1. Slide 1 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. CHAPTER 15 EVALUATION AND MANAGEMENT (E/M) SERVICES

2. Slide 2 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Coding for Services Your job is to code what is __________ in the medical record documented

3. Slide 3 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Your Job Optimize—never ________ –Optimize = “get the most out of” –Maximize = “to increase or make as great as possible” Accurately report documented services maximize

4. Slide 4 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. A Crime! Coding for services not provided is a ______ –Fraud: Billing for services never rendered CRIME

5. Slide 5 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Chapter 15 Reviews E/M (_________ and ___________) section Reports ________ services (Cont’d…) Evaluation Management physician

6. Slide 6 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Chapter 15 Reviews (…Cont’d) Subsections by ____ of service Types of service: –Office –Hospital –Consultations type

7. Slide 7 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Three Factors of E/M Codes _____ of service ____ of service Patient _____ Place Type status

8. Slide 8 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Place of Service Explains setting of service: –Office –Emergency Department –Nursing Home, etc.

9. Slide 9 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Type of Service Physicians provide many types of services: –Office visits –Admissions –Consultations –Prolonged services

10. Slide 10 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Patient Status Four status types: –____ patient –Established patient –_________ –Inpatient New Outpatient

11. Slide 11 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. New Patient Has not received any professional service in last _ years from: –The same physician –From another physician of the exact same _______________________________ _____ New patients more labor intensive for physician and staff 3 Specialty and subspecialty and in same group

12. Slide 12 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Established Patient Has received professional services in last 3 years from: –The same physician or –Another physician of exact same specialty and subspecialty in same group ____________ available with current, relevant information Medical record

13. Slide 13 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Outpatient One who has not been formally admitted to a health care facility –Example: Patient receives service at clinic or same-day surgery center –Example: Patient admitted to “observation” status

14. Slide 14 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Inpatient One who has been formally _______ to a health care facility (e.g., hospital, nursing facility, etc.) Attending physician dictates: –Admission orders –H & P –Requests consultations admitted

15. Slide 15 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Levels of E/M Service Based On 1.______ of the presenting problem (foundation) 2.____ required to provide service 3.____ spent (if 50% of total time is counseling or coordination of care) 4.Level of _________ necessary to treat patient 5.____ required/assumed 6.___________ required Skill Time knowledge Effort Responsibility Nature

16. Slide 16 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. E/M Levels Are Divided Based On ___ Components (KC) Contributory ______ (CF) Every encounter contains varying amount of KC and CF Key Factors

17. Slide 17 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Encounters More of each component/factor –_____ level of service Less of each component/factor –_____ level of service Higher Lower

18. Slide 18 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Key Components History Examination Medical decision making

19. Slide 19 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Contributory Factors Counseling Coordination of ____ Nature of presenting problem care

20. Slide 20 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Four Elements of a History _____________ (CC) ____________________ (HPI) ________________ (ROS) ____________________________ (PFSH) Chief Complaint History of Present Illness Review of Systems Past, Family, and/or Social History

21. Slide 21 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Chief Complaint (CC)— Subjective Reason for encounter –Patient’s current complaint –Usually presented in _______ own words Documented in medical record for each encounter Required for all levels of service May not be stated as “CC” but is inferred from documentation patient’s

22. Slide 22 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. History of Present Illness (HPI)— Subjective Description of development of ______ illness –e.g., date of onset Patient describes HPI If patient cannot answer for themselves, a parent, guardian, or other may provide Eight elements in HPI Provider must document current

23. Slide 23 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Physician and Patient Dialogue Development of a CC of abdominal pain: “Started Thursday night and was mild. During night, it got worse. Friday morning I went to work, but had to leave because pain got so bad.” (Cont’d…)

24. Slide 24 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Physician and Patient Dialogue (…Cont’d) Location—specific location of pain “Pain was in lower left-hand side, a little toward back.” (Cont’d…)

25. Slide 25 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Physician and Patient Dialogue (…Cont’d) ______—Is pain sharp, dull, pressure, burning? (a sensation) “Pain is really sharp and constant.” (Cont’d…) Quality

26. Slide 26 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Physician and Patient Dialogue (…Cont’d) _______—Is pain intense, moderate, mild? –On a scale of 1-10 may be stated “Pain is terrible, worst pain I have ever had.” (intense) (Cont’d…) Severity

27. Slide 27 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Physician and Patient Dialogue (…Cont’d) _______—How long has pain been present? “Pain has been going on now for 3 days.” (Cont’d…) Duration

28. Slide 28 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Physician and Patient Dialogue (…Cont’d) _____—Is pain present all the time, or does it come and go? “Pain just continues. It just doesn’t go away.” (Cont’d…) Timing

29. Slide 29 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Physician and Patient Dialogue (…Cont’d) Context—When does it hurt most?—Is there a correlation to a specific activity (e.g., climbing stairs)? “Pain is just there; it doesn’t matter what I am doing.” (Cont’d…)

30. Slide 30 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Physician and Patient Dialogue (…Cont’d) ______________—Does anything make it better or worse? “Nothing I do makes it any better or any worse.” Aspirin taken, no relief. (Cont’d…) Modifying factors

31. Slide 31 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Physician and Patient Dialogue (…Cont’d) Associated signs and symptoms relating to presenting problem(s)—Does anything else feel different when pain is present? “Yes, I have nausea when pain is worst.” (Cont’d…)

32. Slide 32 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Review of Systems (ROS)—Subjective Organ _______ –Respiratory system –Cardiovascular system There are 14 elements in ROS systems

33. Slide 33 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Extent of ROS Depends on CC Example: Do not usually review musculoskeletal system for CC of chest pain Example: A patient who has sustained trauma from an auto accident and cannot discern difference Medical necessity for the number of OSs inventoried must be implied or documented

34. Slide 34 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Systems in ROS Constitutional—General, Fever, Weight Loss or Gain Eyes—Organ System (OS) Ears, Nose, Mouth, Throat (OS) Cardiovascular (OS) (Cont’d…)

35. Slide 35 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Systems in ROS (…Cont’d) Respiratory (OS) Gastrointestinal (OS) Genitourinary (OS) Musculoskeletal (OS) Integumentary (OS) (Cont’d…)

36. Slide 36 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Systems of ROS (…Cont’d) Neurologic (Neurological) (OS) Psychiatric (OS) Endocrine (OS) Hematologic/Lymphatic (OS) Allergic/Immunologic (OS)

37. Slide 37 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Past, Family, and/or Social History (PFSH) Past and Social History contains relevant information about past: –Major illnesses/injuries –Operations –Hospitalizations –Allergies –Immunizations –Dietary status (Cont’d…)

38. Slide 38 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Past and Social History (…Cont’d) Social history contains relevant information about: –Sexual history –Other relevant social factors (Example: Employment) Past-present medications Social tobacco/alcohol use

39. Slide 39 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Family History Health status of family members: –_______ –________ Family history items related to ___ Parents Siblings Children CC

40. Slide 40 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. History Levels Four history levels: 1._______ focused 2._______________ focused 3._______ 4._____________ Problem Expanded problem Detailed Comprehensive

41. Slide 41 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Problem Focused History Brief history focused on CC ____ HPI __ ROS __ PFSH Brief history includes 1-3 of the eight elements of the HPI Brief No

42. Slide 42 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Expanded Problem Focused History Brief history focused on CC ____ HPI –Less than 3 of 8 elements or 1-2 chronic problems ROS as it _______ to Presenting Problem __ PFSH Brief pertains No

43. Slide 43 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Detailed History Extended history ________ HPI –HPI: 4 or more of 8 elements 3 or more chronic conditions ________ ROS _______ PFSH Extended Pertinent

44. Slide 44 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Comprehensive History Extended history ________ HPI ________ ROS ________ PFSH Extended Complete

45. Slide 45 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Summary of Elements Required for Each Level of History Figure: 15.4

46. Slide 46 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Examination—Objective (Hands-on) Four levels of examination: –_______ Focused –_______________ Focused –_______ –_____________ Problem Expanded Problem Detailed Comprehensive

47. Slide 47 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Problem Focused Examination _______ body area and/or organ system –10 Body areas (BOs) (1995 Guidelines) –12 Organ systems (OSs) (1995 Guidelines) Affected

48. Slide 48 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Expanded Problem Focused Examination ______ examination Affected BO and/or OS Other related BO(s) and/or OS(s) –Often vitals or general appearance of patient Limited

49. Slide 49 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Detailed Examination ________ examination of affected BO(s) and/or related OS(s) Extended

50. Slide 50 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Comprehensive Examination Complete ____________ or complete multisystem examination single specialty

51. Slide 51 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Summary of Elements Required for Each Level of Examination Figure: 15.5

52. Slide 52 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Remember Extent of examination depends on needs of patient and expert judgment of physician

53. Slide 53 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. “If It Isn’t Documented, It Didn’t Happen.” – Wise Coder “It may have happened, but you can’t bill for it unless you documented it.” Extent of examination must be __________ in medical record documented –Wise Coder to Physician

54. Slide 54 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Medical Decision Making Complexity (MDM) Level of MDM is significantly different for: –Patient A chest cold –Patient B severe chest pain

55. Slide 55 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Three Elements of Medical Decision Making (MDM) 1.Number of ________ or management options Minimal, limited, moderate, or extensive (Cont’d…) diagnoses

56. Slide 56 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Elements of MDM (…Cont’d) 2.Amount and/or _________ of data to be reviewed by physician Minimal, limited, moderate, or extensive (Cont’d…) complexity

57. Slide 57 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Elements of MDM (…Cont’d) 3.Risk of complications or _____ (morbidity or mortality) Minimal, low, moderate, or high death

58. Slide 58 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Four Levels of MDM Complexity ____________ Low Moderate High Straightforward

59. Slide 59 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Straightforward MDM Number of diagnoses or management options: ______ Amount and/or complexity of data: ___________ Risk of complications or death: ______ Minimal Minimal/None Minimal

60. Slide 60 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Low Complexity MDM Number of diagnoses or management options: ______ Amount and/or complexity of data: ______ Risk of complications or death: ___ Limited Low

61. Slide 61 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Moderate Complexity MDM Number of diagnoses or management options: ______ Amount and/or complexity of data: ________ Risk of complications or death: ________ Multiple Moderate

62. Slide 62 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. High Complexity MDM Number of diagnoses or management options: ________ Amount and/or complexity of data: ________ Risk of complications or death: ____ Extensive High

63. Slide 63 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Management Options Based on number of possible diagnoses (definitive or differential) and/or various ways condition can be treated

64. Slide 64 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Data Reviewed/Ordered Laboratory, radiology; any test/procedure results are documented in medical record (Cont’d…)

65. Slide 65 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Data Reviewed (…Cont’d) A review of results should be documented in medical record –“Hemoglobin within normal limits” –“Chest x-ray, negative” (Cont’d…)

66. Slide 66 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Data Reviewed (…Cont’d) Old medical records (data) from others may be requested and reviewed

67. Slide 67 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Risks Risks of ________ (poor outcome), complications, or _______ (death) with problem and/or treatment (Cont’d…) morbidity mortality

68. Slide 68 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Risks (…Cont’d) Other diseases or factors that affect risks Diabetes Extreme age (Cont’d…)

69. Slide 69 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Risks (…Cont’d) Urgency relates to risks –Myocardial infarction –Ruptured appendix

70. Slide 70 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Four Risk Levels 1.Minimal 2.Low 3.Moderate 4.High (Cont’d…)

71. Slide 71 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Risk Levels (…Cont’d) 1.______: Self-limited Wasp bite (Cont’d…) Minimal

72. Slide 72 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Risk Levels (…Cont’d) 2.____ : Several minimal levels or one level that is more than minimal Multiple wasp bites (Cont’d…) Low

73. Slide 73 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Risk Levels (…Cont’d) 3. _________ : One or more chronic illnesses –Diabetes Two or more stable but chronic illnesses –Controlled high blood pressure and diabetes (Cont’d…) Moderate

74. Slide 74 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Moderate Risk Level (…Cont’d) Undiagnosed condition with unknown prognosis Breast lump Acute illness Pneumonia (Cont’d…)

75. Slide 75 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Risk Levels (…Cont’d) 4.____: One or more chronic illnesses with current severe exacerbation –Malignant hypertension and uncontrolled diabetes (Cont’d…) High

76. Slide 76 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. High Risk Level (…Cont’d) Illness or injury that is life-threatening, such as: –Myocardial infarction –Cardiac arrest

77. Slide 77 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Summary of Elements Required for Each Level of MDM Figure: 15.6 Only 2 of 3 categories must meet or exceed the element stated to assign the level

78. Slide 78 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Review of Three Key Components History Examination Medical Decision Making

79. Slide 79 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Key Component 1: History CC, HPI, ROS, PFSH Four Levels of History: –Problem Focused –Expanded Problem Focused –Detailed –Comprehensive

80. Slide 80 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Key Component 2: Examination Objective examination of patient Four Levels of Examination: –Problem Focused –Expanded Problem Focused –Detailed –Comprehensive

81. Slide 81 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Key Component 3: MDM Number of diagnoses or management options Data to be reviewed Risks from current encounter to next visit (Cont’d…)

82. Slide 82 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Four Levels of MDM (…Cont’d) Straightforward Low Moderate High

83. Slide 83 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Other Factors Three other factors are considered in establishing level of service: –They are Contributory Factors

84. Slide 84 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Contributory Factors 1.Counseling 2.Coordination of Care 3.Nature of Presenting Problem

85. Slide 85 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. 1.Counseling—face-to-face Provided to patient or family members Discussion of diagnosis, test results, impressions, recommendations Medical documentation must support that more than __% of visit was counseling 50

86. Slide 86 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. 2. Coordination of Care— face-to-face _____ done on behalf of patient by physician to provide care –Example: Arrangements made for admission to a rehabilitation hospital or nursing facility Work

87. Slide 87 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. 3. Nature of Presenting Problem ____ of problem patient presents to physician with Foundation upon which the key components are factored Type

88. Slide 88 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Types of Presenting Problem Minimal Self-limiting Low Moderate High (Cont’d…)

89. Slide 89 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Minimal Presenting Problem (…Cont’d) May not require a ________ –Example: A dressing change or removal of an uncomplicated suture (Cont’d…) physician

90. Slide 90 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Self-Limiting Presenting Problem (…Cont’d) Self-limiting problems are _____ and with a good outcome predicted –Example: Sore throat or a slightly irritated skin tag (Cont’d…) minor

91. Slide 91 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Low Presenting Problem (…Cont’d) Without treatment, ___ risk Example: A middle age, healthy male with an upper respiratory infection (Cont’d…) low

92. Slide 92 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Moderate Presenting Problem (…Cont’d) Without treatment, ________ risk –Example: An elderly male with pneumonia (Cont’d…) moderate

93. Slide 93 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. High Presenting Problem (…Cont’d) Without treatment, ____ risk –Example: An elderly male in very poor health with severe pneumonia high

94. Slide 94 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Time Direct face-to-face: ________ and ______ together –Example: Clinic visit or at bedside in hospital Use to assign time-based codes, beginning and ending times documented in medical record Total time spent and indication that >50% was counseling/coordination of care Physician patient (Cont’d…)

95. Slide 95 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Time (…Cont’d) Unit/Floor: Time spent by physician on patient’s ____ or ___, also at patient’s bedside –Example: Reviewing patient records or at chart desk and then with patient floorunit

96. Slide 96 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. E/M Code Figure: 15.7

97. Slide 97 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Use of E/M Code Codes are grouped by type and place of service –Consultation –Office visit –Hospital admission

98. Slide 98 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. E/M Codes Different codes for various levels of service –99201-99205 services to new patient in office or other outpatient setting

99. Slide 99 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Established Patient 99211, may not require a physician No such code in __________ category; all ____ patients are seen by physician New Patient new

100. Slide 100 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Hospital Observation Status Not officially _______ to a hospital Patient not ill enough to admit but is too ill not to be monitored (Cont’d…) admitted

101. Slide 101 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Hospital Observation Status (…Cont’d) Read notes at beginning of subsection Observation services are not codes for _______ services (Cont’d…) inpatient

102. Slide 102 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Hospital Observation (…Cont’d) Observation admission can only be reported for ___ day of service by the admitting physician (Cont’d…) first

103. Slide 103 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Hospital Observation (…Cont’d) When patient admitted with observation status and discharged on _____ day: –Use code from 99234-99236 (Observation or Inpatient Care Services category) –Medicare has time constraints for these codes (Cont’d…) same

104. Slide 104 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Hospital Observation (…Cont’d) Patient in hospital overnight for observation but less than __ hours: –1st day: ___________ (Initial Observation Care) –2nd day: _____ (Observation Care Discharge Services) (Cont’d…) 48 99218-99220 99217

105. Slide 105 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Hospital Observation (…Cont’d) If observation stay longer than 48 hours: –1st day: ___________ (Initial Observation Care) –2nd day: ___________ (Subsequent Observation Care) –3rd day: _____ (Observation Care Discharge) 99218-99220 99224-99226 99217

106. Slide 106 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Initial Observation Care Beginning of observation care service Does not require a specific hospital unit; can be a regular bed –Status specified as “observation” (Cont’d…)

107. Slide 107 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Initial Observation Care (…Cont’d) Services immediately prior to admission _______ into observation service –Example: Office visit prior to observation, bundled into observation service if performed on same date of service bundled

108. Slide 108 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Hospital Inpatient Services Formally admitted to a ______ setting ____ (all day and night) on a given date of service _____ (all day and no night, or all night and no day, or a variation) Patient starting an observation, then admitted: services are bundled into Initial Hospital Service (99221-99223) hospital Total Partial

109. Slide 109 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Types of Physician Status ________: Primary or admitting physician _________: Physician whose opinion and/or advice requested by another physician –Specific criteria required Attending Consultant

110. Slide 110 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Types of Care _________ care given to patient by more than one physician –Example: Pulmonologist and cardiologist both treating patient for different conditions at same time Concurrent

111. Slide 111 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Two Types of Hospital Inpatient Services 1.Initial 2.Subsequent

112. Slide 112 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. 1.Initial Hospital Care First service includes ________ –Initial paperwork –Initial plans and orders Used only once for each admission by the admitting physician Other physicians would bill consultation or subsequent hospital care, as appropriate admission

113. Slide 113 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. 2. Subsequent Hospital Care After ____ service Physician reviews patient’s interval progress using documentation, information received from nursing staff, examination of patient 2 of the 3 key components met initial

114. Slide 114 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Hospital Discharge Services Final day of hospital stay when patient was in hospital for more than 1 day Documentation indicates final patient status Codes based on time –Time does not need to be continuous Beginning and ending time or total time must be documented to assign extended discharge code

115. Slide 115 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Final Status of Patient Condition Medications Plan for return to physician How hospital stay progressed Discharged to home, nursing facility, etc.

116. Slide 116 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Unique to Discharge Codes Only ________ physician can use a discharge code Code is based on ____ spent in service Beginning and ending time must be documented, total time spent or use lowest level code attending time

117. Slide 117 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Consultation Services (99241-99255) One physician requests another physician’s opinion Either inpatient or outpatient (Cont’d…)

118. Slide 118 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Consultation Services (…Cont’d) Reported as outpatient or inpatient consultation Only one consult by a consultant per hospital admission Consultant provides report of opinion/advice Documented in medical record

119. Slide 119 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Third-Party Payer Consultations Request to confirmation: –Past medical treatment –Current condition –Payers may request prior to approving procedure Bill using inpatient or outpatient consult codes Apply ___ modifier (mandated service) Outpatient consultations include those provided in ED As of January 1, 2010, payment for Medicare consults are no longer reimbursed. –Report with E/M codes (inpatient or outpatient) -32

120. Slide 120 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Emergency Department (ED) Services (99281-99288) Codes for new and established patients Qualified as ED (AKA: ER): must be open __ hours a day, unscheduled visits Usually provided by ED staff 24

121. Slide 121 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Critical Care and ED Codes ED services often require additional codes from Critical Care Services –Example: multiple organ failure Critical Care Services are provided to patients in ____________ situations Type of service (e.g., Critical Care) will depend on condition present on arrival in ED Codes are time based –Total time less than 30 minutes, reported with appropriate E/M code life-threatening

122. Slide 122 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Critical Care Services (99291, 99292) 99291 and 99292 are used to report length of time a physician spends caring for critically ill patient 99291: 30-74 minutes 99292: each additional 30 minutes Over 24 months of age (outpatient) Over 71 months of age (inpatient) Total time under 30 minutes reported with E/M code

123. Slide 123 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Nursing Facility Services (99304-99318) Non-hospital settings with professional medical staff –Provide continuous health care services to patients who are not acutely ill Formerly known as Skilled Nursing Facility (SNF), Intermediate Care Facility (ICF), and Long-Term Care Facility (LTCF)

124. Slide 124 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Comprehensive Nursing Facility Assessment Provided at time of admission (initial visit by physician) (99304-99306) Provided periodically during stay as established by facility regulations (99318) Subsequent Nursing Facility Care codes used if patient stable or condition unchanged (99307-99310)

125. Slide 125 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Domiciliary, Rest Home, or Custodial Care Services (99324-99337) __________ services are not available on site Types of services provided are lodging, meals, supervision, personal care, leisure activities Residents cannot live independently Codes for new and established patients Health care

126. Slide 126 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Domiciliary, Rest Home, or Home Care Plan Oversight Services (99339, 99340) Applies to anyone not in home health, hospice, or nursing facility Reported once per _____ Codes based on ____ month time

127. Slide 127 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Home Services (99341-99350) Care provided in patient’s _____ Services based on history, physical examination, and MDM Codes for new or established patients A “home” is the patient’s private residence (not an assisted care facility) home

128. Slide 128 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Prolonged Services (99354-99359) Time-based codes for direct and non-direct services Codes for first 30-74 minutes Codes for each additional 30 minutes If less than __ minutes, do not report service as prolonged –Add-on code 30

129. Slide 129 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Standby Service Physician not caring for other patient to use this code (99360) Physician _______ by only for that patient, if needed Even if no care was provided to patient during standby time, report and bill service Must be __________ in medical record standing documented

130. Slide 130 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Case Management Services (99363-99368) Used to report __________ of care with other health professionals and anticoagulant management Anticoagulant Management (99363, 99364) –Outpatient management of warfarin therapy 1st 90 days, subsequent 90 days –Any period less than 60 days is not reported (Cont’d…) coordination

131. Slide 131 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Case Management Services (…Cont’d) Medical Team Conferences (99366-99368) –Face-to-Face with patient and/or family―99366 Participation by nonphysician qualified health professional 30 minutes or more –Without patient and/or family―99367 Participation by physician 30 minutes or more –Without patient and/or family―99368 Participation by nonphysician qualified health professional 30 minutes or more

132. Slide 132 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Care Plan Oversight Services (99374-99380) Used to report supervision of patient care under home, domiciliary, or equivalent environment Reported for __-day period Reported in increments of –15-29 minutes –30 minutes or more 30

133. Slide 133 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Preventive Medicine Services (99381-99429) Used to report services when patient is not currently __ –Example: Annual checkup Codes divided on new or established patient status, and _________ (Cont’d…) ill patient age

134. Slide 134 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Preventive Medicine Services (…Cont’d) If significant problem is encountered during preventive examination: –E/M code also reported –Modifier -__ added to E/M code 25

135. Slide 135 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Individual and Group Counseling (99401-99412) Patient is seen specifically to promote _____ –Example: Diet, exercise program (Cont’d…) health

136. Slide 136 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Individual and Group Counseling (…Cont’d) Codes based on –Time –Individual or group –________ review of assessment data Behavior change interventions for individuals –Smoking, tobacco, alcohol Physician

137. Slide 137 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Non-Face-to-Face Physician Services (99441-99449) and Special E/M Services (99450-99456) 99441-99443 report telephone E/M services 99444 reports online E/M services 99446-99449 report interprofessional telephone/internet consultations Codes 99450-99456 are used for services provided for life or _______ insurance disability

138. Slide 138 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Newborn Care and Neonatal/Pediatric Critical Care Services Newborn Care (99460-99463) Delivery/Birthing Room Attendance (99464, 99465) Pediatric Critical Care Patient Transport (99466, 99467) Inpatient Neonatal Critical Care Services (99468, 99469) Inpatient Pediatric Critical Care Services (99471-99476) Initial and Continuing Intensive Care Services (99477- 99480)

139. Slide 139 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Newborn Care (99460-99463) Initial and subsequent care in/other than hospital or birthing center –For normal newborn infant –Per day, for E/M services 99463, initial hospital/birthing center when admission and discharge is same day

140. Slide 140 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. 99464, attendance at delivery –Documented request by attending in medical record –Provides initial stabilization 99465, resuscitation and ventilation –Intubation (31500) not included Delivery/Birthing Room Attendance/Resuscitation (99464-99465)

141. Slide 141 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Neonatal and Pediatric Critical Care Services Subsection (99466-99480) Pediatric Critical Care Patient Transport –Critically ill or injured patient 24 months or younger –99466, 99467 First 30-74 minutes Each additional 30 minutes Reports interfacility transport –Face-to-face service 99485, 99486, supervision by a control physician –First 30 minutes (99485) and each additional 30 minutes (99486)

142. Slide 142 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Inpatient Neonatal Critical Care Services 99468, 99469 Divided by –initial day –subsequent day Critically ill neonate –Age 28 days or younger

143. Slide 143 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Inpatient Pediatric Critical Care Services 99471-99476 Inpatient services Divided by age –29 days through 24 months –2 through 5 years Subdivided by day –Initial –Subsequent

144. Slide 144 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. 99477-99480 Hospital Care 99477 for neonate 28 days of age or younger 99478-99480 divided by birth weight –very low birth weight (VLBW) ≤1500 grams (≤ 3.3 pounds) –low birth weight (LBW) 1500-2500 grams (3.3-5.5 pounds) –normal birth weight 2501-5000 grams (5.51-11.01 pounds) Subdivided on day –Initial –Subsequent Initial and Continuing Intensive Care Services

145. Slide 145 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Other E/M Services (99499) 99499 is seldom used –Requires a ___________ with submission written report

146. Slide 146 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Conclusion CHAPTER 15 EVALUATION AND MANAGEMENT (E/M) SERVICES