7-2 LEARNING OUTCOMES After studying this chapter, you should be able to: 1.Describe the organization of the CPT Evaluation and Management (E/M) section of CPT 2.Discuss the use of the section guidelines as a resource for E/M coding. 3.List five questions that are used to select appropriate E/M code ranges and assign correct codes. 4.State the difference between new and established patients in CPT terms. 5.Discuss the three key components that determine the level of service, listing the four levels of each. 6.Describe the process used to determine the level of service for E/M coding, including the part played by the contributing components. 7.Compare and contrast consultations and new patient (referral) E/M services. 8.Discuss the factors that are important in assigning critical care codes. 9.Define observation and standby services. 10.Assign CPT E/M codes, correctly applying the rules and exceptions for each category of service.
7-3 KEY TERMS category Chief complaint (CC) Consultation Consulting physician Contributory components Coordination of care Counseling Critical care Direct care E/M components Established patient Evaluation and management (E/M) codes Examination Face-to-face time Family history History History of present illness Key components Level of service (LOS) Medical decision making (MDM) New patient 1995 Documentation Guidelines 1996 Documentation Guidelines Observation Past history Place of service (POS) Presenting problem Preventive medicine Problem-oriented Professional services Referral Referring physician Review of systems Roll-up rule Social history Standby Time Unit/floor/time
7-4 CODE ORGANIZATION E/M codes break down into categories and subcategories Categories – examples are: Office or outpatient services Hospital observation services Hospital Inpatient services Subcategories – examples are: New patient Established patient Discharge services See table 7.1 for the complete listing
7-5 SELECTION PROCESS A standard set of questions used for determining the correct E/M code category: 1.Who is the patient? 2.What is the place of service? 3.What is the patient’s status? 4.What type of service is being provided? 5.What level of service is being provided?
7-6 WHO IS THE PATIENT? Determine whether the patient is new or established based on CPT E/M guidelines. A new patient: has not received any professional services from the physician within three years. has not received any professional services from another physician of the same specialty in the same group practice within three years. May have received professional services from another physician in the same group who is in a different specialty within three years.
7-7 WHO IS THE PATIENT? An established patient: –Has received professional services from the physician within the past three years –Has received professional services from another physician of the same specialty in the same group practice within three years. Age categories –Neonate (birth to twenty-eight days) –Pediatric (twenty-nine days to twenty-four months) –Adult –Age ranges required for Preventive Medicine services
7-8 WHAT IS THE PLACE OF SERVICE? Physician office Hospital Nursing facility Outpatient clinic Emergency department Observation area of hospital
7-9 WHAT TYPE OF SERVICE WHAT TYPE OF SERVICE? Examples are: Initial care for a first visit Subsequent care for follow-up visits Prolonged care Standby services
7-10 WHAT IS THE PATIENT’S STATUS? Is the patient: Ill or injured Critically ill or injured To be hospitalized Presenting for preventive services Under the care of an outside agency
7-11 WHAT IS THE LEVEL OF SERVICE WHAT IS THE LEVEL OF SERVICE? Problem-focused (PF) Expanded problem-focused (EPF) Detailed (DET) Comprehensive (COMP)
7-12 CODE SELECTION EXAMPLE A fifty-six year old male patient who has never been seen before by the physician has an office visit for left ankle pain caused by a fall. Who is the patientNew, adult What is the place of serviceOffice What is the patient’s statusInjured, in pain Type of serviceNew, initial Code range will be from 99201-99205 New patient - office/outpatient category
7-13 DETERMINE THE LEVEL OF SERVICE E/M components: History Examination Medical decision making Counseling Coordination of care Nature of the presenting problem Time
7-14 KEY COMPONENTS The first three components in the list are the key components for selecting the level of service of E/M codes. –History, Examination, Medical decision making The next four components are considered contributory components. –Counseling, Coordination of care, Nature of the presenting problem, Time
7-15 DETERMINE HISTORY LEVEL History is the information patients communicate to the physician explaining their illness, injury and/or symptoms. This communication is in response to the physician’s questions. History is considered subjective.
7-16 LEVELS OF HISTORY Problem-focused requires: –Chief complaint –Brief history of the present illness or problem Expanded problem-focused requires: –Chief complaint –Brief history of the present illness or problem –Problem-pertinent system review
7-17 LEVELS OF HISTORY Detailed requires: –Chief complaint –Extended history of present illness or problem –Extended system review (more than just problem pertinent) –Pertinent past history, family history and/or social history directly related to the patient’s problem. Comprehensive requires: –Chief complaint –Extended history of present illness or problem –Review of all body systems –Complete past, family and social history (all three)
7-18 DETERMINE EXAMINATION LEVEL Examination describes the information a physician collects from examining the patient. The examination is based on factual findings. Examination is considered objective.
7-19 LEVELS OF EXAMINATION Problem-focused requires: –Limited exam of affected body area or organ system Expanded problem-focused requires: –Limited exam of affected body area or organ system and other symptomatic or related organ systems Detailed requires: –Extended exam of affected body area or organ system and other symptomatic or related organ systems Comprehensive requires: –General multisystem exam or complete examination of a single organ system
7-20 DETERMINE MEDICAL DECISION MAKING LEVEL Medical decision making (MDM) is the process of establishing a diagnosis and determining treatment or management of the condition. Patients present to their physicians with symptoms. Physicians determine the diagnosis and treatment.
7-21 DETERMINE MEDICAL DECISION MAKING LEVEL Example Patient presents with a three-day history of redness in the left eye. There is no trauma or foreign body present. The patient complains of itching and discharge for the affected eye. There are no changes in vision. Once a history is taken and an examination is done the physician determines the diagnosis and how to treat or manage the diagnosis.
7-22 DETERMINE MEDICAL DECISION MAKING LEVEL CPT departs from the range of problem-focused through comprehensive for MDM. The MDM levels are: Straightforward Low complexity Moderate complexity High complexity
7-23 DETERMINE MEDICAL DECISION MAKING LEVEL Three measurements are used for the level of MDM 1.Number of diagnoses or management options 2.Amount of and/or complexity of medical records, tests, and other information (data). 3.The risk of complications, morbidity, and/or mortality (overall risk).
7-24 LEVELS OF MEDICAL DECISION MAKING Straightforward 1.Minimal diagnoses or management problems 2.Minimal or no data 3.Minimal risk Low complexity 1.Limited diagnoses or management options 2.Limited data 3.Low risk
7-25 LEVELS OF MEDICAL DECISION MAKING Moderate complexity 1.Multiple diagnoses or management options 2.Moderate data 3.Moderate risk High complexity 1.Extensive diagnoses or management options 2.Extensive data 3.High risk
7-26 SELECTING THE LEVELS OF SERVICE 1.Identify the category and subcategory 2.Review guidelines 3.Review code descriptions 4.Determine history, exam, medical decision making 5.Select level
7-27 LEVELS OF SERVICE REQUIREMENTS Know which codes require all 3 key components. Know which codes require only 2 of the 3 key components. The lowest key component controls the level of service.
7-28 CONTRIBUTORY COMPONENTS Counseling Coordination of care Nature of the presenting problem Time
7-29 OFFICE OR OTHER OUTPATIENT SERVICES 99201-99205 New patient Three key components For the purposes of E/M coding selection, the AMA has defined professional services as face-to-face services
7-30 OFFICE OR OTHER OUTPATIENT SERVICES 99211-99215 Established patient Two key components
7-31 HOSPITAL OBSERVATION SERVICES 99217 Observation care discharge The observation care discharge codes include final examination of the patient, discussion of the hospital stay, instructions for continuing care, and preparation of discharge records.
7-32 HOSPITAL OBSERVATION SERVICES 99218-99220 Initial observation care 3 key components Hospital observation codes represent the E/M services provided to patients who are in observation status at the hospital but who have not gone through the hospital admission process.
7-33 ROLL-UP RULE Multiple E/M services provided by the physician to the same patient on the same day are reported by one E/M code in most circumstances. A physician who treats a patient in the physician’s office and then sends the patient to the hospital for observation will report only the observation care codes. The office visit rolls up into the observation care.
7-34 HOSPITAL INPATIENT SERVICES 99221-99223 Initial hospital care Three key components The initial hospital care codes are used to report the first hospital inpatient encounter by the admitting physician. Other physicians who treat the patient during their hospital stay will use either the consultation codes or subsequent hospital care codes.
7-35 HOSPITAL INPATIENT SERVICES 99231-99233 Subsequent hospital care 2 key components The subsequent hospital care codes are used by the admitting physician after the first day of care. Other physicians treating the patient may also use these codes for their hospital visits.
7-36 HOSPITAL INPATIENT SERVICES 99234-99236 Same-day admission and discharge Three key components These codes represent the services provided to patients who are in observation care or have been admitted to the hospital, and are discharged on the same date they were admitted.
7-37 HOSPITAL INPATIENT SERVICES 99238-99239 Hospital discharge services Time based Hospital discharge services can be provided by either the attending or admitting physician on the date of discharge. The codes represent the total amount of time spent by the physician for the patient’s final discharge, whether the time is continuous or not.
7-38 CONSULTATIONS 99241-99245 Office consultation Three key components 99251-99255 Hospital consultation Three key components Consultation codes represent the services of a physician who has been asked by another physician or other appropriate source to give an opinion or advice on a patient.
7-39 EMERGENCY DEPARTMENT (ED) SERVICES 99281-99285 Three key components CPT specifically defines an emergency department as “an organized hospital-based facility for the provision of unscheduled episodic services to patients who present for immediate medical attention. The facility must be available 24 hours a day.”
7-40 EMERGENCY DEPARTMENT (ED) SERVICES 99288 Physician direction of emergency medical systems This code represents the services of a physician located in the hospital emergency department or in the critical care department who is in two-way voice communication with ambulance or rescue personnel who are outside the hospital. The physician directs those personnel in providing medical procedures.
7-41 CRITICAL CARE Critical care is the provision of medical care to a critically ill or critically injured patient. Medical care qualifies as critical care only if both the illness or injury and the treatment being provided meet the critical care requirements. Critical illness or injury impairs one or more vital organ systems, causing a high probability of imminent or life-threatening deterioration in a patient’s condition.
7-42 CRITICAL CARE 99289-99290 Pediatric critical care transport Time based These codes represent the services of a physician who accompanies a critically ill or critically injured pediatric patient during interfacility transport and provides face-to- face services.
7-43 CRITICAL CARE 99291-99292 Critical care services Time based These codes represent critical care services provided to patients beyond the pediatric age criterion of 24 months who are critically ill or critically injured. These codes are also used if outpatient critical care is provided to either pediatric or neonate patients.
7-44 CRITICAL CARE TIME Includes: Patient care at bedside Review of test results on unit or floor Discussion of patient care Documentation of critical care including patient’s condition Documentation of time
7-45 CRITICAL CARE 99293-99294 Inpatient pediatric critical care Per day codes Patient is age 29 days through 24 months
7-46 CRITICAL CARE 99295-99296 Inpatient neonatal critical care Per day codes Patient is 28 days of age or less
7-47 CRITICAL CARE 99298-99300 Continuing intensive care Per day codes These codes represent services provided after the date of admission to patients that are not critically ill but continue to require intensive observation, frequent interventions and other intensive services.
7-48 NURSING FACILITY SERVICES 99304-99306 Initial nursing facility care Per day Three key components These codes are an exception to the roll-up rule. The physician who discharges a patient from the hospital or from observation and then admits that same patient to the nursing facility is allowed to report both codes.
7-49 NURSING FACILITY SERVICES 99307-99310 Subsequent nursing facility care Per day Two key components
7-51 DOMICILIARY, REST HOME, CUSTODIAL SERVICES 99324-99328 New patient Three key components 99334-99337 Established patient Two key components These codes are for patients located in a facility that provides room, board and other personal assistance, generally on a long term basis. The facility must provide a medical component to qualify for these codes.
7-52 DOMICILIARY, REST HOME, HOME CARE PLAN OVERSIGHT SERVICES 99339-99340 Services are provided within a calendar month Not face-to-face services Time-based Comparable to care plan oversight codes 99374-99380
7-53 HOME SERVICES 99341-99345 New patient Three key components 99347-99350 Established patient Two key components Format for these codes is the same as 99201-99215
7-54 PROLONGED SERVICES 99354-99357 Direct care (face-to face) Add-on codes Office/outpatient/inpatient setting Time-based These codes represent services that go beyond typical service in the office/outpatient/inpatient setting.
7-55 PROLONGED SERVICES 99358-99359 Nondirect care (non face-to-face) Add-on codes Office/outpatient/inpatient setting Time-based These codes represent services that go beyond typical service in the office/outpatient/inpatient setting but are not face-to-face services.
7-56 PHYSICIAN STANDBY SERVICES 99360 Require prolonged physician attendance Time-based (each 30 minutes) These codes represent services provided when a physician asks another physician to stand by during treatment of a patient in order to provide additional services that may be needed.
7-57 CASE MANAGEMENT SERVICES Anticoagulant Management 99363-99364 Per days of therapy Medical Team Conferences 99366-99368 Time-based Case Management codes represent the services of a physician or non- physician qualified health care professional who is responsible for the direct care of a patient, and for coordinating, managing access to, initiating, and/or supervising other health care services for the patient.
7-58 CARE PLAN OVERSIGHT SERVICES 99374-99380 Time-based Patient not present These codes represent the services that physicians provide to patients who are under the care of a home health agency, hospice, or a nursing facility.
7-59 PREVENTIVE MEDICINE 99381-99387 New patient initial comprehensive preventive service Age-based Include counseling These codes represent the services provided to new patients for assessment of their general health and to prevent illness or injury. The patient’s age determines the extent of the service provided.
7-60 PREVENTIVE MEDICINE 99391-99397 Established patient comprehensive preventive service Age-based Include counseling These codes represent the services provided to established patients for assessment of their general health and to prevent illness or injury. The patient’s age determines the extent of the service provided.
7-61 PREVENTIVE MEDICINE Counseling Risk Factor Reduction and Behavior Change Intervention 99401-99412 Preventive medicine individual counseling Behavior change individual interventions Preventive Medicine group counseling The preventive medicine counseling codes relate to family problems, diet, exercise, substance abuse, sexual practices, injury prevention, dental health, etc. The behavior change interventions are for persons whose behavior is often considered an illness itself- tobacco use and addiction, substance abuse/misuse or obesity.
7-62 NEWBORN CARE Two codes for initial care of newborn 99431 for child born in the hospital This code includes initiation of diagnostic and treatment programs and preparation of hospital records. 99432 for child born in other than hospital or birthing room. This code includes the physical examination of the baby and conferences with the parents.
7-63 NEWBORN CARE 99433 Subsequent hospital care of normal newborn This code is reported each day the physician provides care to a newborn in the hospital. 99435 History and examination of normal newborn assessed and discharged same day In addition to history and examination this code includes preparation of medical records.
7-64 NEWBORN CARE 99436 Attendance at delivery This code represents the services of a pediatrician who has been asked to attend the delivery because the delivering physician anticipates a problem and wants immediate assistance if needed.
7-65 NON FACE-TO-FACE PHYSICIAN SERVICES Telephone Services 99441-99443 Provided to established patient or established patient’s guardian only Must be initiated by patient or patient’s guardian Note the time constraints related to previous and subsequent E/M services
7-66 NON FACE-TO-FACE PHYSICIAN SERVICES On-Line Medical Evaluation 99444 Provided to established patient, guardian or health care provider Note time constraints related to previous E/M service.
7-67 SPECIAL EVALUATION AND MANAGEMENT SERVICES 99450 -99499 These codes represent services provided to establish baseline information before the issuance of life or disability insurance certificates. They are appropriate for any outpatient setting and for either new or established patients. No active management of the patient’s problems occurs during the encounter. 99455 is for the patient’s treating physician 99456 is for the services of different physician
7-68 MODIFIER 25 For a service that is significant and separately identifiable from a procedure or another E/M service provided on the same date. All procedures include some E/M services To append the modifier 25, the E/M service must go beyond the procedural E/M services.
7-69 NEWBORN CARE Newborn resuscitation 99440 This codes represents the services of a pediatrician who has not attended the delivery but is called in after the delivery to provide assistance a newborn who is not breathing well or whose heart is not pumping correctly.