1 Evaluation and Management Strategies For Success American Academy of Professional Coders Woodland Hills California Chapter Meeting July 2010

2 Part Two Fundamentals of Coding Evaluation and Management Services Presented by: Elizabeth McAllister, CPC, CPC-H, CPC-I, CEMC

3 Evaluation & Management Components KEY COMPONENTS  History  Examination  Medical Decision Making  Counseling  Coordination of Care  Nature of Presenting Problem  Time*

4 History Four Elements The selection of the level of history obtained will depend on the following factors: Chief Complaint History of Present Illness Review of Systems Past, Family & Social History

5 History of Present Illness HPI Eight Elements 1. Location 2. Quality 3. Severity 4. Duration 5. Timing 6. Context 7. Modifying Factors 8. Associated Signs & Symptoms Brief and Extended HPIs are distinguished by the amount of detail needed to accurately characterize the clinical problem(s).

6 ROS CMS/AMA Systems  Constitutional Symptoms  Eyes  Ears, Nose, Mouth & Throat  Cardiovascular  Respiratory  Gastrointestinal  Genitourinary  Musculoskeletal  Integumentatry System  Neurological  Psychiatric  Endocrine  Hematologic/Lymphatic  Allergic/Immunologic

7 Past (Medical) Family and/or Social History (PFSH)  Past History - Review of patient’s previous illness, injuries, hospitalization, current medications, allergies, immunization status.  Family History – Review of patient’s family health status or cause of death of parents, siblings, children. Also includes a review of any diseases that may be hereditary, that may put patient at risk.  Social – Review of current activities, may include alcohol, tobacco use, marital status, occupation, sexual history.

8 Evaluation and Management Examination - Four Levels  Problem Focused -- a limited examination of the affected body area or organ system.  Expanded Problem Focused -- a limited examination of the affected body area or organ system and other symptomatic or related organ system(s).  Detailed -- an extended examination of the affected body area(s) and other symptomatic or related organ system(s).  Comprehensive -- a general multi-system examination or complete examination of a single organ system.

9 Examination For purposes of examination, the following body areas are recognized:  Head, including the face  Neck  Chest, including breasts and axillae  Abdomen  Genitalia, groin, buttocks  Back, including spine  Each extremity

10 Examination The following organ systems are recognized:  Constitutional (e.g., vital signs, general appearance)  Eyes  Ears, nose, mouth and throat  Cardiovascular  Respiratory  Gastrointestinal  Genitourinary  Musculoskeletal  Skin  Neurologic  Psychiatric  Hematologic/lymphatic/immunologic

11 Medical Decision Making Levels Straightforward is the lowest level of Medical Decision-Making. It is impossible not to qualify for it. Low Complexity Medical Decision-Making requires only slightly more intellectual energy than straightforward MDM. The degree of risk remains quite low and corresponds to a patient with one chronic illness which is completely stable. If there is an acute problem, it should be an uncomplicated clinical issue such as allergic rhinitis, cystitis or a sprained ankle.

12 Medical Decision Making Levels Detailed Complexity Medical Decision-Making describes a patient with one chronic illness with a mild exacerbation or two stable chronic illnesses would satisfy the risk requirement for this level of medical decision-making.

13 Medical Decision Making Levels High Complexity Medical Decision-Making truly is complex. Either the patient is quite ill or the physician must review a significant amount of primary data. The patient would need to have a severe exacerbation of a chronic problem or an acute illness which threatens life or bodily function to qualify for this level of risk.

14 Observation Services CPT Code Range  Observation codes are used to identify evaluation and management services delivered to a patient for a condition that isn’t serious enough for admission into the hospital, but the patient is not well enough to go home.  Only the physician who admitted the patient to observation and was responsible for care during the stay may submit the hospital observation codes.  Observation codes may not be utilized for post-op recovery  These services are a perennial favorite on the OIG Work plan

15 Observation Services  Medicare Reimbursement Guidelines  The patient must be admitted to observation status for a minimum of 8 hours.  Observation services paid for the following conditions:  Congestive Heart Failure  Asthma  Chest Pain

16 Initial Observation Care – of 3 Key Components Required  Includes initiation of observation status  Supervision of the care plan  Performance of Periodic Reassessments  Observation Care Discharge   Reports all services on day of discharge. Observation Services

17 Observation Codes Admission/Discharge on Different Dates of Service (3 out of 3 Key Components Required) CPT CodeHistoryExamMedical Decision Making 99218Detailed Straight forward or Low Complexity 99219Comprehensive Moderate Complexity 99220Comprehensive High Complexity

18 Observation Admission & Discharge on Same Date of Service Initial Observation Care – of 3 Key Components Required Includes all evaluation and management services provided by the admitting physician related to the initiation of “observation” status.

19 Observation Codes Admission and Discharge on Same Date of Service (3 out of 3 Key Components Required) CPT CodeHistoryExaminationMedical Decision Making 99234Detailed or Comprehensive Straight forward or Low Complexity 99235Comprehensive Moderate Complexity 99236Comprehensive High Complexity

20 Coding Flow Services Rendered by Same Physician Office or Other Outpatient Services Emergency Department Services Observation Services Inpatient Services

21 Initial Inpatient Hospital Care (3 of 3 Key Components Required)  Evaluation and Management Services provided on the same day, in different sites that are related to the inpatient admission should not be reported separately. CPT CODE HISTORYEXAMINATIONMEDICAL DECISION MAKING 99221Detailed or Comprehensive Straight Forward or Low Complexity 99222Comprehensive Moderate Complexity 99223Comprehensive High Complexity

22 Subsequent Inpatient Hospital Care (2 of 3 Key Components Required)  Includes review of medical record, diagnostic test results, and changes in the patient’s status since last visit. CPT CODE HISTORYEXAMINATIONMEDICAL DECISION MAKING 99231Problem Focused Straight Forward or Low Complexity 99232Expanded Problem Focused Moderate Complexity 99223Detailed High Complexity

23 Inpatient Discharge Management  Report the total duration of time spent by a physician for the final discharge of patient. Time does not need to be continuous.

24 Inpatient Discharge Management  Includes: Final Examination Discussion of Hospital stay Instructions for continuing care Preparation of discharge records Prescriptions and Referral Forms  Discharge Management 30 Minutes or Less  Discharge Management More than thirty Minutes

25 Time Face-to-face (office and other outpatient visits) – Defined as only that time that the physician spends face-to-face with the patient and/or family. Work spent pre/post encounter involved in such activities as reviewing records and tests, arranging further tests and treatment, communicating further with other professionals and the patient through either written reports of telephone contact. Unit/floor time (hospital observation and other inpatient care) includes the time that the physician is present on the patient’s hospital unit and a the bedside rendering services for the patient. This includes the time in which the physician established and/or reviews the patient’s chart, examines the patient, writes notes and communicates with other professionals and the patient’s family.

26 Office Consultation (3 of 3 Key Components Required) CPT Code HistoryExaminationMedical Decision Making 99241Problem Focused Straight Forward 99242Expanded Problem Focused Straight Forward 99243Detailed Low Complexity 99244Comprehensive Moderate Complexity 99245Comprehensive High Complexity

27 Emergency Department Services  An Emergency Department is a hospital based facility that is open 24 hours a day for the purpose of providing unscheduled services to patients who present for immediate medical attention.  The Emergency Department services do not distinguish between new and established patients.  Time is not a factor in code selection.

28 Emergency Department Services (3 of 3 Key Components Required) CPT Code HistoryExaminationMedical Decision Making 99281Problem Focused Straight Forward 99282Expanded Problem Focused Low Complexity 99283Expanded Problem Focused Moderate Complexity 99284Detailed Moderate Complexity 99285Comprehensive High Complexity

29 Critical Care  Critical Care is provided to a critically ill or injured patient during a life threatening medical crisis or trauma requiring immediate intervention and life saving measures.  Critical Care can be provided in any location.  Care by the physician is constant, but does not need to be continuous.  Time includes floor time, consulting with other medical staff and documentation in medical record.  Codes are patient age sensitive.

30 Critical Care – Critical Care Patients are 24 months and older For neonates and pediatric critical care see code range

31 Critical Care Codes  Used to report the first minutes of critical care on a given date.  Less than 30 minutes should be reported with an E & M code.  Coded only once per day.  Physician must devote entire to time to the patient (cannot be seeing other patients at the same time)  Reports each additional 30 minutes beyond the first 74 minutes.  Can be reported for the final 15 minutes (other 15 minute increments are not reported)

32 Elizabeth McAllister, CPC, CPC-H, EMS 32 Critical Care Bundled Codes – Not Separately Reported Elizabeth McAllister, CPC, CPC-H, EMS32 Bundled Service(s) RenderedCPT Code(s) Vascular Access Procedures36000, 36410, 36540, Gastric Intubation43752, Chest x-rays71010, 71015, Temporary Transcutaneous Pacing Interpretation of cardiac output measurements 93561, Ventilator Management94656, 94657, 94660, Pulse oximetry94760, 94761, Blood gasses & information data stored in computers (ECG’s, BP) 99090

33 Critical Care Time Includes Patient care at bedside Review of test results on unit or floor Discussion of patient care Documentation of critical care including patient’s condition Documentation of Time

34 Critical Care – Transport Coding Physical attendance and direct face-to-face care during the inter facility transport of a critically ill or injured patient are time (and age) based codes. The time begins when the physician assumes primary responsibility of the patient at the referring hospital and concludes when the receiving hospital accepts responsibility for the patient. Codes are reported in thirty minute increments 99466, months of age or younger 99291, older than 24 months

35 Newborn Care  Code 99460: Initial Evaluation of the normal newborn infant. Hospital or birthing room. Includes initiation of diagnostic and treatment programs, and preparation of hospital records.  Code 99461: Normal Newborn Care outside the hospital or birthing room. Includes physical examination and conference with parents.  Code 99462: Subsequent Hospital care (per day), evaluation and management of a normal newborn  Code 99463: Evaluatin and management of a normal newborn that is delivered and discharged on the same date of service.

36 Newborn Care  Attendance at Delivery and initial stabilization of the newborn.  Delivery/Birthing room resuscitation, (provision of positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output.

37 Pediatric and Newborn Care – Initial and Subsequent inpatient neonatal critical care Initial hospital care, per day for the evaluation and management of neonate 28 days or less who requires intensive observation, frequent interventions and other intensive care services – Subsequent intensive care, per day, evaluation and management recovering low and very low birth weight infant

38 Preventive Care Services Code Range Used to code for routine examinations or asymptomatic patients of all ages Examinations are age appropriate Divided into new and established patients Age & Gender Specific – Counseling/Anticipatory guidance/Risk factor reduction interventions Documentation Requirements – Comprehensive History & Exam History does not contain a CC or HPI Does require a complete ROS Not synonymous with the comprehensive requirements of an E/M service Preventive Medicine Services Do Not Have Medical Decision Making.

39 Preventive Medicine New Patient Examination  Initial exam - infant age 1 and under  Initial exam - ages 1-4  Initial exam - ages 5-11  Initial exam - ages  Initial exam - ages  Initial exam - ages  Initial exam - age 65 years and over

40 Evaluation & Management Categories & Sub-Categories Prolonged Services With Direct Patient Contact Without Direct Patient Contact Standby Services Anticoagulant Management Medical Team Conferences – Care Plan Oversight

41 Preventive Medicine Counseling Service  Individual: New or Established Patient:  Preventive Medicine Counseling - 15 minutes  Preventive Medicine Counseling - 30 minutes  Preventive Medicine Counseling - 45 minutes  Preventive Medicine Counseling - 60 minutes  Group Counseling and or Risk Factor Reduction  Approximately 30 minute session  Approximately 60 minute session

42 Evaluation & Management Categories & Sub-Categories Nursing Facility Services Domiciliary, Rest Home Oversight Services Home Services

43 Coding resources AAPC website CMS – Medical Learning Network Associates and colleagues

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