1. Coding 101: Getting Paid for What You Do
Jeannine Z. P. Engel, MD
Assistant Professor of Medicine
Vanderbilt University Medical Center

2. Background
HCFA, now CMS (Center for Medicare and Medicaid Services) issued guidelines for documentation of different service codes in They were revised in Either can be used.
In general, the 1995 guidelines are more favorable for General Internists.
This presentation will focus on 1995 guidelines.
Prior to 1995, there were no specific guidelines for documentation of different level service codes.
When the first guidelines were introduced in 1995, there were some complaints from subspecialists that those guidelines were too “generalist-oriented.” The 1997 guidelines tend to allow for an exam focused in particular areas.
You can use either 1995 or 1997 guidelines for any given visit. You can not mix 1995 and 1997 guidelines in a single visit.

3. Why should we care? Individual Benefits
Thought vs. Action: General IM reimbursement traditionally lower than procedure-based specialties
Getting paid for what we do - reimbursement for practice groups and individuals can increase
“Playing the game” vs. “Changing the game”
Cognitive-based specialties such as General Internal Medicine have traditionally lower reimbursement, as Evaluation and Management (E & M) Code RVU values are undervalued compared to most procedures.
It is imperative that Internists know and apply the rules of coding to be fully compensated for the work that they perform each day.
While the rules are cumbersome and complex, they CAN be deciphered and mastered.
ACP and other groups are working to change the reimbursement structure for Primary Care, but for now, we must play by the rules we have!

4. Disclaimer
This presentation will provide basic information regarding documentation and coding. Before applying this information at your institution or practice site, YOU MUST CHECK WITH YOUR COMPLIANCE OFFICE or LOCAL MEDICARE CARRIER to be sure these general principles are appropriate for your practice situation.
While the requirements of Current Procedural Terminology (CPT) and the Centers for Medicare and Medicaid Services (CMS) apply nationally, different insurers and Medicare contractors have leeway in some areas in interpretation of these requirements.

5. Learning Objectives
Review documentation requirements for basic outpatient office visits, including Annual Exams
Learn efficient documentation of Medical Decision Making
Discuss appropriate use of Office Consultation by General Internist
Gain comfort in coding levels 3, 4, 5 return office visits

6. Basic Coding Rules and Regulations

7. New vs. Return
A new patient has not received professional services from you or a member of your group in any service location (e.g. hospital) in the past 3 years
Multi-specialty groups: variable
If established patient has not been seen in 3 years, bill them as New
The location or type of the service does not matter. It could be an inpatient consult 2.5 years ago when the patient was post-op after a knee replacement – it would still be considered an established patient.
Your group is defined as those physicians with the same Medicare billing group identification in the same specialty.
If billing a patient that has not been seen before or it has been more than three years since the patient was last seen, you must fulfill New Patient documentation guidelines.

8. Elements for E&M visits
History
Chief Complaint (CC)
History of Present Illness (HPI)
Review of Systems (ROS)
Past, family, and social history (PFSH)
Exam
Number of organ systems (1995 guidelines)
Medical Decision Making (MDM)
# diagnoses or management options
Amount of data/complexity
Risk level to patient

9. New Patient- outpatient visit 3/3 needed
CPT
99201
99202
99203
99204
99205
HPI
ROS
PFSH 1 4 2 10 3
Exam 5 8
MDM
Straight-forward
Low
Moderate
High
Time
(min) 20 30 45 60
Remember- you need all three: History, Exam and MDM at the level to bill at that level.
Time is designated for coding based on COUNSELING ONLY.
Note that at low level visits, very little is needed in History and Exam.

10. New Outpatient Visit Need 3 of 3 99201 99202 99203 99204 99205
History (need all)
HPI
ROS
PFSH 1 4 2 10 3
Exam 5 8
MDM (2/3)
#Dx
Data
Risk
No meds
1 stable prob
1new no w/u
or 3 stable
Prescription med
Or 2 stable pr.
1new w W/U or 2 worse
Life threaten
Time if counseling is >50%
10 min 20 30 45 60
Another way of looking at the same information
More information is included in Medical Decision Making: the most common scenarios that are seen in GIM clinic visit.

11. Elements for E&M visits
History
Chief Complaint
History of Present Illness (7)
Location
Quality
Severity
Duration
Timing
Modifying Factors
Associated signs and symptoms
To bill the highest level of service (level 5), you need to document at least 4 HPI elements.

12. Elements for E&M visits
History
Chief Complaint
History of Present Illness
Review of Systems (14)
Constitutional-fever/wt
Eyes
Ears/nose/mouth/throat CV
Respiratory GI GU
Musculoskeletal
Skin
Neurologic
Psychiatric
Endocrine
Heme/lymphatic
Allergic/immunologic
To code the highest level of service (level 5), you must document at least 10 systems in your ROS.

13. Elements for E&M visits
History
Chief Complaint
History of Present Illness
Review of Systems
Past, Family, and Social History
Past Medical History
Family history
Social history

14. Pearls for documenting History
Can refer to previously documented elements: “Problem list updated as part of today’s visit”
“All other systems reviewed and negative” may be used in most cases to document negatives.
Taking history from someone other than the patient increases level of medical decision making.
Single bullets satisfy PFSH requirements - does not need to be exhaustive
An auditor must be able to find any problem lists or previous notes that you refer to. For example, you may document that family history is unchanged since documented on July 6, 2007.

15. Elements for E&M visits
History
Exam
# of organ systems (12)
Constitutional-VS, general appearance
Eyes
Ears, nose, mouth, throat
Cardiovascular (inc edema)
Respiratory GI GU
Musculoskeletal
Skin
Neurologic
Psychiatric
Heme/lymph/immuno-logic
To code the highest level of service (level 5), you must document at least 8 organ systems.
Note that eyes are separate from ears, nose, mouth, and throat.
Note that “extremities” is NOT a separate organ system, but included in the cardiovascular system.

16. Physical Exam
How many organ systems can you document before you lay a stethoscope on your patient??
Though I am NOT endorsing that you skip the examination of your patient…

17. Physical Exam SEVEN!! General appearance
Eyes - sclera anicteric/injected
HENT - hearing intact (hard of hearing)
MSK - normal gait/limping
Psych - normal (depressed/flat) affect
Skin - no rash on face, arms
Immunologic - NKDA (use for PMH or PE)

18. Coding New Patient Visits
Need 3 of 3 elements documented (history, exam, decision making)
MDM and MEDICAL NECESSITY SHOULD DRIVE CODING
To bill Level 4 new patient (99204), the history, PE and MDM must meet or exceed level 4 criteria to bill at that level.

19. MDM and MEDICAL NECESSITY SHOULD DRIVE CODING
MEDICAL NECESSITY is ALWAYS the most important driver of billing. While you can perform a level 5 history and PE for a simple skin abrasion, you can NOT bill a level 5 visit as this level of service is NOT medically necessary.
Medical necessity means that you should only perform the services that the patient requires to diagnose or treat the presenting problem.

20. Coding Return Patient Visits
Only need 2 of 3 elements documented to meet level of service coded (History, PE, MDM)
MDM and MEDICAL NECESSITY STILL DRIVE CODING
There will be occasional exceptions where history and exam may be the 2/3 elements that are counted, but in the majority of visits, medical decision making will be one of the counted elements.

21. Return Patient- outpatient visit 2/3 needed
CPT
99211
99212
99213
99214
99215
HPI
ROS
PFSH
Non-physician visit
1-3
None 1
none 4+
2-9
10+ 2
Exam
1 system
2-4 systems
5-7 systems
8+ systems
MDM
Straight-forward
Low
Moderate
High
Time
10 min
15 min
25 min
40 min
Remember - you only need two of three: History, exam and MDM at the particular level to bill at that level.
Time is designated for coding based on COUNSELING ONLY.
99211 is typically used for nurse visits (e.g. blood pressure checks, weight checks). A should not be coded when a physician sees the patient.

22. Return Outpatient Visit
Element (Need 2 of 3)
99212
99213
99214
99215
History HPI ROS PFSH 1
4 (or 3 chronic) 2
10 (“o/w neg”)
Exam (# systems) 5 8
Complexity
(need 2 of 3) Dx
Data
Risk
1 prob
No meds
2 est prob-stable or
1 est prob-worse
1 stable prob
3 stable est prob or
1 new, no w/u 3
Prescriptn med or 2 stable prob
2 prob-worse or 1 new, w/u 4
Severe side effects, DNR
Time if counseling is >50%
10 min 20 30 45
Same information, presented in minimalist way.
MDM has most common GIM scenarios filled in.

23. Documenting Medical Decision Making
The Real Meat of Internal Medicine

24. Medical Decision Making
Diagnoses
Data
Risk

25. Medical Decision Making
Number of diagnoses
Number and type of presenting problems
Amount/complexity of data reviewed
Ordering tests and reviewing of tests
Obtaining records or history from others
Overall risk of complications to patient before seeing another medical professional
See “Table of Risk”
Full MDM audit worksheet is provided in supplemental learning material.
Points are assigned to each of the elements in these categories.

26. Number of Diagnoses Self-limited or minor: 1 point each (2 max)
Established problem, stable: 1 point
Established problem, worsening: 2 points
New problem, no addt’l workup: 3 points
New problem, with further workup: 4 points
Complexity (and thus level of service)
Straight-forward=1; Low=2, Moderate=3, High=4
A new problem is a problem that is new TO THE EXAMINER. It may or may not be new to the patient.
Thus if you have never seen the patient before, the problem will be NEW to you.

27. Amount and Complexity of Data
Review and/or order of clinical test: 1 point
Basically all labs
Review and/or order of radiology: 1 point
Review and/or order of medical test: 1 point
Includes vaccines, ECG, echo, PFTs
Discussion of test with performing MD: 1 point
Independent review of test: 2 points
Old records or hx from another person
Decision to do this: 1 point
Doing it and summarizing: 2 points
“Clinical tests” include all tests in the section of the CPT book (e.g. labs, blood work)
“Radiology tests” include all xrays, CTs, MRIs, etc. These are in the section of CPT book.
“Medical tests” are all testing listed in section of the CPT book. This includes IM or IV abx, other injections you may order, ordering ecg, echo, vascular doppler studies, even ordering chiropractic care!
You can order a sed rate or every lab tests out there- it counts for 1 pt only
Be SURE to document if YOU review the ECG, the urine dip, the CXR, also if you call the radiologist- those 2 activities get you 3 pts, and a moderate level on the overall MDM for data (i.e )
Just deciding to get old records gets you one point- be sure to document this in your note. On the next visit, if you summarize the key findings, that is 2 pts.
Documenting the spouse/parent/friend’s report about the syncopal episode gets you 3 pts (you both decided to get a hx from someone else, AND you documented it), add in a few lab tests, and you are at 4 pts, high MDM in the data category (i.e !)

28. Overall Risk Table Learn and Love the overall risk table
3 categories: presenting problem, dx procedures, management options
Highest level of risk in ANY of the 3 categories is the overall risk level for that patient
See Table of Risk in supplemental materials

29. Overall Risk Table Pearls: Prescription drug management: moderate
2+ stable chronic illnesses: moderate
Abrupt mental status change: high
1 chronic illness w/ severe exacerbation: high

30. Overall Decision Making Table Need 2 of 3 elements to qualify for given level
Type of MDM
Straight-forward
99201/02
99212
Low
99203
99213
Moderate
99204
99214
High
99205
99215
# dx 1 2 3 4+
Amt data
0 or 1
Overall Risk
minimal
low
moderate
high
The numbers are points assigned for various types of problems or types of data, as previously outlined.
2 of 3 elements must be met or exceeded to qualify for a given overall level of decision making.
For example, if # dx is high (4 points), data is low (2 points) and risk is moderate (3 points), then overall would be MODERATE.

31. Counseling, Annual Exams and Office Consultation

32. Counseling
When time spent counseling >50% of total visit, then TIME becomes the deciding factor for coding
Total billing physician face to face time
99213: 15 min
99214: 25 min
99215: 40 min
Must document time spent and reason for counseling
“I spent 45 minutes face to face with patient today. 25 minutes spent counseling about new diagnosis and treatment of heart failure.”
This is all the documentation that is required in order to meet the requirements of coding by time based on CPT requirements. You may need to document more in order to communicate full extent of the visit.

33. Counseling is:
• “A discussion with the patient and/or family concerning one or more of the following areas” CPT book
Recommended tests, diagnostic results, impressions
Prognosis
Risks/benefits of treatment (management) options
Instructions for treatment (management) options and follow up
Importance of compliance with treatment (management) options
Risk factor reduction
Patient and family education

34. Preventative Service Visits
NO Chief complaint or HPI
MUST HAVE
Comprehensive ROS (10 organ systems)
Comprehensive or interval PFSH
Comprehensive assessment of risk factors appropriate to age
Multi-system physical exam appropriate to age and risk factors (RF)
Assessment/Plan which includes counseling, anticipatory guidance and RF reduction

35. Preventative Service Visits
New vs. Return rules are the same
Coding based on age of patient
NO specific guidelines for what to include with each age group
Documentation of anticipatory guidance/risk factor reduction is the common missing element
Can refer to previous ROS, PMH, FH, etc.
Can only bill NEW annual exam when patient is new to your practice and you perform Annual exam on the first visit.
Anticipatory guidance and risk factor reduction for adult patients will include items such as smoking cessation, seat belt use, gun safety, future cancer screening, etc.

36. Outpatient Consultation
Consultations require:
A request from another provider
The provision of a consultation evaluation service
A report of the service to the requesting provider
Simply put, one provider asks a question, and the consultant answers it.

37. Consultation Requirements
New CMS requirements as of Jan 2006:
The written request for a consultation must be included in the requesting provider’s plan of care.
A consultation request may be written on an order form in a shared medical record.
The consultant must also document the reason for the consultation.
The “Question” must be documented in 2 medical records

38. Consultation Requirements
The written report may be part of a common medical record or in a separate letter to the requesting provider and must be readily available.
The written report must include the findings and recommendations (the “answer” to the original provider’s question.)
The consultant is expected to have expertise beyond that of the requesting provider.
The written report can be your note, sent to the requesting MD.

39. Coding Outpatient Consultations
CPT codes
Documentation requirements are identical to New Patient visit codes
Outpatient Consult F/U codes were deleted in Jan 2006
Remember that all three elements, Hx, Exam and MDM will need to be at the level of service to bill at that level.

40. Pre-Operative Consultations
This is the most common scenario for a General Internist
You CAN bill Consultation on an established patient, as long as all the criteria are met
CMS rules state: “a pre-operative consultation at the request of a surgeon is payable if the service is medically necessary and not routine screening.”
If the surgeon asks you for pre-operative clearance on a patient, and there is medical necessity for the visit, you can bill a consult code for the visit.
You must document appropriately and send the recommendations back to the requesting MD. (“cc” your note is fine)

41. Pre-Operative Consultations
Following a pre-operative consultation, if the same MD/NPP assumes responsibility for management of all or part of the patient’s care postoperatively, the subsequent visit codes must be used.
Example – IM performs preop consult for patient prior to surgery; surgery occurs and surgeon requests IM inpatient MD to provide post operative care, in this scenario the inpatient IM MD cannot bill a second consult.
Basically, you can not bill a consult in the clinic and then bill another one for management of their known medical problems.

42. Second Opinions - Outpatient
For 2nd opinion evaluations in the outpatient or office setting, report the appropriate Office or other outpatient codes (new or established patient) for the level of service performed.
Confirmatory Consultation codes were deleted in Jan 2006

43. Consults Within a Group
Payment will continue to be made for a consultation if a provider in a group practice requests a consultation from another MD in the same group practice when the consulting MD has expertise in a specific medical area beyond the requesting professional’s knowledge.
examples include Cardiology practices where there are arrhythmia or heart failure sub-specialists, GIM practices with geriatricians, Med-Peds practices with Down-Syndrome specialists.

44. Let’s apply them to some real cases!
You have the Basics
Let’s apply them to some real cases!

45. Case #1 CC: 55 yo woman (known to you) presents with back pain
Level 3, 4, or 5?
Depends on:
medical necessity
what is done
what is documented
How you construct the visit according to the patient’s needs, and how you construct the documentation according to what you did will determine if this is a level 3, 4, or 5.

46. Case #1 CC: 55 yo woman (known to you) presents with back pain HPI
Patient awoke 1 week ago with constant, sharp, moderately-severe LBP assoc w/ intermittent spasms. Improves w/ ibuprophen. Remote history of similar sx. No trauma, fevers, weakness, bowel or bladder sx.

47. Case #1 (cont’d) Exam Assessment Plan Gen: BP 110/60
Back: lumbar paraspinous tenderness
Assessment
LBP, probably muscular
Plan
Continue ibuprofen
Begin cyclobenzaprine 10mg TID prn
Return in 2 weeks if not better, sooner prn

48. Outpatient Established Patient
Element
(need 2 of 3)
99211
99212
99213
99214
99215
History
HPI
ROS
PFSH
Min. prob. may 1
4 (or 3 chronic) 2 10
Exam* # systems
not 5 8
Complexity (2/3) Dx
Data
Risk
need MD
No meds
1 stable prob
3 (1 new no w/u) 3
Prescription med
Or 2 stable pr.
4 (1 new w/ W/U) 4
Life threaten
Time (≥50%counsel’g) 15 25 40
Using this coding rubric, please code the case just presented, and decide which level of service you would bill.
Hx: location, quality, severity, duration, timing, modifying factors (or status of 3)
*Exam: ’95 audit tool definitions (’97: 6 bullet points and 12 bullet points 99215)
Dx: est prob-stable 1; est. prob-worse 2; new-no W/U 3(max3); new prob W/U 4
Data: lab 1; xray 1; other 1; disc w/testing MD 1; decision to review records/hx 1; review old records/hx from non-pt 2; discuss w/ another provider 2; independent review test 2

49. Outpatient Established Patient
Element
(need 2 of 3)
99211
99212
99213
99214
99215
History
HPI
ROS
PFSH
Min. prob. may 1
4 (or 3 chronic) 2 10
Exam* # systems
not 5 8
Complexity (2/3) Dx
Data
Risk
need MD
No meds
1 stable prob 3
Prescription med
Or 2 stable pr.
4 (1 new w/ W/U) 4
Life threaten
Time (≥50%counsel’g) 15 25 40
As documented, this should be a level 3 return visit
While there are plenty of HPI points and 2 ROS, there is NO PFSH recorded.
The PE has only 2 elements, making it also a level 3 exam.
The MDM is moderate due to this being a new problem (3 pts, moderate in presenting problem), and prescription drug management (moderate in Risk).
With 2 elements at level 3 and 1 at level 4, this visit becomes a
Hx: location, quality, severity, duration, timing, modifying factors (or status of 3)
*Exam: ’95 audit tool definitions (’97: 6 bullet points and 12 bullet points 99215)
Dx: est prob-stable 1; est. prob-worse 2; new-no W/U 3(max3); new prob W/U 4
Data: lab 1; xray 1; other 1; disc w/testing MD 1; decision to review records/hx 1; review old records/hx from non-pt 2; discuss w/ another provider 2; independent review test 2

50. Case #1 - Modification A More Documentation
Add reference to PFSH (PMH, FH, or SH)
“Problem list and medications reviewed, see summary page” OR
50 yo woman with HTN OR
50 yo non-smoker OR
Patient with NKDA OR
Meds-Premarin

51. Outpatient Established Patient
Element
(need 2 of 3)
99211
99212
99213
99214
99215
History
HPI
ROS
PFSH
Min. prob. may 1
4 (or 3 chronic) 2 10
Exam # systems
not
5 (or Detailed) 8
Complexity (2/3) Dx
Data
Risk
need MD
No meds
1 stable prob 3
Prescription med
Or 2 stable pr.
4 (1 new w/ W/U) 4
Life threaten
Time (≥50%counsel’g) 5 15 25 40
Now we have a level 4 history, which changes the tic tac toe game to a
Hx: location, quality, severity, duration, timing, modifying factors (or status of 3 chronic)
Exam: Check with compliance or local Medicare intermediary for their rules re: detailed
Dx: est prob-stable 1; est. prob-worse 2; new-no W/U 3(max3); new prob W/U 4
Data: lab 1; xray 1; other 1; disc w/testing MD 1; decision to review records/hx 1; review old records/hx from non-pt 2; discuss w/ another provider 2; independent review test 2

52. Case #1 - Modification B More Complexity
Now consider if the patient has a T:102.1
Additional history:
PFSH: “non-smoker”
ROS: “complete 10 organ ROS o/w negative”
No change in exam
Additional workup:
Will order CBC, urgent MRI lumbar spine, discuss with spine surgeon
“Concern for epidural abscess”
To obtain 2 points in PFSH one needs items from 2 different sub-elements, that is at least one PMH and one SH, not 2 items within in PMH.

53. Outpatient Established Patient
Element
(need 2 of 3)
99211
99212
99213
99214
99215
History
HPI
ROS
PFSH
Min. prob. may 1
4 (or 3 chronic) 2 10
Exam # systems
not 5 8
Complexity (2/3) Dx
Data
Risk
need MD
No meds
1 stable prob 3
Prescription med
Or 2 stable pr. 4
Life threaten
Time (≥50%counsel’g) 15 25 40
Now the history is at level 5 due to ROS and PFSH
Given more complex patient presentation, you would likely perform a more thorough PE, but it is not necessary from a billing perspective
The High MDM now comes from presenting diagnosis: new with work-up, and data category at 4 points: lab + x-ray + discussing with another provider
You CAN bill level 5 visits when medically necessary and when documented appropriately.
Hx: location, quality, severity, duration, timing, modifying factors (or status of 3 chronic)
Exam: Check with compliance or local Medicare intermediary for their rules re: detailed
Dx: est prob-stable 1; est. prob-worse 2; new-no W/U 3(max3); new prob W/U 4
Data: lab 1; xray 1; other 1; disc w/testing MD 1; decision to review records/hx 1; review old records/hx from non-pt 2; discuss w/ another provider 2; independent review test 2

54. Case #2
60 yo male presents for 3 month f/u visit for HTN, AODM. Also reports mild fatigue and some leg cramps, occurring 2-3 times per week. BP better since addition of HCTZ at last visit. Sugars running <160. Pt denies CP, SOB, LE edema.
Meds updated in problem list
PE: BP:138/80 HR:75 RR:16
Gen: looks well
CV: RRR, no m,r,g
Lungs: Clear
Ext: no edema, no calf tenderness to palpation

55. Case #2 (cont’d) A/P: 1. HTN, well controlled, continue same meds
2. AODM, well controlled, continue meds/diet, exercise, check HgA1c
3. Leg cramps- possible low K, check BMP, Mg.
F/U in 3 months

56. Case #2 (cont’d)
60 yo male presents for 3 month f/u visit for HTN, AODM. Also reports mild fatigue and some leg cramps, occurring 2-3 times per week. BP better since addition of HCTZ at last visit. Sugars running < Pt denies CP, SOB, LE edema. 2 chronic problems, stable and 1 new; 5 HPI 3ROS
Meds updated in problem list 1 PFSH level 4 Hx
PE: BP:138/80 HR:75 RR:16
Gen: looks well
CV: RRR, no m, r, g
Lungs: Clear PE level 3 Exam
Ext: no edema, no calf tenderness to palpation
with 5 HPI bullets, 3 ROS and PMH, this is level 4 history
There are 4 organ systems documented: General, CV (includes edema), lungs and MSK (calf tenderness), thus a level 3 exam

57. Case #2 (cont’d) A/P: 1. HTN, well controlled, continue same meds
2. AODM, well controlled, continue meds/diet, exercise, check HgA1c
3. Leg cramps, fatigue - possible low K, check BMP, Mg. F/U in 3 months
Moderate MDM: diagnoses-high; data-low; risk- moderate
(count History and MDM)
Medical Decision Making
presenting problems- 6 points: HIGH
Data- 1 point (lab tests): LOW
Risk- prescription drug management: MODERATE
OVERALL MDM: MODERATE

58. Final thoughts
The coding rules initially appear complex but can be mastered.
It takes some practice.
Use these tools to “self-audit.”
It is your responsibility to select the right code for the work that you do.
Audit your own notes, and see where you may be over-documenting.
The goal is efficient documentation, along with excellent patient care.