1. 6th Annual National Congress on Health Care Compliance
University of Florida
Health Science Center/Jacksonville
6th Annual National Congress on Health Care Compliance
2.02 What Every Compliance Officer Should Know About Coding Evaluation and Management Services Furnished by Physicians and Hospitals Washington, D.C. - February 6, 2003
Robert A. Pelaia, JD, CPC
Associate General Counsel
Director of Compliance

2. Basics of Evaluation & Management Coding CPT Code Range: 99201 – 99499
University of Florida
Health Science Center/Jacksonville
CPT
Basics of Evaluation & Management Coding
CPT Code Range: – 99499

3. OFFICE / OTHER OUTPATIENT VISITS NEW PATIENT: 99201-99205
University of Florida
Health Science Center/Jacksonville
OFFICE / OTHER OUTPATIENT VISITS NEW PATIENT:
One who has not received any E/M service from the provider, or another provider of the same specialty who belongs to the same group practice, within the past three years.
Requires 3 of 3 Key Components (History, Exam and Medical Decision Making)
OFFICE / OTHER OUTPATIENT VISITS ESTABLISHED PATIENT:
One who has received professional services from the provider, or another of the same specialty who belongs to the same group practice, within the past three years
Requires 2 of 3 Key Components (History, Exam and Medical Decision Making)

4. SELECTING LEVEL OF NEW PATIENT VISIT History
University of Florida
Health Science Center/Jacksonville
SELECTING LEVEL OF NEW PATIENT VISIT History
5 Levels of E&M Codes:
99201, 99202, 99203, & 99205
4 Types of History:
Problem Focused, Expanded Problem Focused, Detailed & Comprehensive
3 Subcomponents of History:
History of Present Illness, Review Of Systems, Past Family Social History

5. History of Past, Family & Present Illness Social History Review of
University of Florida
Health Science Center/Jacksonville
SELECTING LEVEL OF NEW PATIENT VISIT History - 3 Subcomponents
Past, Family &
Social History
History of
Present Illness
Review of
Systems

6. SELECTING LEVEL OF NEW PATIENT VISIT Exam
University of Florida
Health Science Center/Jacksonville
SELECTING LEVEL OF NEW PATIENT VISIT Exam
5 Levels of E&M Codes:
99201, 99202, 99203, & 99205
4 Types of Exam:
Problem Focused, Expanded Problem Focused, Detailed & Comprehensive
2 Examination Methods:
Multi-System & Single System

7. Multi-System Exam Single System Exam
University of Florida
Health Science Center/Jacksonville
SELECTING LEVEL OF NEW PATIENT VISIT Exam – 2 Methods
Multi-System
Exam
Single System
Exam

8. SELECTING LEVEL OF NEW PATIENT VISIT Medical Decision Making
University of Florida
Health Science Center/Jacksonville
SELECTING LEVEL OF NEW PATIENT VISIT Medical Decision Making
5 Levels of E&M Codes:
99201, 99202, 99203, & 99205
4 Types of Medical Decision Making:
Straightforward, Low Complexity, Moderate Complexity & High Complexity
3 Subcomponents of Medical Decision Making:
Management, Data & Risk

9. University of Florida
Health Science Center/Jacksonville
SELECTING LEVEL OF NEW PATIENT VISIT Medical Decision Making – 3 Subcomponents
Management
Risk
Data

10. History, Exam & Medical Decision Making
University of Florida
Health Science Center/Jacksonville
SELECTING LEVEL OF NEW PATIENT VISIT
EXAMPLE
NEW PATIENT VISIT
History, Exam & Medical Decision Making

11. 2- Expanded Problem Focused
University of Florida
Health Science Center/Jacksonville
SELECTING LEVEL OF NEW PATIENT VISIT History - Levels and Types
1- Problem Focused
2- Expanded Problem Focused
3- Detailed
4- Comprehensive
5- Comprehensive

12. University of Florida
Health Science Center/Jacksonville
SELECTING LEVEL OF NEW PATIENT VISIT History - History of Present Illness

13. SELECTING LEVEL OF NEW PATIENT VISIT History - Review of Systems
University of Florida
Health Science Center/Jacksonville
SELECTING LEVEL OF NEW PATIENT VISIT History - Review of Systems

14. This is LEVEL 3 (Detailed)
University of Florida
Health Science Center/Jacksonville
SELECTING LEVEL OF NEW PATIENT VISIT History - Past Family and Social History
This is LEVEL 3 (Detailed)

15. 2- Expanded Problem Focused
University of Florida
Health Science Center/Jacksonville
SELECTING LEVEL OF NEW PATIENT VISIT Exam - Levels and Types
1- Problem Focused
2- Expanded Problem Focused
3- Detailed
4- Comprehensive
5- Comprehensive

16. This is LEVEL 4 (Comprehensive)
University of Florida
Health Science Center/Jacksonville
SELECTING LEVEL OF NEW PATIENT VISIT Exam
This is LEVEL 4 (Comprehensive)

17. University of Florida
Health Science Center/Jacksonville
SELECTING LEVEL OF NEW PATIENT VISIT Medical Decision Making - Levels and Types
1- Straightforward
2- Straightforward
3- Low Complexity
4- Moderate
5- High

18. University of Florida
Health Science Center/Jacksonville
SELECTING LEVEL OF NEW PATIENT VISIT Medical Decision Making - Management

19. SELECTING LEVEL OF NEW PATIENT VISIT Medical Decision Making - Data
University of Florida
Health Science Center/Jacksonville
SELECTING LEVEL OF NEW PATIENT VISIT Medical Decision Making - Data

20. This is LEVEL 4 (Moderate)
University of Florida
Health Science Center/Jacksonville
SELECTING LEVEL OF NEW PATIENT VISIT Medical Decision Making - Risk
This is LEVEL 4 (Moderate)

21. SELECTING LEVEL OF NEW PATIENT VISIT Putting It All Together - HISTORY
University of Florida
Health Science Center/Jacksonville
SELECTING LEVEL OF NEW PATIENT VISIT Putting It All Together - HISTORY
LEVEL 3 (Detailed)

22. LEVEL 4 (Comprehensive)
University of Florida
Health Science Center/Jacksonville
SELECTING LEVEL OF NEW PATIENT VISIT Putting It All Together - EXAM
LEVEL 4 (Comprehensive)

23. SELECTING LEVEL OF NEW PATIENT VISIT Putting It All Together - MDM
University of Florida
Health Science Center/Jacksonville
SELECTING LEVEL OF NEW PATIENT VISIT Putting It All Together - MDM
LEVEL 4 (Moderate)

24. University of Florida
Health Science Center/Jacksonville
SELECTING LEVEL OF NEW PATIENT VISIT Putting It All Together - Finally!
99203
New Patient Visit

25. SELECTING A LEVEL OF E&M SERVICE – Billing Based on Time
University of Florida
Health Science Center/Jacksonville
SELECTING A LEVEL OF E&M SERVICE – Billing Based on Time
Counseling and/or coordination of care dominates (more than 50%) of encounter
Extent of counseling and/or coordination of care must be documented in the medical record.
Include both total time and counseling time.

26. University of Florida
Health Science Center/Jacksonville
CONSULTATIONS
A consultation is a type of service provided by a provider whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another provider or appropriate source.

27. CONSULTATIONS There are 4 types of consultations:
University of Florida
Health Science Center/Jacksonville
CONSULTATIONS
There are 4 types of consultations:
Office/Other outpatient
Initial Inpatient
Follow-up Inpatient
Confirmatory

28. University of Florida
Health Science Center/Jacksonville
CONSULTATIONS
An E/M service must meet the “three Rs” in order to be billed as a consultation:
A request from a provider must be documented in the patient’s record;
The receiving provider must render the service; AND
The consulting provider must prepare and send a written report of his/her findings back to the requesting provider.

29. CRITICAL CARE SERVICES – 99291 – 99292
University of Florida
Health Science Center/Jacksonville
CRITICAL CARE SERVICES – – 99292
99291 First Minutes
99292 Each Additional 30 Minutes
Less than 30 minutes, use E/M Code
Time spent MUST BE documented in the Medical Record

30. CRITICAL CARE SERVICES – 99291 – 99292
University of Florida
Health Science Center/Jacksonville
CRITICAL CARE SERVICES – – 99292
EXAMPLES
Minutes X 1 & X 1
Minutes X 1 & X 2
Etc., Etc.,

31. OTHER E&M SERVICES 99499 Unlisted Evaluation & Management Service
University of Florida
Health Science Center/Jacksonville
OTHER E&M SERVICES
99499 Unlisted Evaluation & Management Service

32. Questions & Answers University of Florida
Health Science Center/Jacksonville
Questions & Answers