “fainting spell.” ROS: ROS: Constitutional: weight stable, + fatigue. Constitutional: weight stable, + fatigue. Eyes: + loss of peripheral vision. Eyes: + loss of peripheral vision. Ear, Nose, Mouth, Throat: no complaints. Ear, Nose, Mouth, Throat: no complaints. Cardiovascular: + palpitations; denies chest pain; denies calf pain, pressure, or edema. Cardiovascular: + palpitations; denies chest pain; denies calf pain, pressure, or edema. Respiratory: + shortness of breath on exertion. Respiratory: + shortness of breath on exertion. Gastrointestinal: appetite good, denies heartburn and indigestion. Gastrointestinal: appetite good, denies heartburn and indigestion. + episodes of nausea. Bowel movement daily; denies constipation or loose stools. + episodes of nausea. Bowel movement daily; denies constipation or loose stools. Urinary: denies incontinence, frequency, urgency, nocturia, pain, or discomfort. Urinary: denies incontinence, frequency, urgency, nocturia, pain, or discomfort. Skin: + clammy, moist skin. Skin: + clammy, moist skin. Neurological: + fainting; denies numbness, tingling, and tremors. Neurological: + fainting; denies numbness, tingling, and tremors. Psychiatric: denies memory loss or depression. Mood pleasant. Psychiatric: denies memory loss or depression. Mood pleasant.

49 Past Medical History MedicalFamilySocial

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

51 History - PFSH Pertinent Pertinent review of the history areas directly related to the problem(s) identified in the HPI. 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. 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: 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. 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 Complete A review of two or all three of the areas, depending on the category of E/M service. 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. 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. 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: 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; Office or other outpatient services, new patient; Hospital observation services; Hospital observation services; Hospital inpatient services, initial care; Hospital inpatient services, initial care; Consultations; Consultations; Comprehensive Nursing Facility assessments; Comprehensive Nursing Facility assessments; Domiciliary care, new patient; and Domiciliary care, new patient; and Home care, new patient. Home care, new patient.

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

55 History Algorithm History Type HPIROSPFSH Problem Focused (1 point) BriefNoneNone Expanded Problem Focused (2 points) Brief Problem pertinent None Detailed (3 points) ExtendedExtendedPertinent Comprehensive (4 points) ExtendedCompleteComplete

56 Physical Examination

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

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

59 Physical Exam Organ systems recognized Organ systems recognized Constitutional Constitutional Eyes Eyes ENT, Mouth ENT, Mouth Cardiovascular Cardiovascular Respiratory Respiratory GI GI GU GU Musculoskeletal Musculoskeletal Skin Skin Neurologic Neurologic Psychiatric Psychiatric Hematologic; Lymphatic; Immunologic Hematologic; Lymphatic; Immunologic The general multi-system exam should include findings of at least 8 of the above 12 organ systems 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 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 Brief statement indicating negative or normal is sufficient for unaffected or asymptomatic systems Describe abnormal or unexpected findings of asymptomatic areas or organs Describe abnormal or unexpected findings of asymptomatic areas or organs

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

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

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

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

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

70 Exam Bullets Musculoskeletal Musculoskeletal Examination of gait and station Examination of gait and station Examination of joints, bones and muscles of one or more of the following 6 areas Examination of joints, bones and muscles of one or more of the following 6 areas Head and Neck Head and Neck Spine, ribs and Pelvis Spine, ribs and Pelvis Right Upper Extremity Right Upper Extremity Left Upper Extremity Left Upper Extremity Right Lower Extremity Right Lower Extremity Left 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 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 Skin Examination of skin and subcutaneous tissue Examination of skin and subcutaneous tissue Palpation of skin and subcutaneous tissue Palpation of skin and subcutaneous tissue Neurologic Neurologic Test cranial nerves with notation of deficit Test cranial nerves with notation of deficit Examination of DTR Examination of DTR Examination of sensation Examination of sensation Psychiatric Psychiatric Description of judgment and insight Description of judgment and insight Brief assessment of mental status Brief assessment of mental status

72 Medical Decision Making

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

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

75 Documentation to Support Complexity Consider the following for risk Consider the following for risk Chronic illness(es) Chronic illness(es) Well controlled Well controlled Mild exacerbation Mild exacerbation Severe exacerbation Severe exacerbation Acute illness Acute illness Uncomplicated like allergic rhinitis Uncomplicated like allergic rhinitis With systemic symptoms like pneumonitis 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 1 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… Consider the following… Did you order/review labs? Did you order/review labs? Did you order/review X-rays, US, MRI Did you order/review X-rays, US, MRI Did you order/review any other testing Did you order/review any other testing Did you visualize image, tracing, or specimen Did you visualize image, tracing, or specimen Did you review or summarize old records Did you review or summarize old records Must document this on the record Must document this on the record …old records reviewed which noted …. …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) 1 Review/order tests (9xxxx medicine) 1 Discuss test results with performing physician 2 Independent review of tracing, specimen, image 2 Decision to obtain medical records 1 Review, summarize old records and/or obtain history 2

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

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

83 Counseling and Coordination of Care Discussion with patient or family concerning one or more of the following: Discussion with patient or family concerning one or more of the following: Diagnostic results Diagnostic results Prognosis Prognosis Risk & benefits of management options Risk & benefits of management options Instruction for management Instruction for management Compliance 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 Appropriate in cases where counseling and/or coordination of care dominates (>50%) of the patient and/or family encounter Documentation requirements Documentation requirements Total face to face time or encounter Total face to face time or encounter Total counseling/coordination time Total counseling/coordination time Content of counseling/coordination Content of counseling/coordination

85 Time based billing…example cc: Depression cc: Depression Hx cc: 59 y/o female w/depression and anxiety. Denies suicidal ideations. Hx ativan use in past Hx cc: 59 y/o female w/depression and anxiety. Denies suicidal ideations. Hx ativan use in past Exam: vitals (list) Exam: vitals (list) A/P: Depression. Had long discussion w/patient and counseled him on exacerbating factors and treatment options. Rx ordered (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 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 3 of 3 rule Go to the lowest component Go to the lowest component i.e., 2,3,4 = 2 i.e., 2,3,4 = 2 3,3,4 = 3 3,3,4 = 3 Used for new patient, initial consults, initial hospital care and emergency department visits Used for new patient, initial consults, initial hospital care and emergency department visits 2 of 3 rule 2 of 3 rule Go to the middle component Go to the middle component 2,3,4 = 3 2,3,4 = 3 3,3,4 = 3 3,3,4 = 3 Used for established patient, subsequent hospital f/u, f/u consult Used for established patient, subsequent hospital f/u, f/u consult

88 New vs. Established Patient New Patient New Patient All key components must meet or exceed the stated requirements to qualify for a particular level All key components must meet or exceed the stated requirements to qualify for a particular level Established Patient Established Patient Two key components must meet or exceed stated requirements to qualify for a particular level 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 HistoryExamination Medical Decision Making Problem focused Straight forward complexity Expanded problem focused Straight forward complexity 99203DetailedDetailed Low complexity 99204ComprehensiveComprehensive Moderate complexity 99205ComprehensiveComprehensive High complexity

90 Documentation Requirements New Patient Office Visit 3 of 3 rule Level of Service HistoryExamination Medical Decision Making Problem focused Straight forward complexity Expanded problem focused Straight forward complexity 99203DetailedDetailed Low complexity 99204ComprehensiveComprehensive Moderate complexity 99205ComprehensiveComprehensive High complexity

91 Documentation Requirements New Patient Office Visit 3 of 3 rule Level of Service HistoryExamination Medical Decision Making Problem focused Straight forward complexity Expanded problem focused Straight forward complexity 99203DetailedDetailed Low complexity 99204ComprehensiveComprehensive Moderate complexity 99205ComprehensiveComprehensive High complexity

92 Documentation Requirements New Patient Office Visit 3 of 3 rule Level of Service HistoryExamination Medical Decision Making Problem focused Straight forward complexity Expanded problem focused Straight forward complexity 99203DetailedDetailed Low complexity 99204ComprehensiveComprehensive Moderate complexity 99205ComprehensiveComprehensive High complexity

93 Established Patient CPT E&M Guidelines 2 of 3 rule CodeHistory Physical Exam Medical Decision making Time Nursing service only N/A Nursing order Problem Focused (1) Straight forward (1) Expanded Problem Focused (2) Low Complexity (2) Detailed (3) Moderate Complexity Comprehensive (4) High Complexity (4) 40

94 Established Patient CPT E&M Guidelines 2 of 3 rule CodeHistory Physical Exam Medical Decision making Time Nursing service only N/A Nursing order Problem Focused (1) Straight forward (1) Expanded Problem Focused (2) Low Complexity (2) Detailed (3) Moderate Complexity (3) Comprehensive (4) High Complexity (4) 40

95 Established Patient CPT E&M Guidelines 2 of 3 rule CodeHistory Physical Exam Medical Decision making Time Nursing service only N/A Nursing order Problem Focused (1) Straight forward (1) Expanded Problem Focused (2) Low Complexity (2) Detailed (3) Moderate Complexity (3) Comprehensive (4) High Complexity (4) 40

96 Inpatient Codes Follow 3 of 3 rule Follow 3 of 3 rule Inpatient Services and Observation Inpatient Services and Observation Inpatient Consults Inpatient Consults Inpatient follow ups follow the 2 of 3 rule 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. 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 Documentation MUST include Request for consultation documented in the medical record Request for consultation documented in the medical record Reason for consultation (medical necessity) Reason for consultation (medical necessity) Report- Consultant’s opinion, advice and evaluation of the patient (this MUST be communicated back to the requesting physician) Report- Consultant’s opinion, advice and evaluation of the patient (this MUST be communicated back to the requesting physician) Have separate initial coding Have separate initial coding Follow up visits use established patient visits Follow up visits use established patient visits

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

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

102 Rules for Consultation Opinion or advise regarding E&M of a specific problem is requested Opinion or advise regarding E&M of a specific problem is requested Documented request from appropriate source is required (if patient generated for ) Documented request from appropriate source is required (if patient generated for ) Written report sent to referring provider (a letter for an outpatient) Written report sent to referring provider (a letter for an outpatient) Initiation of care at time of consult is acceptable 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 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 ConfirmConsult Initial consult New patient History Physical Exam Medical Decision Making Time Problem Focused (1) Straight forward (1) Expanded prob. focused (2) Expanded prob. focused (2) Straight forward (1) Detailed (3) Low Complex (2) Comprehensive (4) Moderate Complexity (3) Comprehensive (4) High Complexity 60

104 Coding Examples

105 Documentation Requirements Established Patient Office Visit Level of service HistoryExamination Medical decision making Nursing service only Nursing order Problem focused Straight forward complexity Expanded problem focused Low complexity 99214DetailedDetailed Moderate complexity 99215ComprehensiveComprehensive High complexity

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

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

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

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

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

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

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

113 OMT Billing

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

115 Other Billable Services

116 Injections/Immunizations Injections/Immunizations Smoking Cessation Smoking Cessation Visit and procedures Visit and procedures

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

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

119 Other Billable Services Digital Rectal Exam for Prostate Cancer Screening Digital Rectal Exam for Prostate Cancer Screening G0102 G0102 Visual Acuity Exam (Snellen Chart) Visual Acuity Exam (Snellen Chart) Needle Sticks!! Needle Sticks!! – 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 – 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 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 Modifier 25 should be added to the evaluation and management service to identify that it is a separate service

121 Other Coding Opportunities Modifiers Modifiers 22 Unusual procedural service 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 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 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 3 rd party (HMO) 32 Mandated by 3 rd party (HMO) 51 Multiple Procedures 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. 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 Use appropriate E&M code if < 30 minutes First minutes of evaluation and management First minutes of evaluation and management Each additional 30 minutes (can round up after 15 minutes) Each additional 30 minutes (can round up after 15 minutes) e.g., minutes = x 1 and x 2 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 Threshold time is 30 minutes over the time component allotted for the E&M code Outpatient Outpatient Face to face time Face to face time Inpatient Inpatient Inpatient or outpatient office/floor/unit time without direct patient contact Inpatient or outpatient office/floor/unit time without direct patient contact e.g., IV running for rehydration in your office for 1 hour e.g., IV running for rehydration in your office for 1 hour

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

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


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