1. HI250 Medical Coding II Seminar 9

2. Unit 9 E/M codes E/M codes Evaluation and Management coding Evaluation and Management coding Documentation in the patient’s chart must support the E/M level of service reported Documentation in the patient’s chart must support the E/M level of service reported

3. Unit 9 Accurate assignment of E/M codes depends on four components: Accurate assignment of E/M codes depends on four components: 1. Identify the place of service (POS) 2. New or established patient 3. Level of service (high, moderate) 4. Apply CMS’s Documentation Guidelines for E/M

4. Unit 9 Place of Service Place of Service The physical location where healthcare is provided The physical location where healthcare is provided Outpatient hospital Outpatient hospital Physician’s office Physician’s office Consult in hospital Consult in hospital Nursing home Nursing home Emergency department Emergency department

5. Unit 9 Type of Service Type of Service The kind of healthcare services provided to patients The kind of healthcare services provided to patients Includes: critical care, consultation, initial hospital care, subsequent hospital care, consultations Includes: critical care, consultation, initial hospital care, subsequent hospital care, consultations

6. Unit 9 New Vs. Established Patient New Vs. Established Patient New patient: New patient: One who has not received any professional services from the physician or anyone in the group within the last 3 years One who has not received any professional services from the physician or anyone in the group within the last 3 years Established patient: Established patient: One who has received services from physician or someone in the group within the last 3 years One who has received services from physician or someone in the group within the last 3 years

7. Unit 9 E/M code selection is based on three key components: E/M code selection is based on three key components: 1. Extent of history 2. Extent of examination 3. Complexity of medical decision making

8. Unit 9 Levels of History Levels of History Problem focused history: Problem focused history: Chief complaint, brief history of present illness or problem Chief complaint, brief history of present illness or problem Expanded problem focused: Expanded problem focused: Chief complaint, brief history of present illness, problem pertinent system review Chief complaint, brief history of present illness, problem pertinent system review Detailed history: Detailed history: Chief complaint, extended history of present illness, problem pertinent system review extended Chief complaint, extended history of present illness, problem pertinent system review extended Comprehensive history: Comprehensive history: Chief complaint, extended history of present illness, review of systems directly related to problems identified in the history of the present illness, complete past/family/social history Chief complaint, extended history of present illness, review of systems directly related to problems identified in the history of the present illness, complete past/family/social history

9. Unit 9 Levels of Exam Levels of Exam Problem focused exam: Problem focused exam: Limited exam of the affected body area or organ system Limited exam of the affected body area or organ system Expanded problem focused exam: Expanded problem focused exam: Limited exam of the affected body area or organ system and other symptomatic or related organ system Limited exam of the affected body area or organ system and other symptomatic or related organ system Detailed exam: Detailed exam: An extended exam of the affected body areas and other symptomatic or related organ An extended exam of the affected body areas and other symptomatic or related organ Comprehensive exam: Comprehensive exam: A general multisystem exam or a complete exam of a single organ system A general multisystem exam or a complete exam of a single organ system

10. Unit 9 Complexity of Medical Decision Making Complexity of Medical Decision Making There are four levels of complexity There are four levels of complexity 1. Straightforward 2. Low complexity 3. Moderate complexity 4. High complexity See table:

11. Unit 9 # of Diagnosis Amount/complexity of data reviewed Risk of complication/ mortality Level of medical decision making MinimalMinimal or NoneMinimalStraightforward Limited LowLow Complexity MultipleModerate Complexity Extensive HighHigh Complexity

12. Unit 9  E/M Codes: ◦ Which components are considered the key components in selecting an E/M level of service? a. Counseling, Time, and Examination b. History, Examination, and Medical Decision Making c. History, Time, and Medical Decision Making d. Time, Examination, and Medical Decision Making

13. Unit 9  E/M Codes: ◦ Which components are considered the key components in selecting an E/M level of service? a. Counseling, Time, and Examination b. History, Examination, and Medical Decision Making c. History, Time, and Medical Decision Making d. Time, Examination, and Medical Decision Making

14. Unit 9 Mary was seen in Dr. Jones’ office after scalding her hand with steam from a pot of boiling water. Dr. Jones had seen Mary four years ago before she moved out of state. Today, Dr. Jones documents a detailed history and performs a detailed exam. Medical decision making is of low complexity. He writes her a prescription for an antibiotic cream and asks her to check with him in one week if the burn is not healing. Mary was seen in Dr. Jones’ office after scalding her hand with steam from a pot of boiling water. Dr. Jones had seen Mary four years ago before she moved out of state. Today, Dr. Jones documents a detailed history and performs a detailed exam. Medical decision making is of low complexity. He writes her a prescription for an antibiotic cream and asks her to check with him in one week if the burn is not healing. a. 99203 b. 99213 c. 99221 d. 99243

15. Unit 9 Mary was seen in Dr. Jones’ office after scalding her hand with steam from a pot of boiling water. Dr. Jones had seen Mary four years ago before she moved out of state. Today, Dr. Jones documents a detailed history and performs a detailed exam. Medical decision making is of low complexity. He writes her a prescription for an antibiotic cream and asks her to check with him in one week if the burn is not healing. Mary was seen in Dr. Jones’ office after scalding her hand with steam from a pot of boiling water. Dr. Jones had seen Mary four years ago before she moved out of state. Today, Dr. Jones documents a detailed history and performs a detailed exam. Medical decision making is of low complexity. He writes her a prescription for an antibiotic cream and asks her to check with him in one week if the burn is not healing. a. 99203 b. 99213 c. 99221 d. 99243

16. Unit 9 Mary was seen in Dr. Jones’ office after scalding her hand with steam from a pot of boiling water. Dr. Jones had seen Mary four years ago before she moved out of state. Today, Dr. Jones documents a detailed history and performs a detailed exam. Medical decision making is of low complexity. He writes her a prescription for an antibiotic cream and asks her to check with him in one week if the burn is not healing. Mary was seen in Dr. Jones’ office after scalding her hand with steam from a pot of boiling water. Dr. Jones had seen Mary four years ago before she moved out of state. Today, Dr. Jones documents a detailed history and performs a detailed exam. Medical decision making is of low complexity. He writes her a prescription for an antibiotic cream and asks her to check with him in one week if the burn is not healing. a. 99203 b. 99213 c. 99221 d. 99243

17. Unit 9 A physician receives a phone call from a woman who has just moved to town. She wants an interim refill on her birth control pills until she can see the physician the following week. The physician calls in a prescription for the patient and sees her the following Monday for an office visit. What is the appropriate E/M code for this “visit”? A physician receives a phone call from a woman who has just moved to town. She wants an interim refill on her birth control pills until she can see the physician the following week. The physician calls in a prescription for the patient and sees her the following Monday for an office visit. What is the appropriate E/M code for this “visit”? a. 99201 b. 99211 c. 99241 d. 99242

18. Unit 9 A physician receives a phone call from a woman who has just moved to town. She wants an interim refill on her birth control pills until she can see the physician the following week. The physician calls in a prescription for the patient and sees her the following Monday for an office visit. What is the appropriate E/M code for this “visit”? A physician receives a phone call from a woman who has just moved to town. She wants an interim refill on her birth control pills until she can see the physician the following week. The physician calls in a prescription for the patient and sees her the following Monday for an office visit. What is the appropriate E/M code for this “visit”? a. 99201 (new patient) b. 99211 c. 99241 d. 99242

19. Unit 9 What code would you use to code the following for an established patient? What code would you use to code the following for an established patient? A comprehensive history A comprehensive history A comprehensive exam A comprehensive exam Medical decision making of high complexity Medical decision making of high complexity

20. Unit 9 What code would you use to code the following for an established patient? What code would you use to code the following for an established patient? A comprehensive history A comprehensive history A comprehensive exam A comprehensive exam Medical decision making of high complexity Medical decision making of high complexity 99215 99215

21. Unit 9 What code would you use to code a visit in which the physician first met with a patient in the hospital for a: What code would you use to code a visit in which the physician first met with a patient in the hospital for a: Comprehensive history Comprehensive history Comprehensive exam Comprehensive exam Moderate medical decision making Moderate medical decision making

22. Unit 9 What code would you use to code a visit in which the physician first met with a patient in the hospital for a: What code would you use to code a visit in which the physician first met with a patient in the hospital for a: Comprehensive history Comprehensive history Comprehensive exam Comprehensive exam Moderate medical decision making Moderate medical decision making 99222 99222

23. Unit 9 A patient was admitted overnight to the local hospital due to complaints of abdominal and chest pain. Today the patient is seen by his primary care physician, who will also be his attending physician during this hospital stay. On this initial visit, the physician documents a comprehensive history and exam. Medical decision making is moderate. A patient was admitted overnight to the local hospital due to complaints of abdominal and chest pain. Today the patient is seen by his primary care physician, who will also be his attending physician during this hospital stay. On this initial visit, the physician documents a comprehensive history and exam. Medical decision making is moderate. a. 99221 b. 99222 c. 99223 d. 99233

24. Unit 9 A patient was admitted overnight to the local hospital due to complaints of abdominal and chest pain. Today the patient is seen by his primary care physician, who will also be his attending physician during this hospital stay. On this initial visit, the physician documents a comprehensive history and exam. Medical decision making is moderate. A patient was admitted overnight to the local hospital due to complaints of abdominal and chest pain. Today the patient is seen by his primary care physician, who will also be his attending physician during this hospital stay. On this initial visit, the physician documents a comprehensive history and exam. Medical decision making is moderate. a. 99221 b. 99222 c. 99223 d. 99233

25. Unit 9 A patient was admitted overnight to the local hospital due to complaints of abdominal and chest pain. Today the patient is seen by his primary care physician, who will also be his attending physician during this hospital stay. On this initial visit, the physician documents a comprehensive history and exam. Medical decision making is moderate. A patient was admitted overnight to the local hospital due to complaints of abdominal and chest pain. Today the patient is seen by his primary care physician, who will also be his attending physician during this hospital stay. On this initial visit, the physician documents a comprehensive history and exam. Medical decision making is moderate. a. 99221 b. 99222 –For an inpatient visit, all 3 components must be met or exceeded c. 99223 d. 99233

26. Unit 9 A 6 year old child is seen by her family physician for her annual check-up and immunizations. Her last encounter was one year ago. Which E/M code is reported? A 6 year old child is seen by her family physician for her annual check-up and immunizations. Her last encounter was one year ago. Which E/M code is reported? a. 99211 b. 99251 c. 99383 d. 99393

27. Unit 9 A 6 year old child is seen by her family physician for her annual check-up and immunizations. Her last encounter was one year ago. Which E/M code is reported? A 6 year old child is seen by her family physician for her annual check-up and immunizations. Her last encounter was one year ago. Which E/M code is reported? a. 99211 b. 99251 c. 99383 d. 99393

28. Unit 9 A patient with severe chest pain is admitted for observation. A comprehensive history and exam are performed. Medical decision making is moderate. Patient is released the same day. A patient with severe chest pain is admitted for observation. A comprehensive history and exam are performed. Medical decision making is moderate. Patient is released the same day. a. 99202 b. 99219 c. 99222 d. 99235

29. Unit 9 A patient with severe chest pain is admitted for observation. A comprehensive history and exam are performed. Medical decision making is moderate. Patient is released the same day. A patient with severe chest pain is admitted for observation. A comprehensive history and exam are performed. Medical decision making is moderate. Patient is released the same day. a. 99202 b. 99219 c. 99222 d. 99235

30. Unit 9 A physician performs a scheduled follow-up visit to a 65 year old patient in a nursing facility who is recovering from pneumonia. The patient has responded well to treatment, & no complications are noted. A physician performs a scheduled follow-up visit to a 65 year old patient in a nursing facility who is recovering from pneumonia. The patient has responded well to treatment, & no complications are noted. a. 99307 b. 99308 c. 99324 d. 99341

31. Unit 9 A physician performs a scheduled follow-up visit to a 65 year old patient in a nursing facility who is recovering from pneumonia. The patient has responded well to treatment, & no complications are noted. A physician performs a scheduled follow-up visit to a 65 year old patient in a nursing facility who is recovering from pneumonia. The patient has responded well to treatment, & no complications are noted. a. 99307 (the patient is “recovering” which means code 99307 is reported b. 99308 c. 99324 d. 99341

32. Unit 9 A subsequent hospital visit is required for a 58 year old patient admitted with an esophageal neoplasm who has begun to spit up blood. Metastasis is suspected. A subsequent hospital visit is required for a 58 year old patient admitted with an esophageal neoplasm who has begun to spit up blood. Metastasis is suspected. a. 99233 b. 99236 c. 99255 d. 99285

33. Unit 9 A subsequent hospital visit is required for a 58 year old patient admitted with an esophageal neoplasm who has begun to spit up blood. Metastasis is suspected. A subsequent hospital visit is required for a 58 year old patient admitted with an esophageal neoplasm who has begun to spit up blood. Metastasis is suspected. a. 99233 b. 99236 c. 99255 d. 99285

34. Unit 9 An inpatient follow-up consultation is performed for a 40 year old patient who is experiencing foot drop after leg surgery. The foot has regained normal positioning. An inpatient follow-up consultation is performed for a 40 year old patient who is experiencing foot drop after leg surgery. The foot has regained normal positioning. a. 99221 b. 99231 c. 99241 d. 99251

35. Unit 9 An inpatient follow-up consultation is performed for a 40 year old patient who is experiencing foot drop after leg surgery. The foot has regained normal positioning. An inpatient follow-up consultation is performed for a 40 year old patient who is experiencing foot drop after leg surgery. The foot has regained normal positioning. a. 99221 b. 99231 c. 99241 d. 99251

36. Unit 9 Questions???