2. All CPT codes trademarked by the American Medical Association. All rights reserved. CARRIERS may differ on E&M auditing criteria--see TRAILBLAZER. This should not be the only source used for coding and billing. All coding and billing decisions should be made on a case-by-case basis based upon documentation and insurance guidelines. All information contained herein is valid for the date of this seminar only. This presentation is based on national guidelines. Some E/M guidelines are very subjective and decisions about levels can be up to an individual auditor. This presentation is a summary only. For Medicare regulations, see http://www.cms.hhs.govor your local Medicare web site.

7. Source: CMS E/M Documentation Guidelines

39. Dx./mgt. options0-1234 Amount of data0-1234 Overall riskMinimalLowModerateHigh Level of MDM Straightforward 99241 99242 Low 99221 99231 99243 Moderate 99222 99232 99244 High 99223 99233 99245 Two of the three areas: Dx. Options, Amount of Data, and Risk Establish the MDM Level

43. Amount and/or Complexity of data reviewed Points are assigned to each section below based on the number of data items reviewed max = 4 pts PointsTotal Review and/or order of clinical labs11 Review and/or order of tests radiologic study, other non invasive diagnostic study 1 Discussion of diagnostic study w/interpreting MD1 Decision to obtain old records and/or obtaining history from someone other than the patient 1 Review and summarization of old records or gathering data from source other than patient 2 Independent visualization of image, tracing or specimen itself 2 2 Total Points 3

48. Key Factors 2 of 3 Level 5Level 4Level 3 History HPI ROS PFSH 4 10 2 of 3 4 2 1 of 3 1 NA EXAM≥ 8 organ systems a) An extended exam of affected area or b) 12 bullets (1997) a) Limited exam of affected and related system or b) 6 bullets (1997) MDM (2 of 3) Dx/Tx Options Data Risk High Complexity Extensive High Moderate Multiple Moderate Low Complexity Limited Low

51. Key Factors 3 of 3 Level 5Level 4Level 3 History HPI ROS PFSH 4 10 All Three 4 10 All Three 4 2 1 of 3 EXAM≥ 8 organ systems a) An extended exam of affected area or b) 12 bullets (1997) MDM (2 of 3) Dx/Tx Options Data Risk High Complexity Extensive High Moderate Multiple Moderate Low Complexity Limited Low

52. 52

53. 53

54. Service Performed CPT Code Documentation required History/Exam/MDM Problem SeverityMedicare Consult level 1 99241(15 min) PF/PF/Straightforward Self limited or minor 99201 (10 min) Consult level 2 99242 (30 min) EPF/EPF/Straightforward Low severity 99202 (20 min) Consult level 3 99243 (40 min) Detailed/Detailed/Low Moderate severity 99203 (30 min) Consult level 4 99244 (60 min) Comp./Comp./Moderate Moderate to high severity 99204 (45 min) Consult level 5 99245 (80 min) Comp./Comp./High Moderate to high severity 99205 (60 min) 54

55. Service Performed CPT CodeDocumentation required (All 3 to 2 out of 3) History/Exam/MDM Problem SeverityMedicare Consult level 199241 (15 min) PF/PF/StraightforwardSelf limited or minor99212 (10 min) Consult level 299242 (30 min) EPF/EPF/Straightforward or Low for 99213 Low severity99213 (15 min) Consult level 399243 (40 min) Detailed/Detailed/Low or Moderate for 99214 Moderate severity99213 or 99214 (15-25 min) Consult level 499244 (60 min) Comp./Comp./Moderate or High for 99215 Moderate to high severity99214 or 99215 (25-40 min) Consult level 599245 (80 min) Comp./Comp./HighModerate to high severity99215 (40 min) 55

56. CPT CodeHistoryExamMDM Traditional Medicare 99251 (20 min) PF HxPF ExamSF MDM 99252 (40 min) EPF HXEPF ExamSF MDM 99253 (55 min) Det HxDet ExamLow MDM99221 (30 min) 99254 (80 min) Comp HxComp ExamModerate MDM99222 (50 min) 99255 (110 min) Comp HxComp ExamHigh MDM99223 (70 min) 56

57. 57

58. 58 Consult CodeMaps toPercentage Mapped 2010 Price 99241 ($48.69) 99201 99211 50% $38.95 $19.12 99242 ($91.61) 99202 99212 50% $67.44 $38.95 99243 ($125.15) 99203 99213 50% $97.74 $65.54 99244 ($185.38) 992o4 99214 50% $151.48 $98.46 99245 ($226.50) 99205 99215 50% $190.43 $132.73 Source: CMS Website from Frank Cohen; 2010 NF RVUs; 2009 CF and GPCIs =1

59. 59

60. 60

61. 61

62. 62

65. o PEER REVIEW! Physicians should use forms or software to audit their partners’ E&M. This works in two ways-- improves understanding and brings pressure to change. Read the E&M guidelines EVERY SIX MONTHS. Read PRACTICAL E/M by Stephen Levinson. Use templates, forms, and EMR algorithms wisely.