CPT Evaluation and Management Chapter 9 CPT Evaluation and Management

E/M Section Codes 99201–99499 First section in CPT Review guidelines at beginning section Apply applicable notes

E/M Coding Tips Notes located beneath headings and/or subheadings apply to all codes in heading or subheading Parenthetical notes located below a specific code apply to that code only Unless the note indicates otherwise

E/M Overview Introduced in 1992 Between three and five levels of service Reflects amount of work involved in providing health care to a patient

Levels of Service Organized according to: Place of service Physical location where health care is provided to patients (e.g., office, hospital, home, nursing facility) Type of service Type of health care services provided to patients (e.g., new or initial encounter, follow-up or subsequent encounter, consultation)

Example Dr. Miller completed Jennifer Sullivan’s history and physical on the first day of her inpatient admission Place of service: hospital Type of service: initial care E/M category: hospital inpatient services E/M subcategory: initial hospital care

E/M Section Guidelines Located at beginning of section Includes: Classification of E/M services Definitions of commonly used terms Unlisted service Special report Clinical examples Instructions for selecting level of E/M service

Classification of E/M Categories (e.g., office, outpatient visits, consultations) Subcategories (e.g., new and established patients) Five-digit numerical codes (99201–99499) (continued)

Classification of E/M Code descriptions include: Place and/or type of service Content of service Detailed history and examination Nature of presenting problem Time required to provide service

E/M Key Terms New patient Established patient Concurrent care Unlisted service Special report Clinical examples (Appendix C)

Levels of E/M Service When selecting, require key components of history, examination, and medical decision making Contributory components include counseling, coordination of care, nature of presenting problem, and time

Key Components Three components: New patients Established patients Extent of history Extent of examination Complexity of medical decision making New patients Three components required Established patients Two of three components required

Extent of History Includes: Four types: History of present illness (HPI) Review of systems (ROS) Past/Family/Social history (PFSH) Four types: Problem-focused Expanded problem-focused Detailed Comprehensive

Extent of Examination Four types: Problem-focused Expanded problem-focused Detailed Comprehensive

Complexity of Medical Decision Making Measured by: Number of diagnoses or management options Amount and/or complexity of data Risk of complications and/or morbidity or mortality (continued)

Complexity of Medical Decision Making Documentation includes: Ancillary test results (e.g., laboratory) Known diagnoses Opinions of other physicians Planned course of action Review of previous records

Medical Decision Making Four types of complexity: Straightforward Low Moderate High

Medical Decision Making E/M Code Selection Current Procedural Terminology © 2008 American Medical Association. All rights reserved. Select E/M code based on extent of history and examination and complexity of medical decision making History Problem- focused Expanded problem- focused Expanded problem-focused Detailed Compre-hensive Examina-tion Expanded problem- focused Medical Decision Making Straight- forward Low complexity Moderate complexity Moderate Complexity High Complexity Go to appropriate E/M category/subcategory and select code based on this information

Contributory Components Counseling and/or coordination of care components “drive” CPT code selection only when they dominate the encounter.

Counseling Diagnostic results Prognosis Risks and benefits of treatment options Instructions for treatment and/or follow-up Compliance with treatment options Risk factor reduction Patient and family education

Nature of the Presenting Problem Five types: Minimal Self-limited or minor Low severity Moderate severity High severity

Time Face-to-face time Unit/Floor time Amount of time office or outpatient care provider spends with patient and/or family Unit/Floor time Amount of time provider spends at patient’s bedside and managing patient’s care on unit/floor

Billing According to Length of Time Document: Total length of time for the encounter Length of time spent coordinating and/or counseling Issues discussed Relevant history, exam, and medical decision making

Code 99211 Nurse visit Reported when ancillary personnel provide E/M services Document chief complaint and description of service provided

Hospital Observation Services Subcategories Observation care discharge services Initial observation care Discharge services Final examination of patient Discussion of hospital stay Instructions for continuing care

Initial Observation Care Reported for patients who are admitted for observation services on one date and discharged from observation status on a different date

Hospital Inpatient Services Subcategories Initial hospital care Subsequent hospital care Observation or inpatient care services Hospital discharge services

Hospital Discharge Services Includes: Final examination of patient Discussion of hospital stay Instructions for continuing care Preparation of discharge records, prescriptions, and referral forms

Consultations Consultation criteria Subcategories Office or other outpatient services Initial inpatient consultations Preoperative clearance

Pediatric Critical Care Patient Transport Definition Interfacility transport Critical illness or injury

Critical Care Services Physician directly delivers medical care to critically ill or injured patient Manages life-threatening conditions Single or multiple vital organ system failure Does not have to be provided in a critical care unit May be continuous or interrupted (continued)

Critical Care Services Includes the following procedures: Blood gases Chest x-rays Gastric intubation Information data stored in computers Cardiac output measurements Pulse oximetry (continued)

Critical Care Services Includes the following procedures: Temporary transcutaneous pacing Vascular access procedures Ventilatory management

Inpatient Neonatal and Pediatric Critical Care Neonate Low birth weight Less than 1500 grams (g)

Nursing Facility Services Includes: Nursing facility (NF) Skilled nursing facility (SNF) Intermediate care facility (ICF)/Mentally retarded Long-term care facility (LTCF) Psychiatric residential treatment facility

Prolonged Services Reported in addition to an E/M service at any level Physician’s services involving patient contact that are considered beyond the usual service in either an inpatient or outpatient setting (continued)

Prolonged Services Reported only when time is greater than 30 minutes Time must be documented

Physician Standby Services Physician spending a prolonged period of time without patient contact waiting for an event to occur that will require the physician’s services (continued)

Physician Standby Services Standby types: Operative Pathology Diagnostics Obstetrics Pediatrics

Case Management Services Physician is responsible for: Direct care of patient Coordinating and controlling access to or initiating and/or supervising other health care services needed

Care Plan Oversight Services Cover physician’s time while supervising a complex and multidisciplinary care treatment program for a specific patient under the care of a home health agency, hospice, or nursing facility

Preventive Medicine Services Routine examinations or risk management counseling for children and adults who exhibit no overt signs or symptoms of a disorder while presenting to the medical office for a preventive medical physical Wellness visits Risk factors

Newborn Care Service provided in a variety of health care settings, hospitals, birthing centers, and homes that include: History and examination of normal infant Attendance at delivery and initial stabilization of newborn Newborn resuscitation

Counseling Risk Factor Reduction Preventive Medicine Counseling (99401-99404) Used for promoting health and preventing illness and injury (continued)

Counseling Risk Factor Reduction Intervention should address family problems, diet and exercise, substance use, injury prevention, and dental health No illness should be present with these codes

Behavior Change Intervention For patients who have behavior that is considered an illness, itself Smoking and tobacco cessation Alcohol and/or substance abuse

Non-Face-to-Face Physician Service Telephone Service (99441-99443) E/M service provided by a physician using the telephone (continued)

Non-Face-to-Face Physician Service Code is not reported if service ends with decision to see patient within 24 hours or within seven days of a previously completed procedure Provided to an established patient

Special E/M Services Provided to: Establish baseline information prior to issuance of life or disability insurance certificates Examine a patient with a work-related or medical disability problem