1. E&M Coding

2. Cover office visits Hospital visits Physicals Counseling

3. 99211 “an office or other outpatient visit that may or may not require the presence of a physician” presenting problem is simple 5 minutes no documentation needed for hx, px or complexity of medical decision making. Use a flow sheet! –E.g B-12 shot, suture removal, dressing change, allergy injections

4. Depo-Provera Flow Sheet Name:__________________ DOB:_____/_____/_______ MRN:__________________ Drs. order to give Depo-Provera 150mg 150mg IM q3 mo: ________________________________________ MD/DO

5. You can’t bill for the administration of an injectable medication (90782), or the for the administration of an immunization (90471, 90472) and a nurse visit at the same time. You can either bill for the 99211 plus the medications or bill for the injection plus the medication.

6. 99201 The 99201 code has more specific requirements than the 99211!!! 99201 cannot be used for nurse visits. 99201 requires a problem focused history, a problem focused exam and straightforward decision making e.g. an out of town patient needing a refill of her NSAID.

7. 99201 quick reference 99201 Key components (need all three)Elements Minimum requirements Problem-focused historyHPI 11 ROS00 PFSH00 Problem-focused examBody areas/organ systems 1 Straightforward medical decision making (need at least two) Diagnoses/management options 1 point (minimal) Amount/complexity of data0-1 point (minimal or none) Risk1 (minimal) Unlike code 99211, which has no specific documentation requirements, code 99201 for the evaluation and management of a new patient requires a problem-focused history, a problem- focused examination and straightforward decision making, as outlined in the table at right.

8. 99212 For the evaluation an management of an established patient, which requires at least 2/3 of these components: –a problem focused history –a problem focused exam –straightforward decision making 10 minutes

9. 99202 Office or other outpatient visit for the evaluation and management of a new patient which requires all three: –expanded problem focused history –expanded problem focused exam and –straightforward decision making 20 minutes

10. 99213 For an established patient and requires 2/3 components of: an expanded problem focused history expanded problem focused exam medical decision making of low complexity 15 minutes average

11. 99203 For new patient and requires all three components: –a detailed history –a detailed examination –low complexity decision making –30 minutes

12. 99214 For the evaluation and management of an established patient and requires 2/3 of: –a detailed history –a detailed examination –medical decision making of moderate complexity –25 minutes

13. 99204 Evaluation and management of new patient which requires all 3 components: –a comprehensive history –a comprehensive exam –medial decision making of moderate complexity –45 minutes

14. 99215 Evaluation and management of an established patient which requires 2/3 components: –a comprehensive history –a comprehensive exam –medical decision making of high complexity –40 minutes

15. 99205 Evaluation and management of a new patient which requires all three components: –a comprehensive history –a comprehensive exam –medical decision making of high complexity –60 minutes

16. A point threshold is the minimum Number of documentation points to attain a code level CC: No points HPI: 1 point per element ROS: 1 point per element PMH, FH, SH: 1 point for each PE: 1 point per element Data from testing/imaging or sources such as reports and old medical records: 1 point Diagnosis: 1 point each Plans/Management options: 1 point for each

17. Documentation elements include: The HPI: 10 possible elements such as location, quality, severity, duration, etc. ROS: 15 possible elements based on organ systems reviewed. The PMH, FH, SH are each an element.

18. Data Elements Can Include: Test results Imaging, ECG, PFT results Old Records

19. Diagnosis can include: New Diagnoses Chronic problems that are either stable or getting worse.

20. Management Options Can Include: Prescription or OTC meds Activity recommendations PT, OT, etc Referrals Immunization other parental needs

21. Total E&M Point Thresholds

22. E&M Point Thresholds by Category for Established Patients “ 2 out of 3 will do”

23. Established patients “Two out of three will do” for established patients point thresholds only need be met for 2 of the 3 categories.Total points for established patients are less important than the point thresholds for each category because the point thresholds only need be met for 2 of the 3 categories. –For example, if the history is 2 points (limited), the examination is less than 6 points (problem focused), but the decision making is 5 points (low complexity), then 99213 may be used even though the total of 13 was not reached.

24. E&M Point Threshold for New Patients 3 are required

25. Coding Time Three types of time: –face-to-face: physician meets directly with the patient or family. Outpatient/office visits only. –Floor/unit time: physician is physically present on the hospital floor delivering bedside service. It includes time spent with the patient & time spent charting, discussing care with nurses/others. –Non-face-to-face: work related to pt care that occurs before or after face to face time

26. The greater than 50% rule: “If a physician spends more than 50% of a face-to-face visit counseling or coordinating a patient’s care, the physician can code the visit on the basis of time, even if the history, exam or medical decision making are lacking.”

27. Prolonged Services Codes: Prolonged services codes are reported in addition to the E/M code when the length of time spent with a patient goes at least 30 minutes beyond what is typical for that service. Use 99354 for the fist 30 - 74 min beyond what is typical, 99355 for each half hour after that. Prolonged services can also be coded using a modifier-21.*

28. Document the time: “Time spent with the individual patient should be recorded in the patient’s chart” E.g. “20 minutes face-to-face; counseling/coordination of care>50% of visit”

29. Undercoding and Overcoding: Family physicians overcode new patient evaluation and management visits 82% of the time and undercode established patients 33% of the time.* *Journal of the American Board of Family Practice; May/June 2002

30. Average and Recommended Code Distributions

32. Medicare Payment for CPT code 99213 in Colorado