Evaluation & Management Codes The Complete Procedure Coding Book By Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 4 Evaluation & Management Codes Part 1 McGraw Hill/Irwin Copyright © 2009 by The McGraw-Hill Companies, Inc. All rights reserved

Learning Outcomes Apply the guidelines for proper E/M coding. 4 - 2 Apply the guidelines for proper E/M coding. Calculate the appropriate level of patient history taken. Ascertain the appropriate level of physical exam performed by the physician.

Learning Outcomes 4 - 3 Determine the appropriate level of medical decision-making provided by physician. Distinguish between the various types of encounters. Choose the best, most appropriate code for E/M services.

Introduction 4 - 4 Evaluation and management (E/M) codes are used to describe the encounter between provider and patient. They are used to compensate the provider for meeting face-to-face with the patient and his or her family.

You Need to Know… Location of the encounter 4 - 5 Location of the encounter Relationship between provider and patient Key components provided: history, exam, and medical decision-making (MDM)

Location 4 - 6 Where did the encounter between physician and patient take place? For example: Office or other outpatient services Hospital Emergency department Nursing facility Home services

Location More than one location in one day? 4 - 7 More than one location in one day? If a patient is seen by the physician in the office and then is admitted into the hospital on the same day, code the E/M location as Hospital.

Relationship How well does this physician know this patient? 4 - 8 How well does this physician know this patient? New patient Established patient Consultation

Relationship New Patient 4 - 9 New Patient A patient who has not been seen by this physician, or another of the same specialty in the same group practice, within the last three years.

Relationship Established Patient 4 - 10 Established Patient A patient who has been seen by this physician, or another of the same specialty in the same group practice, within the last three years.

Relationship Consultation 4 - 11 Consultation A patient seen by a physician, at the request of another health care professional, for further evaluation or a second opinion Note: If this second opinion is requested by the patient, code as a regular new patient visit.

Relationship Consultation 4 - 12 Consultation A consultation is expected to be a short-term relationship. If the consulting physician takes over care of the patient, the second and subsequent visits are coded as established patient.

Key Components 4 - 13 Some E/M codes are determined by the provision of services in three key components: Patient history taken Physical exam performed MDM

Key Components Level of Patient History Problem-focused 4 - 14 Level of Patient History Problem-focused Expanded problem-focused Detailed Comprehensive

Key Components Level of Physical Exam Problem-focused 4 - 15 Level of Physical Exam Problem-focused Expanded problem-focused Detailed Comprehensive

Key Components Level of MDM Straightforward Low complexity 4 - 16 Level of MDM Straightforward Low complexity Moderate complexity High complexity

Time 4 - 17 E/M codes may be chosen based on time spent with the patient when: More than half (51% or more) of the total time is used to counsel the patient. Providing critical care services.

Prolonged Services 4 - 18 Report E/M services that are at least 30 minutes longer than the amount of time represented by the standard E/M codes. Codes 99354 - 99359 Less than 30 minutes, append modifier 21 to standard E/M .

Consultations Referral 4 - 19 Referral When a physician transfers care of a patient to another physician, this patient is a new patient, not a consultation. Example: Dr. Kottman sends Joe to a cardiologist, Dr. Frankel, because the tests show Joe has an arrhythmia.

Consultations 4 - 20 Dr. Frankel’s first encounter with Joe will be coded as a new patient. 99201 - 99205

Consultation Consultation 4 - 21 Consultation A physician requests an opinion of another physician; this is a consultation. Example: Dr. Cannon asks Dr. Jackman to evaluate Susan to see whether he agrees that she needs surgery.

Consultations 4 - 22 Dr. Jackman’s one and only encounter with Susan will be coded as a consultation. He saw Susan in his office. 99241 - 99245 He saw Susan while she was an inpatient in the hospital. 99251 - 99255

Consultations 4 - 23 After Dr. Cannon and Dr. Jackman disagree as to whether Susan needs surgery, Susan decides to call Dr. Hesse for her opinion. Because Susan, the patient, requested this consultation, Dr. Hesse’s E/M will be coded as a new patient visit 99201 – 99205.

Reading The Notes Get to know how the physician writes his notes… 4 - 24 Get to know how the physician writes his notes… “This new patient” “Is seen for the first time” “Initial examination” These phrases all indicate this is a new patient.

Chapter Summary 4 - 25 E/M codes report the time and expertise a health care professional puts into gathering information, reviewing data, and determining the best course of treatment for the patient’s current condition.