Thomas Weida, M.D. Professor, CMO, Associate Dean for Clinical Affairs The University of Alabama College of Community Health Sciences Coding Conundrums:

Thomas Weida, M.D. Professor, CMO, Associate Dean for Clinical Affairs The University of Alabama College of Community Health Sciences Coding Conundrums: CPT Gems

Disclosures I have nothing up my sleeve. I have nothing to disclose other than I’m on everyone’s best loved committee – the RUC

Objectives 1.Utilize proper documentation for CPT E&M coding 2.Apply proper CPT code use for common clinical situations, thereby avoiding under-coding or over-coding 3.Use medical decision making to guide E&M level 12/3/2015© 2015, Thomas J. Weida, M.D. 4

Office visit for a 70 year old female, established patient, with diabetes mellitus and hypertension, presenting with a 2 month history of increasing confusion, agitation and short term memory loss. 12/3/2015© 2015, Thomas J. Weida, M.D. 7 1.99211 2.99212 3.99213 4.99214 5.99215

Office visit for a 50 year old female with dyspepsia and nausea who you last saw in the office four years ago. 12/3/2015 © 2015, Thomas J. Weida, M.D. 8  99201  99202  99203  99204  99205  99211  99212  99213  99214  99215

12/3/2015 © 2015, Thomas J. Weida, M.D. 9 New and Established Patient New: A patient who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years. Established: A patient who has been seen within the past three years. New > Three Years

12/3/2015 © 2015, Thomas J. Weida, M.D. 10 Reasons For Not Coding Properly Afraid of over coding and audit Takes too much time to document Don’t understand system Too complex Base coding on length of visit Charge does not seem reasonable

12/3/2015 © 2015, Thomas J. Weida, M.D. 13 History Physician must record chief complaint and HPI Staff may record past medical, social and family history. Staff may record review of systems. Intake sheet can be used instead of staff asking questions for ROS & PFSH.

12/3/2015 © 2015, Thomas J. Weida, M.D. 15 Past History Prior major illnesses and injuries Prior operations and hospitalizations Current medications Allergies(drug, food) Age appropriate immunization status Age appropriate feeding/dietary status

12/3/2015 © 2015, Thomas J. Weida, M.D. 17 Social history Marital status or living arrangements Current employment Occupational history Use of drugs, alcohol and tobacco Level of education Sexual history Other relevant social factors

12/3/2015© 2015, Thomas J. Weida, M.D. 18 Review of Systems Constitutional (fever, weight loss) Eyes Ears, Nose Mouth, Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculosckeletal Integumentary (skin or breast) Neurological Psychiatric Endocrine Hematologic/Lymph-atic Allergic/Immunologic

12/3/2015 © 2015, Thomas J. Weida, M.D. 19 Physical Exam Body Areas Head Neck Chest including breast and axilla Abdomen Genitalia, groin Back Each extremity Organ Systems Eyes ENT CV Respiratory GI GU Musculoskeletal Skin Neuro Psych Heme, Lymph, Immuno Organ Systems Eyes ENT CV Respiratory GI GU Musculoskeletal Skin Neuro Psych Heme, Lymph, Immuno

12/3/2015© 2015, Thomas J. Weida, M.D. 20 Established Patient Element9921199212992139921499215 CCNARequired HPINA1-3 4+ ROSN/ANAPertinent2-910 PFSHN/A NA1 of 31of each ExamNAFocusedExpandedDetailedComp Dx/MgtNAMinimalLimitedMultipleExtensive DataNAMinimalLimitedModerateExtensive RiskNAMinimalLowModerateHigh Hx Px Decision Making location quality severity duration timing context modify fct assoc sx 2 of 3 One self limited problem 2 Minor self limited problems One stable chronic problem Acute simple illness OTC Drug, PT, OT, Minor surg IV no additives 1 or > chronic problem with progression or side effect 3 Stable Chronic Illnesses Undx new problem, uncertain px Acute complicated injury Prescription drug 1 or > chronic with severe exacerbation Threat to life or function Abrupt neuro change Parenteral controlled sub. Major surgery Rx with intensive monitoring PennState Hershey Medical Center 2 of 3

12/3/2015© 2015, Thomas J. Weida, M.D. 21 New Patient Element9920199202992039920499205 CCRequired HPI1-3 4+ ROSN/APertinent2-910 PFSHN/A 1 of 31 of each ExamFocusedExpandedDetailedComp Dx/MgtMinimal LimitedMultipleExtensive DataMinimal LimitedModerateExtensive RiskMinimal LowModerateHigh Hx Px Decision Making location quality severity duration timing context modify fct assoc sx 2 of 3 One self limited problem 2 Minor self limited problems One stable chronic problem Acute simple illness OTC Drug, PT, OT, Minor surg IV no additives 1 or > chronic problem with progression or side effect 2 Stable Chronic Illnesses Undx new problem, uncertain px Acute complicated injury Prescription drug 1 or > chronic with severe exacerbation Threat to life or function Abrupt neuro change Parenteral controlled sub. Major surgery Rx with intensive monitoring PennState Hershey Medical Center 3 of 3

Medical Decision Making Putting It All Together Overall MDMProblem PointsData Points Level of Risk Straightforward Complexity (992x2) 11Minimal Low Complexity (992x3) 22Low Moderate Complexity (992x4) 33Moderate High Complexity (992x5) 44High 12/3/2015 © 2015, Thomas J. Weida, M.D. 22 Need Two of Three to Qualify for Level

Medical Decision Making: Diagnosis/Management Options Problem Points 12/3/2015 © 2015, Thomas J. Weida, M.D. 23 ProblemPoints Self limited or minor (maximum of 2)1 each Established problem, stable or improving1 each Established problem, worsening2 each New problem, no additional work up planned (maximum of 1)3 New problem, with additional work up planned4

Medical Decision Making: Data Points Data ReviewedPoints Review or order clinical laboratory tests1 Review or order radiology tests (except echo or heart cath)1 Review or order medicine test (PFT, EKG, Cardiac Cath, Echo, etc. *)1 Discuss test with performing physician1 Independent review of tracing, image or specimen (i.e. EKG, KOH, UA)2 Decision to obtain old records1 Review and summation of old records2 12/3/2015 © 2015, Thomas J. Weida, M.D. 24 * EKGs, EEGs, PFTs, echocardiograms, cardiac catheterizations, cardiac stress tests, audiometry, speech or swallow studies, pacemaker interrogations, arterial or venous doppler studies, plethysmography, non-invasive arterial studies (such as ABIs), transcranial doppler studies, allergy testing, sleep studies, EMGs, evoked potentials, tensilon testing and nutritional assessments

Medical Decision Making: Table of Risk – Highest Level Wins RiskPresenting Problems Diagnostic OptionsManagement Options Minimal (992x2) MinimalRoutine Labs, EKG, X-rays, USN, Echo, EEG Advice Low (992x3)LowPFT, Contrast X-rays, ABG, Skin Biopsy OTC, PT, OT, Minor Surgery, IV – no additives Moderate (992x4) MediumStress tests, endoscopies, Cardiac cath, LP, Thoracentesis Prescription Drugs, IV’s with additives, Major surgery – no risk factors, Minor surgery with risk, Closed fracture, Nuclear med treatment High (992x5) HighCardiovasc imaging with risk factors, EP studies, Endoscopy with risk, Discography Surgery with risk, Emergency surgery, Narcotics, Drug therapy with extensive monitoring, DNR decision 12/3/2015 © 2015, Thomas J. Weida, M.D. 25

12/3/2015 © 2015, Thomas J. Weida, M.D. 26 99215 1 or more chronic illnesses with severe exacerbation, progression or side effects of treatment Acute or chronic illnesses or injuries posing threat to life or function (MI, PE, Resp distress) Abrupt neuro status change (TIA, Sx, weakness, sensory loss) 4 HPI elements 10 ROS 1 of each PFSH Comprehensive (general multisystem or complete single organ) Decision Making History Physical 40 min

12/3/2015 © 2015, Thomas J. Weida, M.D. 27 99214 3 chronic stable illnesses 2+ or more chronic stable illnesses 1+ chronic illness with exacerbation Undiagnosed new problem with uncertain diagnosis Acute illness with systemic symptoms Acute complicated injury 4 HPI elements 2-9 ROS 1 of 3 PFSH Detailed (affected area and related organ system) Decision Making History Physical 25 min

12/3/2015 © 2015, Thomas J. Weida, M.D. 28 99213 2 or more self limited problems 1 stable chronic illness acute uncomplicated illness (cystitis, sprain) 1-3 HPI elements Pertinent ROS Expanded problem focused Decision Making History Physical 15 min

12/3/2015 © 2015, Thomas J. Weida, M.D. 29 99205 1 or more chronic illness with severe exacerbation, progression or side effects of treatment Acute or chronic illnesses or injuries posing threat to life or function (MI, PE, Resp distress) Abrupt neuro status change (TIA, Sx, weakness, sensory loss) 4 HPI elements 10 ROS 1 of each PFSH Comprehensive (general multisystem or complete single organ) Decision Making History Physical 60 min

12/3/2015 © 2015, Thomas J. Weida, M.D. 30 99204 3 chronic stable illnesses 2+ or more chronic stable illnesses 1+ chronic illness with exacerbation Undiagnosed new problem with uncertain diagnosis Acute illness with systemic symptoms Acute complicated injury 4 HPI elements 10 ROS 1 of each PFSH Comprehensive (general multisystem or complete single organ) Decision Making History Physical Looks like a 99215 45 min

12/3/2015 © 2015, Thomas J. Weida, M.D. 31 99203 2 or more self limited problems 1 stable chronic illness acute uncomplicated illness (cystitis, sprain) 4 HPI elements 2-9 ROS 1 of 3 PFSH Detailed (affected area and related organ system) Decision Making History Physical Looks like a 99214 30 min

Medical Decision Making: Putting It All Together Overall MDMProblem PointsData Points Level of Risk Straightforward Complexity (992x2) 11Minimal Low Complexity (992x3) 22Low Moderate Complexity (992x4) 33Moderate High Complexity (992x5) 44High 12/3/2015 © 2015, Thomas J. Weida, M.D. 32 Need Two of Three to Qualify for Level Established problem, stable or improving – 1 pt Established problem, worsening – 2 pt each New problem, no additional work up planned (maximum of 1) 3 pt Established problem, stable or improving – 1 pt Established problem, worsening – 2 pt each New problem, no additional work up planned (maximum of 1) 3 pt Prescription Drugs

12/3/2015 © 2015, Thomas J. Weida, M.D. 33 20 min 10 min One self limited problem Focused exam 1-3 HPI elements 99212 99202 One self limited problem Expanded problem focused exam 1-3 HPI elements Pertinent ROS Looks like a 99213

12/3/2015 © 2015, Thomas J. Weida, M.D. 34 99211 BP check by nurse Weight check for CHF Lab draw Picking up prescription refill Picking up return to work or school certificate. (If mail or call in, no CPT code allowed) May not require physician presence Document nurse activity and physician review 5 min “Coding from the Bottom Up,” Thomas Weida, David O’Gurek, Family Practice Management, November 2008

12/3/2015 © 2015, Thomas J. Weida, M.D. 35 Time The specific times expressed in the visit code descriptors are averages, and therefore represent a range of times which may be higher or lower depending on actual clinical circumstances. Face-to-face for office and outpatient Unit/floor for hospital and inpatient Time is not a criteria for level of service. 99205 – 60 min 99204 – 45 min 99203 – 30 min 99215 – 40 min 99214 – 25 min 99213 – 15 min 99205 – 60 min 99204 – 45 min 99203 – 30 min 99215 – 40 min 99214 – 25 min 99213 – 15 min

12/3/2015 © 2015, Thomas J. Weida, M.D. 36 Counseling: The Time Component Counseling: a discussion with a patient and/or family concerning: –Diagnostic results, or recommended studies –Prognosis –Risks & benefits of treatment –Importance of compliance –Risk factor reduction –Patient and family education Not just psychological counseling If counseling > 50% of visit time, can use counseling documentation for level. Document total time, counseling time and nature of counseling

Office visit for a 68 year old female, established patient, for routine review and follow-up of non-insulin dependent diabetes, obesity, hypertension and CHF. Complains of vision difficulties and dietary noncompliance. Pt counseled concerning diet and current meds adjusted. Examples - Outpatient 12/3/201538© 2015, Thomas J. Weida, M.D. What else is needed? 4 HPI 2-9 ROS or 1 of PFSH Detailed physical (affected and related organ system)  99211  99212  99213  99214  99215

Office visit for the quarterly follow-up of a 45 year old male with stable chronic asthma requiring regular drug therapy. 12/3/201539© 2015, Thomas J. Weida, M.D. What else is needed?  99211  99212  99213  99214  99215 1-3 HPI elements Pertinent ROS or Expanded problem focused physical

Office visit for a 55 year old male, established patient, with increasing night pain, limp and progressive varus of both knees. 12/3/2015© 2015, Thomas J. Weida, M.D. 40 1.99211 2.99212 3.99213 4.99214 5.99215

Office visit for a 60 year old female, established patient, diabetic, blood sugar controlled by diet. She now complains of frequency of urination and weight loss, blood sugar of 320 and negative ketones on dipstick. 12/3/2015© 2015, Thomas J. Weida, M.D. 41 1.99211 2.99212 3.99213 4.99214 5.99215

Evaluation for a 28 year old male, established patient, with new onset of low back pain. 12/3/2015© 2015, Thomas J. Weida, M.D. 42 1.99211 2.99212 3.99213 4.99214 5.99215 Overall MDMProblem Points Data Points Level of Risk Straightforward Complexity (992x2) 11Minimal Low Complexity (992x3) 22Low Moderate Complexity (992x4) 33Moderate High Complexity (992x5) 44High ProblemPoints Self limited or minor (maximum of 2)1 each Established problem, stable or improving1 each Established problem, worsening2 each New problem, no additional work up planned (maximum of 1)3 New problem, with additional work up planned4

Office visit for 68 year old male, established patient, with stable angina, two months post MI, who is not tolerating one of his medications. 12/3/2015© 2015, Thomas J. Weida, M.D. 43 1.99211 2.99212 3.99213 4.99214 5.99215

Office visit with 55 year old male, established patient, for management of hypertension, mild fatigue, on beta blocker/thiazide regimen. 12/3/2015© 2015, Thomas J. Weida, M.D. 44 1.99211 2.99212 3.99213 4.99214 5.99215

Office visit for an 82-year old female, established patient, for a monthly B12 injection with documented B12 deficiency. 12/3/2015© 2015, Thomas J. Weida, M.D. 45 1.99211 2.99212 3.99213 4.99214 5.99215

Office visit with 30 year old male, established patient for 3 month history of fatigue, weight loss, intermittent fever, and presenting with diffuse adenopathy and splenomegaly. 12/3/2015© 2015, Thomas J. Weida, M.D. 46 1.99211 2.99212 3.99213 4.99214 5.99215

Outpatient visit for a 77 year old male, established patient, with hypertension, presenting with a three month history of episodic sub-sternal chest pain on exertion. 12/3/2015© 2015, Thomas J. Weida, M.D. 50 1.99211 2.99212 3.99213 4.99214 5.99215

Office visit for an established patient who lost prescription for hydrocodone. Returned for new copy. 12/3/2015© 2015, Thomas J. Weida, M.D. 51 1.99211 2.99212 3.99213 4.99214 5.99215 6.No Charge Truly correct answer is: No prescription

Initial office visit for a 17 year old female with depression. 12/3/2015© 2015, Thomas J. Weida, M.D. 52 1.99201 2.99202 3.99203 4.99204 5.99205 Medical decision making of 99214 History and physical of 99215

Office visit for reassessment and reassurance/counseling of a 40 year old female, established patient, who is experiencing increased symptoms while on a pain management treatment program. 12/3/2015© 2015, Thomas J. Weida, M.D. 53 1.99211 2.99212 3.99213 4.99214 5.99215

Office visit for an established patient having acute migraine with new onset neurological symptoms and whose headaches are unresponsive to previous attempts at management with a combination of preventive and abortive medication. 12/3/2015© 2015, Thomas J. Weida, M.D. 55 1.99211 2.99212 3.99213 4.99214 5.99215

Office visit for a 50 year old female with dyspepsia and nausea who you last saw in the office four years ago. 12/3/2015 © 2015, Thomas J. Weida, M.D. 58 Post Test  99201  99202  99203  99204  99205  99211  99212  99213  99214  99215

Office visit for a 70 year old female, established patient, with diabetes mellitus and hypertension, presenting with a 2 month history of increasing confusion, agitation and short term memory loss. 12/3/2015© 2015, Thomas J. Weida, M.D. 60 1.99211 2.99212 3.99213 4.99214 5.99215 Post Test

Lost Revenue/Year Due to Undercoding Medicare Rates 12/3/2015© 2015, Thomas J. Weida, M.D. 62 Undercoded/day123458 Non facility $ 8,331 $ 16,663 $ 24,994 $ 33,326 $ 41,658 $ 66,652 Facility $ 6,903 $ 13,807 $ 20,710 $ 27,614 $ 34,518 $ 55,228

Making It Happen Pull 10 notes and check coding against easy to use guidelines. Mentally calculate how much revenue lost Kick self Repeat process till no longer kicking self Simple 12/3/2015 © 2015, Thomas J. Weida, M.D. 63

Comorbidities are important Outpatient tends to under-code Inpatient tends to over-code

12/4/2014 © 2014, Thomas J. Weida, M.D. 65 Initial Hospital Care – New or Established: 3 Key Components 99221: Ave 30 min bedside or floor –Decision making – low complexity –Detailed history, detailed physical 99222: Ave 50 min bedside or floor –Decision making moderate complexity –Comprehensive history, comprehensive physical 99223: Ave 70 min bedside or floor –Decision making of high complexity –Comprehensive history, comprehensive physical

Initial hospital visit for a 50 year old male with acute chest pain and diagnostic electrocardiographic changes of an acute anterior myocardial infarction. 12/4/2014 © 2014, Thomas J. Weida, M.D. 69 1.99221 2.99222 3.99223

Initial hospital visit for a 65 year old female for acute onset of thrombotic cerebrovascular accident with contralateral paralysis and aphasia 12/4/2014 © 2014, Thomas J. Weida, M.D. 70 1.99221 2.99222 3.99223

Initial hospital visit for a 78 year old male, transfers from nursing home with dysuria,and pyuria, increasing confusion, and high fever. 12/4/2014 © 2014, Thomas J. Weida, M.D. 76 1.99221 2.99222 3.99223

Hospital admission, examination, and initiation of treatment program for a 67 year old male with uncomplicated pneumonia who requires IV antibiotic therapy. 12/4/2014 © 2014, Thomas J. Weida, M.D. 77 1.99221 2.99222 3.99223

Hospital admission for a 78 year old female with left lower lobe pneumonia and a history of coronary artery disease, congestive heart failure, osteoarthritis and gout. 12/4/2014 © 2014, Thomas J. Weida, M.D. 79 1.99221 2.99222 3.99223

12/4/2014 © 2014, Thomas J. Weida, M.D. 80 Subsequent Hospital Care 99231: Patient is stable, recovering or improving. Average of 15 minutes. 2 of 3 Key Components –Decision making: Low Complexity –Problem focused interval history –Problem focused physical

12/4/2014 © 2014, Thomas J. Weida, M.D. 81 Subsequent Hospital Care 99232 – Patient is not responding to treatment or has developed a minor complication. Average of 25 minutes. 2 of 3 Key Components –Decision making: Moderate Complexity –Expanded problem focused interval history –Expanded problem focused physical

12/4/2014 © 2014, Thomas J. Weida, M.D. 82 Subsequent Hospital Care 99233 – Patient is unstable or has developed a significant complication or a significant new problem. Average of 35 minutes. 2 of 3 Key Components –Decision making: High Complexity –Detailed interval history –Detailed physical

Subsequent hospital visit for a 37 year old female on day five of antibiotics for bacterial endocarditis, who still has low- grade fever. 12/4/2014 © 2014, Thomas J. Weida, M.D. 85 1.99231 2.99232 3.99233

Subsequent hospital visit for a 17 year old female with fever, pharyngitis, and airway obstruction, who after 48 hours develops a maculopapular rash. 12/4/2014 © 2014, Thomas J. Weida, M.D. 87 1.99231 2.99232 3.99233

Subsequent hospital visit for a 60 year old female, four days post uncomplicated inferior myocardial infarction who has developed severe chest pain, dyspnea, diaphoresis, and nausea. 12/4/2014 © 2014, Thomas J. Weida, M.D. 89 1.99231 2.99232 3.99233

Subsequent hospital visit for a 4 year old female, admitted for acute gastroenteritis and dehydration, requiring IV hydration, now stable. 12/4/2014 © 2014, Thomas J. Weida, M.D. 91  99231  99232  99233

Subsequent hospital visit for a 54 year old female admitted for myocardial infarction, but who is now having frequent premature ventricular contractions. 12/4/2014 © 2014, Thomas J. Weida, M.D. 94 1.99231 2.99232 3.99233

Subsequent hospital visit for a 54 year old patient, post MI who is out of the CCU but is now having frequent premature ventricular contractions on telemetry. 12/4/2014 © 2014, Thomas J. Weida, M.D. 97 1.99231 2.99232 3.99233

Subsequent hospital visit for a 50 year old Type II diabetic who is clinically stable and without complications requiring regulation of a single dose of insulin daily. 12/4/2014 © 2014, Thomas J. Weida, M.D. 98 1.99231 2.99232 3.99233

Subsequent hospital visit for 65 year old male with acute myocardial infarction who now demonstrates complete heart block and congestive heart failure. 12/4/2014 © 2014, Thomas J. Weida, M.D. 99 1.99231 2.99232 3.99233

Initial Observation Care: New or Established, 3/3 Key Components 99218 –Low Complexity Decision Making –Detailed History, Detailed Exam 99219 –Moderate Complexity Decision Making –Comprehensive History, Comprehensive Exam 99220 –High Complexity Decision Making –Comprehensive History, Comprehensive Exam 12/4/2014 © 2014, Thomas J. Weida, M.D. 102

Observation or Inpatient Admission & Discharge Same Day 3/3 Key Components 99234 –Low Complexity Decision Making –Detailed History, Detailed Exam 99235 –Moderate Complexity Decision Making –Comprehensive History, Comprehensive Exam 99236 –High Complexity Decision Making –Comprehensive History, Comprehensive Exam 12/4/2014 © 2014, Thomas J. Weida, M.D. 103 Must be more than 8 hours and less than 24 hours

Subsequent Observation Care 2/3 Key Components 99224 – Stable, Recovering, Improving 15 min –Low Complexity Decision Making –Problem focused interval history –Problem focused exam 99225 – Not responding or new minor problem 25 min –Moderate Complexity Decision Making –Expanded problem focused interval history –Expanded problem focused exam 99226 – Unstable or significant new problem 35 min –High Complexity Decision Making –Detailed interval history –Detailed exam 12/4/2014 © 2014, Thomas J. Weida, M.D. 104

Prolonged Physician Service with Direct Patient Contact, Inpatient Does not have to be continuous time CPT: face-to-face and on unit Medicare: face-to-face Use with E&M code which has average time listed < 30 min: NO Code 30-74 min: 99356 X 1 75-104 min: 99356 X 1 and 99357 >105 min: 99356 X 1 and 99357 X 2 or more for each additional 30 min (must be greater than 15 min additional for each use of 99357) Document time 12/4/2014 © 2014, Thomas J. Weida, M.D. 105

99356 Example 34- year old primigravida presents to hospital in early labor. Patient has severe preeclampsia. Physician supervises management of preeclampsia, IV magnesium, labor augmentation with pitocin and close maternal-fetal monitoring. Physician face-to-face involvement includes 40 minutes of continuous bedside care until the patient is stable, then is intermittent over several hours until the delivery. 12/4/2014 © 2014, Thomas J. Weida, M.D. 107

Observation Care Discharge Services: 99217 Discharge on separate day than admission from observation status Cannot use 99224- 99226 and 99217 for service on the same day. 12/4/2014 © 2014, Thomas J. Weida, M.D. 108

12/3/2015 © 2015, Thomas J. Weida, M.D. 109 Review: 99214 3 chronic stable illnesses 2+ or more chronic stable illnesses 1+ chronic illness with exacerbation Undiagnosed new problem with uncertain diagnosis Acute illness with systemic symptoms Acute complicated injury

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Thomas Weida, M.D. Professor, CMO, Associate Dean for Clinical Affairs The University of Alabama College of Community Health Sciences Coding Conundrums:

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