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EVALUATION & MANAGEMENT SERVICES Documentation and Coding Guidelines

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1 EVALUATION & MANAGEMENT SERVICES Documentation and Coding Guidelines
Presented by Carolyn Duncan, CPC, CPC-H May, 2011

2 Objectives Participants will understand the following:
Components of Evaluation and management services and documentation requirements Coding the level of service for the E/M Coding requirements for reporting diagnoses Preventive medicine services Coding for more than one service Preventive medicine and E/M E/M and procedures E/M and injections Coding RHC x-rays, EKGs, lab services

3 Documentation- Why? Tracks physician’s evaluation, plan, or treatment status over time Allows for communication to other providers Supports the services that are to be reimbursed by payers-thus the guidelines for documentation required for specific requests for reimbursement through code communication

4 Elements Needed For Filing Claims
Documentation to support the E/M services and procedures performed CPT-4 Procedure codes ICD-9 Diagnosis codes


6 CPT Coding Current Procedural Terminology, 4th Edition cognitive
Identifies all, procedural & material services provided to patients Updated every year

7 Components of E/M Documentation
7 components to E/M History Exam Medical decision making Counseling Coordination of care Nature of presenting problem Time

8 E/M KEY Components 3 KEY components History Exam
Medical decision-making Per Medicare – “Medical necessity of a service is the overarching criteria for payment in addition to the CPT code requirements”

9 TIME as Key Component Exception: Time key component
When over 50% of the face-to-face encounter is in spent in counseling or coordination of care, bill on TIME per average time defined by CPT Documentation requirement – must define total time of visit and amount of time spent in counseling/coordination of care, nature of the counseling Example: “visit time 40 minutes – spent 25 counseling the patient on his medications and the importance of compliance with treatment, consequences of non-compliance. Patient seems to understand importance.”

10 CMS Defines Two Sets of Documentation Guidelines
1995 Guidelines - generally more favorable to the physician 1997 Guidelines – very specific in the exam component – requires a specific number of “bullets” (information about the system) to meet code criteria Auditors must use whichever guidelines benefit the physician

11 1st Key Component HISTORY-3 Elements
Documentation – chief complaint A chief complaint is indicated at all levels (1)-History of the presenting illness (HPI)- Location – chest, arm, localized, diffuse Quality- acute, sharp, crushing, improving Severity- mild, immobilizing, scale 1 to 10 Duration- yesterday, 2 weeks, for years Timing- off & on, constant, sporadic Context- during exertion, after large meals Modifying factors- applied heat, took OTC Associated symptoms- also short of breath Physician must document the HPI

12 History – 2nd Element (2)-Review of systems (ROS) – A ROS is an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced. For purposes of ROS, the following systems are recognized:

13 Recognized Systems in ROS
• Constitutional symptoms (e.g., fever, weight loss) • Eyes • Ears, Nose, Mouth, Throat • Cardiovascular • Respiratory • Gastrointestinal • Genitourinary • Musculoskeletal • Integumentary (skin and/or breast) • Neurological • Psychiatric • Endocrine • Hematologic/Lymphatic • Allergic/Immunologic

14 History – 3rd Element (3)-Past medical, family, social history
past history (the patient's past experiences with illnesses, operations, injuries and treatments); family history (a review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk); and social history (an age appropriate review of past and current activities).

15 History Level Dependent Upon How Much is Documented
Problem Focused 1-3 HPIs – chest pain x 3 days Expanded Problem Focused 1-3 HPIs + 1 ROS – chest pain x 3 days. Also having abdominal pain Detailed 4 HPIs, 2-9 ROS, 1 PFSH – chest pain off & on x 3 days, some SOB, also moderate abd pain, no nausea/vomiting, hx of anemia OR Status of 3 chronic conditions/illnesses Comprehensive 4 HPIs, 10 ROS, 2 PFSH (est pt) 3 PFSH new – severe chest pain for 3 hours with difficulty breathing, nausea/vomiting, blood in emesis, (must have 10 systems reviewed), hx of MI, smoker, father had MI at age 40.

16 Documentation Tips History
Always define presenting problem “Follow up” must define condition Avoid “check up”, “routine check,” “physical” (unless truly wellness visit) “follow up after CABG” Document information pertinent to visit (OIG looking for same documentation across services) Caution: ROS – needs to correlate with rest of the note May reference info located elsewhere but must note date and location of the referenced information ROS- may define pertinent positive and negatives with “all other systems are reviewed and negative” OR “a 10/14-point ROS is negative” Avoid “all systems rev and negative” as the only ROS note -need system relating to presenting problem

17 Documentation Tips - of HX (cont.)
Patient is comatose or incoherent – document attempt to obtain information and reason why unable to get hx components Avoid “see chart” for other information Avoid “see med list” when it is not up to date Avoid “ROS reviewed and updated” without defining where the info is located Avoid “non-contributory”, “negative”, “unremarkable” in reference to PFSH Acceptable “no known fm hx of cardiac disease” or “Negative for smoking”

18 2nd E/M Component – Exam 1995 Guidelines & 1997
1 body area or organ system=focused bullets 2-7 body areas/organ systems briefly described=expanded bullets 2-7 body areas/organ systems with at least one described in specific detail=detailed bullets 8 or more body systems –comprehensive bullets from 9 systems or all elements identified by a bullet from 9 organ systems or body areas

19 Exam Systems (1995) For purposes of examination, the following organ systems are recognized: • Constitutional (e.g., vital signs, general appearance) • Eyes • Ears, nose, mouth and throat • Cardiovascular • Respiratory • Gastrointestinal • Genitourinary • Musculoskeletal • Skin • Neurologic • Psychiatric • Hematologic/lymphatic/immunologic

20 Exam Body Areas (1995) For purposes of examination, the following body areas are recognized: • Head, including the face • Neck • Chest, including breasts and axillae • Abdomen • Genitalia, groin, buttocks • Back, including spine • Each extremity

21 Documentation Guidelines- Exam
DG: Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented. A notation of "abnormal" without elaboration is insufficient. DG: Abnormal or unexpected findings of the examination of the unaffected or asymptomatic body area(s) or organ system(s) should be described. DG: A brief statement or notation indicating "negative" or "normal" is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s). DG: The medical record for a general multi-system examination should include findings about 8 or more of the 12 organ systems.

22 Documentation Tips- Exam
Reference “GI” rather than “abdomen” especially when a template check system is utilized Reference “Lymph” system in describing the neck or may document each separately Reference “Musculoskeletal” rather than “back” Exam must include the system affected in the presenting problem Exam (except constitutional) must be performed by the physician – physician must reference vitals

23 3rd Component-E/M Medical Decision Making
3 Elements to medical decision making #1-Number of diagnoses & treatment options #2 Data ordered or reviewed #3-Risk of significant complications, morbidity and/or mortality, as well as comorbidities, associated with the patient's presenting problem(s), the diagnostic procedure(s) and/or the possible management options (SEE TABLE of RISK)

24 Medical Decision Making (cont.)
Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M services “unless” their presence significantly increases the complexity of the medical decision making. CPT 2011, page 9

25 Determination of Level of Service
What level of service was the history? What level of service was the exam? What level of service was the medical decision making? (2 of the 3 components) Determine if patient is new or established Determine encounter type, ie, office service, consultation, hospital service

26 New vs. Established Patient
New Patient-Patient has not been seen face-to-face for 3 years by member of same specialty of same group Established patient-Patient has been seen by the provider or a member in the group within 3 years

27 Services Requiring Just Two of the Key Components
These services require 2 components to meet or exceed the descriptor of the chosen CPT code Established patient office visits Subsequent hospital or SNF visits

28 Services Requiring Three of the Key Components
These services require all 3 key components to meet or exceed the descriptor of the selected CPT code New patient visits Initial hospital visit Initial SNF visit ER visit Consultation Observation care

29 Consultation Consultation
Opinion or advice regarding the E/M of a specific problem is requested by another physician The request for a consultation, the name of the requesting physician, and the condition prompting the consultation are documented in the chart The consultant prepares his/her findings which is provided to the requesting physician Transfer of care – bill appropriate E/M

30 Key Element –Diagnosis Documentation
ICD-9 Diagnosis Guidelines

31 ICD-9 Codes International Classification of Diseases-Ninth Edition (legislation requires ICD-10 by 2013) Guidelines found in the front of the ICD-9 coding book Identifies patient condition, illness, disease, syndrome or symptoms ICD-9 book divided in two parts: Alphabetic Index Tabular list

32 ICD-9 Coding Guide For each encounter, an assessment, clinical impression, or diagnosis should be documented Code to highest level of specificity Avoid “suspect” “probable” “questionable”-list sign & symptoms for out-patient documents – perfectly appropriate to discuss thoughts on paper For a presenting problem with an established diagnosis the record should reflect whether the problem is: a) improved, well controlled, resolving or resolved; or, b) inadequately controlled, worsening, or failing to change as expected.

33 ICD-9 – Codes Guidelines (Out-patient)
Primary diagnosis must correlate with the reason for the encounter Primary dx should be acute problem of the day-not always most significant problem Secondary diagnosis-other problem treated or chronic problem affecting the treatment of the presenting illness Same diagnoses for the encounter should be included on the charge ticket for the claim

34 Diagnoses for Diagnostic Orders
For every test ordered there must be a diagnosis to support medical necessity that is documented Mandated by the Balanced Budget Act that diagnosis must be given at the time of the order

35 Documentation for Medical Decision Making- Tips
Assure that level of service selected meets medical necessity- MDM should be considered in selection of E/M Describe patients conditions to explain the complexity in coding high levels of service – think on paper

36 Preventive Wellness Visit
CPT codes Based on age for NEW patient – Based on age for ESTABLISHED patient Coverage: Commercial – dependent upon patient contract Medicaid – Covered once a year for adults and per EPSDT periodicy for 21 and under- more frequently if medically necessary Medicare – CPT NOT a covered service

37 CPT Components to Preventive Medicine Services
Age and gender appropriate history and examination Counseling/anticipatory guidance Risk factor reduction interventions Ordering of ancillary services: lab, radiology, other screening tests Immunization status age appropriate Instructions for follow up

38 Documentation Reason for Visit
Reason for encounter should be for a wellness exam, routine check-up, well woman, or 6 month well child check It must be very clear per documentation – determines claim payment

39 Diagnosis Requirement
Assessment-“V” code to represent wellness type V70.0 General medical exam V20.2 Well child health check V72.3 Routine gynecological exam MUST have a wellness diagnosis to correlate with CPT as PRIMARY diagnosis

40 Preventive Medicine

41 Preventive Medicine and Incidental Finding
IF during the preventive medicine exam a problem is encountered, but it does not need additional work-up, code the preventive medicine diagnosis first Code second the diagnosis to reflect the medical problem encountered Do NOT code an E/M as the first listed CPT code if the intent of the visit was for preventive care

42 Preventive Medicine with Significant Medical Treatment
IF a significant problem is encountered during a preventive medicine visit the hx, exam, and medical decision making concerning the problem must be documented Commercial- Code BOTH the preventive medicine code & the E/M service Attach modifier -25 to the E/M service (Some payers may not recognize) Medicaid – Never pays for more than one service – assign the code that most represents the reason for the visit UNLESS…

43 EPSDT and Medical Care for Problem (Missouri Example)
A provider cannot bill for an office visit and and HCY screen on the same date of service for a patient unless documentation in the medical record indicates a medical need for the office visit. The provider must include a “Certificate of Medical Necessity” with the claim when submitting it for payment

44 Preventive Medicine with Significant Medical Problem Medicare
Generally,preventive medicine codes NOT covered ( ) (see Exception next slide) IF perform non-covered physical & E/M, bill for both Subtract the covered service from the non-covered services – amount patient pays Example: 99396 is $100 E/M is $60 Patient pays $40

45 MEDICAID Preventive Care
– Used to report age appropriate preventive service to Medicaid EPSDT (Early Periodic Screening, Diagnosis and Treatment) EP modifier must be added to indicate a full screening was performed UC modifier is child was referred as part of the screening (use both EP and UC)

46 Medicaid Full EPSDT Documentation
Must use either paper copy of the Healthy Children and Youth (HCY) Screening Guide and the Lead Risk Assessment Guide OR an electronic version of it as long as ALL components of the paper version are included

47 EPSDT (HCY) Documentation Requirements
ALL components Interval history Unclothed physical exam Anticipatory guidance Lab/Immunizations Lead assessment (6-72 months of age verbal, 12 & 24 months- blood lead) Development personal – social and language Fine motor/gross motor skills Hearing Vision Dental

48 Medicare Covered Preventive Care
Medicare does cover SOME preventive services: IPPE – Initial Preventive Physical Exam (G0402) AWV – Annual Wellness Visit (G0408) Subsequent annual wellness visit (G0409) Screening pelvic exam (G0101) Ultrasound screening for abdominal aortic aneurysm (must come from IPPE referral) Cardiovascular Disease Screening DM screening – for patients with risk factors for DM DM self management training

49 Medicare Covered Preventive Services
Screening mammography Bone mass measurements Colorectal cancer screening Prostate cancer screening Glaucoma (by an optometrist or ophthalmologist) Flu and pneumonia immunizations Hepatitis B (at high risk patients) Tobacco use counseling HIV immunodeficiency virus screening (at risk pt)

50 Medicare Quick Reference
All covered services are in this grid:

51 Initial Preventive Physical Exam
Medicare pays one initial physical performed within the first year of Medicare eligibility EKG no longer required as of 1/1/2009 Very strict concerning the documentation Medicare Claims Processing Manual Chapter 12, Section page 36

52 Components of IPPE Acquire beneficiary history
Exam patient – ht. wt. BP, visual screen, hearing, BMI Counsel- Preventive services and need based on two above components

53 Components to IPPE Initial Preventive Physical Examination components: (G0402) (Must be on the UB FL 44) Review of MEDICAL and SOCIAL hx including illnesses, hospital stays, operations, allergies, injuries, treatment, meds, fm hx Review of individual’s RISK factors for DEPRESSION. Must use an approved screening instrument EXAMINATION, ht, wt, BP, VISUAL ACUITY, HEARING impairment, screen and other systems as appropriate ACTIVITIES OF DAILY LIVING, fall risks, home safety PLAN for PREVENTIVE work up END OF LIFE PLANNING

54 Billing the IPPE G0402 for complete physical with all components (no co-ins or ded.) G0404 – EKG tracing only (bill to Part B under provider’s own number) co-ins and deductible apply (NOT waived) G0405 – EKG interpretation and report – List separately on the claim co-ins applies (NOT waived)

55 Annual Wellness Visit – New for 2011
G0438 – One time only benefit for Annual Wellness Visit Acquire medical & family hx: Past medical and surgical hx Use of or exposure to medications and supplements Medical events in the patient’s parents, siblings, or children that may be hereditary

56 Annual Wellness Visit Review risk factors
Depression Review functional ability & safety Hearing impairment Ability to successfully perform activities of daily living Fall risk Home Safety

57 Annual Wellness Visit cont.
Examination Height, weight, BMI or waist circumference, BP & whatever the physician thinks List of current providers and suppliers that are regularly involved in providing medical care to the individual Detection of any cognitive impairment that the individual may have through direct observation and concerns raised by others

58 AWV (cont) Counsel Beneficiary
Establish a written screening schedule such as a check list for the next 5-10 years Determine patient’s screening history List risk factors and conditions that need intervention Furnish advice and refer as appropriate Weight loss Physical activity Smoking Fall prevention Nutrition

59 Subsequent Annual Wellness Exam
G0439 billed each year after the initial wellness visit – components same as initial AWV just updated See regs in Transmittal 2109, Dec 3, 2010.

60 Frequency Limitations
IPPE – performed within the first 12 months of Medicare eligibility AWV – performed at least one year after the IPPE AWV subsequent visit – performed one year after initial AWV If patient had an IPPE, still bill the AWV initial visit No payment for AWV in first 12 months of Medicare eligibility – need IPPE

61 Preventive Well-Woman
Medicare’s descriptor is different: G0101-Allowed once every 2 years July 1, 2001, allowed once every 2 years, HCFA Transmittal 1823 Must have 7 of these 11 components: Inspection & palpation of breasts Digital rectal exam including sphincter tone, presence of hemorrhoids, and rectal masses Pelvic exam with or without collection of smears and cultures External genitalia-general appearance, hair distribution, or lesions

62 G0101 (cont.) Note: Breast exam now 1 of 11 components
Urethral-masses, tenderness, scaring Bladder-fullness, masses, or tenderness Vagina-general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, or rectocele Cervix-appearance, lesions or discharge Uterus-size, contour, position, mobility, tenderness, consistency, descent, or support Adnexa-masses, tenderness, organomegaly Anus and perineum Note: Breast exam now 1 of 11 components

63 G0101 (cont.) V76.2-for screening for malignant neoplasm, cervix
V76.49-screening for malignant for patients who do not have a uterus or a cervix

64 G0101 for High Risk May perform more than every 23 mo. IF
Early onset of sexual activity (under 16 yrs) Multiple sex partners (five or more) Hx of sexually transmitted disease Fewer than 3 negative pap smears within the previous 7 years DES-exposed daughters of women who took diethylstilbestrol (DES) Dx code-V15.89-personal Hx presenting hazards to health

65 Billing GO101& Q0091 Q0091 – Obtaining and preparing a pap specimen for submitting to a laboratory for SCREENING pap only – paid every other year (Part of RHC claim) Must track internally frequency of tests Sign ABN if more frequent than guidelines Do not need to send claim to Medicare Part B deductible is waived Co-insurance waived

66 Prostate Preventive Care
Paid by Medicare 1 time every 12 months Digital rectal exam-G0102 Not payable if any other E/M service paid on the same day Payable if another non-payable service is performed, e.g. routine check-up Code V76.44 PSA-G0103 Dx code V76.44

67 Waived Co-insurance & Deductible

68 Other RHC Services

69 Coding E/M & Procedure Document each service separately
Report one line entry on claim with revenue code 521 and the dollar value of the E/M and procedure OR procedure only (billing guidelines for Medicare applicable in RHCs) May charge E/M for same diagnosis as the procedure if significant service above and beyond what is always performed for the procedure

70 Correct Coding Initiative Edits
If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. CCI Edits, Chpt 3

71 Coding Injections Injections are payable as incident to services-Medicare 96372 – Administration of therapeutic injection “J” code – to represent serum May be billed in addition to E/M services under the 521 revenue code Medicaid – most do not cover adm – check your state regulations

72 Coding X-rays & EKGs Professional services ARE RHC services – bill under the 521 revenue center (must also have a face-to-face visit) TC – bill as non RHC service Independent – submit CPT code to Part B under name of ordering provider Provider based – submit CPT code under hospital’s provider number

73 Coding Lab Lab is NOT a RHC service
Independent – code all labs performed IN-house and submit to Part B under ordering provider’s number Provider-based – code all labs including RHC required labs and submit under hospital’s provider number

74 Resources Medicare Preventive Quick Reference Information
Websites listed throughout presentation MoHealthNet Healthy Children and Youth Program Section 8 CPT 2011 Medicare Claims Processing Manual, Chpt 9, Rural health Clinics/Federally Qualified Health Centers

75 References Current Procedural Terminology (CPT)
International Classification of Disease 9th Revision Clinical Modification (ICD-9-CM) 1995 Documentation Guidelines for E/M Services 1997 Documentation Guidelines for E/M Services

76 References Wisconsin Physician Services Medicare Manual
WPS Questions and Answers Claims Processing Manual, Chpt. 9 Rural Health Clinics/Federally Qualified Health Centers Websites referenced throughout the presentation

77 THANK YOU! Carolyn Duncan, BS, CPC, CPC-H
Health Care Consulting Services, Inc. 21019 W 61st St. Shawnee, KS 66218 or Cell

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