Presentation on theme: "Detailed E&M Coding Course"— Presentation transcript:
1 Detailed E&M Coding Course Click on these links to go directly to the topic:Common E&M categoriesConsultationsLevels of serviceHistoryExamMedical decision makingDocumentation requirements at various levelsTime-based servicesModifier 25Clinical examples at various E&M levelsUNC SOM Compliance
2 E&M Services Classifications – most common Outpatient - clinic visitsConsultNewEstablishedInpatient – hospital visitsInitialSubsequentConsult, initial and follow-up
3 Medicare Outpatient E & M Approximate AllowablesOutpatient Visit CategoryCPT Code LevelEstablishedNewConsultation1$18.90$32.00$44.202$34.00$57.90$81.903$47.40$86.50$109.004$74.50$123.20$155.005$109.40$201.00
4 New or Established Patient New patient: has not received any professional evaluation and management (E&M) services from the physician or another physician of the same specialty who belongs to the same group practice within the past three yearsEstablished patient: has received an E&M service from group within three years
5 ConsultationsA Consultation is an E&M service provided by a physician whose opinion and advice is requested by another physician or appropriate sourceConsultations should be viewed as a three-part cycle (1) a request is made (2) an evaluation is undertaken and (3) an opinion is rendered and sent to the requesting physician.The consultant may initiate diagnostic and/or therapeutic services at the same visit
6 ConsultationsA patient who is self-referred or “referred for management of a condition” is a new or established patient, not a consultIf ongoing care of a particular condition is assumed in advance, service is not a consult but a new/est. patient visit
7 Consult Documentation Requirements Written or verbal request must be documented. As an example: “Mr. Jones is seen in consultation at the request of Dr. Smith for evaluation of worsening cough.”Consultant’s opinion must be communicated by written report to the requesting physician
9 Defining Levels of Service HistoryPhysical ExaminationMedical Decision MakingOther ConsiderationsTimeCounselingCoordination of CareNature of Presenting Problem
10 History – Three PartsHistory of Present IllnessReview of SystemsPast, Family and Social History
11 History of the Present Illness (HPI) LocationQualitySeverityDurationTimingContextModifying factorsAssociated signs and symptoms
12 Two Levels of HPIBrief = 1-3 elements describedExtended = 4+ elements described ORStatus of at least 3 chronic or inactive conditions“Mr. Peters has for two weeks felt a sharp pain in his left shoulder when he raises his arm.”DurationQualityLocationContext
13 Review of Systems (ROS) An inventory of body systems obtained through questions seeking to identify signs and/or symptoms which the patient has or has had.Constitutional symptoms (e.g. fever, weight loss)EyesEars, Nose, Mouth, ThroatCardiovascularRespiratoryGastrointestinalGenitourinaryMusculoskeletalIntegumentary (including breasts)NeurologicalPsychiatricEndocrineHematologic/LymphaticAllergic/Immunologic
14 Review of Systems (ROS) Three levels of ROS:Problem Pertinent (1 system)Extended (2-9)Complete (at least 10)May be completed by patient, nurse or other staffPertinent positives and negatives must be referred to in the noteMay use “all other systems negative” or “the balance of ten systems reviewed is negative” indicating a complete ROS was doneIf unable to obtain, document why
15 Past, Family and Social History (PFSH) Current medicationsPrior illnesses/injuriesDietary statusOperations/hospitalizationsAllergiesFamilyHealth status or cause of death of siblings/parentsHereditary/high risk diseasesDiseases related to the chief complaint, HPI, ROSSocialLiving arrangementsMarital statusDrug or tobacco useOccupational/educational history
16 Two Levels of PFSHPertinent: one of the three areasComplete: document specific item from all three areasComplete for established patients: two of three areas is sufficient
17 Four Levels of HistoryProblem focusedBrief HPIExpanded problem focusedBrief HPI, Pertinent ROS, no PFSHDetailedExtended HPI and ROS, 1 PFSH elementComprehensiveExtended HPI, Complete ROS and PFSH
18 History Example2 y/o male c/o vomiting/diarrhea & 2 day fever. Diarrhea watery for 4 days, temp Vomited 2X this a.m., appetite. Started Pedialyte 3 days ago. Drank several oz Pedialyte this a.m. Ø rhinorrhea, Ø cough, Ø daycare
19 History Example2 y/o male c/o vomiting/diarrhea & 2 day fever. Diarrhea watery for 4 days, temp Vomited 2X this a.m. appetite. Started Pedialyte 3 days ago. Drank several oz Pedialyte this a.m. Ø rhinorrhea, Ø cough, Ø daycarebchief complaintb HPI durationb HPI qualityb HPI severityb HPI modifying factors
20 Ø rhinorrhea, Ø cough, Ø daycare History Example2 y/o male c/o vomiting/diarrhea & 2 day fever. Diarrhea watery for 4 days, temp Vomited 2X this a.m. appetite. Started Pedialyte 3 days ago. Drank several oz Pedialyte this a.m.Ø rhinorrhea, Ø cough, Ø daycareb ROS GIb ROS EENTb ROS Respb PFSH Social
21 History Documented in Example Chief Complaint Always requiredHPI, 4 descriptors ExtendedROS, 4 systems ExtendedPFSH, social (1) PertinentDetailed= Outpatient established E&M 99214new patient or 99203, 99243
22 Documenting the Physical Exam A general multi-system exam or any single organ system exam may be performed by any provider.The type and content are selected by the provider depending upon medical necessity.Note specific abnormal & relevant negative findings of the affected or symptomatic area(s)--“abnormal” is insufficient.Describe abnormal or unexpected findings of asymptomatic areas or systems.Noting “negative” or “normal” is sufficient to document normal findings in unaffected areas.
23 The Physical Exam Component The following slides describe two methods of determining the level of physical exam: 1995 Guidelines and 1997 Guidelines. Either may be used. There is no need to satisfy the requirements of both methods.
24 Physical Exam Guidelines (1995) Problem FocusedA limited examination of the affected body area or organ systemExpanded Problem FocusedA limited examination of the affected body area or organ system and other symptomatic or related organ system(s)DetailedAn extended examination of the affected body area(s) and other symptomatic or related organ systemsComprehensiveA general multi-system examination (8 or more of the 12 systems) or complete examination of a single organ system
25 General Multi-system Exam (1997) See next page for the list of multi-system exam elements referred to belowProblem FocusedDocumentation of 1-5 elementsExpanded Problem FocusedAt least 6 elementsOne or more organ/body systemDetailedat least 6 organ/body system coveredfor each system/area, at least 2 elements notedORAt least 12 elements total2 or more organ/body systemsComprehensiveAt least nine organ systems/areas coveredFor each, all elements should be performedDocument at least 2 elements in each system/area
26 General Multi-system Examination (1997 Guidelines)
27 Single Organ System Examination Requirements for elements documented similar to 1997 multi-systemSingle organ system exams for the following:EyesEars, Nose, Mouth, and ThroatCardiovascularRespiratoryGenitourinaryMusculoskeletalSkinNeurologicalPsychiatricHematologic/Lymphatic/Immunologic
28 Medical Decision Making (MDM) Based on any two of the following:Number of Diagnostic and/or Management OptionsAmount and Complexity of DataRisk
29 Medical Decision Making Elements Diagnostic and/or management options(max = 4 “points”)Self-limited, minor (1 ea)Established problem stable, improved (1 ea)Established problem worsening (2 ea)New problem, no add’l workup planned (3 ea)New problem, add’l workup planned (4 ea)
30 Medical Decision Making Elements Amount & complexity of data (max = 4 points)Review/order of clinical lab, radiologic study, other non-invasive diagnostic study (1 ea type)Discussion of diag study w/interpreting phys. (1)Independent review of diagnostic study (2)Decision to obtain old records or get data from source other than patient. (1)Review/summary old med records or gathering data from source other than patient (2)
31 Medical Decision Making Elements RiskPresenting problemDiagnostic proceduresManagement optionsChoose the highest level of associated risk expressed in any one of these three categories on the table on the next page.
32 Table of Risk Risk Level Presenting Problem(s) Diagnostic Procedure(s) OrderedManagement Options SelectedMinimalOne self-limited or minor problem, eg, cold, insect bite, tinea corporisLaboratory tests requiring venipuncture•Chest x-rays•EKG/EEG•Urinalysis•Ultrasound, eg, echocardiography•KOH prepRest•Gargles•Elastic bandages•Superficial dressingsLowTwo or more self-limited or minor problems•One stable chronic illness, eg, well controlled hypertension, non-insulin dependent diabetes, cataract, BPH•Acute uncomplicated illness or injury, eg, cystitis, allergic rhinitis, simple sprainPhysiologic tests not under stress, eg, pulmonary function tests•Non-cardiovascular imaging studies with contrast, eg, barium enema•Superficial needle biopsies•Clinical laboratory tests requiring arterial puncture•Skin biopsiesOver-the-counter drugs•Minor surgery with no identified risk factors•Physical therapy•Occupational therapy•IV fluids without additivesModerateOne or more chronic illnesses with mild exacerbation, progression, or side effects of treatmentTwo or more stable chronic illnessesUndiagnosed new problem with uncertain prognosis, eg, lump in breastAcute illness with systemic symptoms, eg, pyelonephritis, pneumonitis, colitisAcute complicated injury, eg, head injury with brief loss of consciousnessDiagnostic endoscopies with no identified risk factors•Deep needle or incisional biopsy•Cardiovascular imaging studies with contrast and no identified risk factors, eg, arteriogram, cardiac catheterization•Obtain fluid from body cavity, eg lumbar puncture, thoracentesis, culdocentesisMinor surgery with identified risk factors•Elective major surgery (open, percutaneous or endoscopic) with no identified risk factors•Prescription drug management•Therapeutic nuclear medicine•IV fluids with additives•Closed treatment of fracture or dislocation without manipulationHighOne or more chronic illnesses with severe exacerbation, progression, or side effects of treatment•Acute or chronic illnesses or injuries that pose a threat to life or bodily function, eg, multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure•An abrupt change in neurologic status, eg, seizure, TIA, weakness, sensory lossCardiovascular imaging studies with contrast with identified risk factors•Cardiac electrophysiological tests•Diagnostic Endoscopies with identified risk factors•DiscographyElective major surgery (open, percutaneous or endoscopic) with identified risk factors•Emergency major surgery (open, percutaneous or endoscopic)•Parenteral controlled substances•Drug therapy requiring intensive monitoring for toxicity•Decision not to resuscitate or to de-escalate care because of poor prognosis
33 Level of Medical Decision Making Documented Four levels:StraightforwardLow complexityModerate complexityHigh complexityTwo of the three areas:dx options, amount of data, risk establish the MDM levelDiag/mgt options0-1234Amount of dataOverall riskMinimalLowModerateHighLevel of MDMStrghtfwd
34 Note on Medical Decision Making Level Co-morbidities and 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.
38 Subsequent Hospital and Follow-up Consults LevelHistoryExamMDM99231, 99261PFSF/LOW99232, 99262EPFModerate99233, 99263DetailedHigh
39 Documenting Time-based Coding If time spent counseling and/or coordinating care is more than 50% of encounter, use timeMay count TP face-to-face time only for OP, coordination, time on floor for IPDocument amount of time counseling and total time spent on encounter and describe counseling, coordination activitiesDocument only minimal history, exam OR medical decision making
40 Time as the Controlling Factor Established patientNew patient, ConsultationApproximate time99211Nurse visit, 5 supv9921299201, 9924110 / 10 / 159921399202, 9924215 / 20 / 309921499203, 9924325 / 30 / 409921599204, 9924440 / 45 / 6099205, 9924560 / 80
41 Examples of Time-based Codes Critical careOther E&M visits where >50% counselingIndividual psychotherapy codes (non E&M)Prolonged servicesTP presence or concurrent observation for entirety of time-based servicesResident note may support level and type service, add’l TP summary note to document involvement
42 Modifier 25Append a modifier 25 to an E&M code if a significant, separately identifiable E&M service is performed by the same physician on the same day of a procedure or other service.The patient’s condition must require E&M services above and beyond what would normally be performed in the provision of the procedure.The necessity for the E&M service may be prompted by the same diagnosis as the procedure.A new patient E&M service is considered separate from the same day surgery or procedure—no 25 modifier needed.
43 Modifier 25For an established patient, if the E&M service resulted in the initial decision to perform a minor procedure (0-10 days global period) on the same day and medical necessity indicates an E&M service beyond what is considered normal protocol for the procedure, the 25 modifier is appropriate.To determine the correct level of E&M service to submit, identify services unrelated to the procedure and use as E&M elements.Clearly mark the encounter form to indicate that a 25 modifier should be attached to the E&M.
44 Clinical Examples—Primary Care New patient 99204Initial office visit for a 17-yr-old female with depressionInitial office visit for initial evaluation of a 63-yr-old male with chest pain on exertionInitial office visit for evaluation of 70-yr-old patient with recent onset of episodic confusion.
45 Clinical Examples—Primary Care Established patient 99213Office visit for a 62-yr-old female, established patient, for follow-up for stable cirrhosis of the liver.Office visit for a 60-yr-old, established patient, with chronic essential hypertension on multiple drug regimen, for blood pressure check.Office visit for a 50-yr-old female, established patient, with insulin-dependent diabetes mellitus and stable coronary artery disease, for monitoring.
46 Clinical Examples—Primary Care Established Patient 99214Office visit for a 28-yr-old male, established patient, with regional enteritis, diarrhea, and low-grade fever.Office visit for a 28-yr-old female, established patient, with right lower quadrant abdominal pain, fever, and anorexia.Office visit with 50-yr-old female, established patient, diabetic, blood sugar controlled by diet; complains of frequency of urination and weight loss, blood sugar of 320 and negative ketones of dipstick.
47 Clinical Examples—Primary Care Established Patient 99215Office visit with 30-yr-old, est. patient, for 3- month history of fatigue, weight loss, intermittent fever, and presenting with diffuse adenopathy and splenomegaly.Office visit for evaluation of recent onset syncopal attacks in a 70-yr-old woman, est. patient.Office visit for a 70-yr-old female, est. patient, with diabetes mellitus and hypertension, presenting with a two-month history of increasing confusion, agitation and short-term memory loss.
48 Where To Get Help www.med.unc.edu/compliance/ UNC P&A Professional ChargesSchool of Medicine Compliance OfficeConfidential Help LineAMA CPT Manual