1. Evaluation and Management Codes Justine Strand, MPH, PA-C Patricia Castillo, MS, PA-C Victoria Kaprielian, MD

2. Basics of E&M coding history physical examination medical decision making time

3. Categories of E&M codes Outpatient Inpatient Consultation Emergency department

4. Categories of E&M codes, contd Nursing home Rest home Home visits Other

5. Levels of codes Problem focused Expanded problem focused Detailed Comprehensive

6. History levels Problem focused (PF) –chief complaint –brief HPI Expanded problem focused (EPF) –CC, HPI –problem-pertinent ROS

7. History, continued Detailed (D) –CC, HPI –extended ROS –pertinent PMH, FH, or SH Comprehensive (C) –CC, HPI –complete ROS, PMH, FH, SH

8. History examples: asthma PF: Breathing fine, no complaints EPF: include medication use, recent URI sx D: add assessment of exposure to allergens, family hx asthma, some ROS C: lifelong history of asthma; full PMH, FH, SH, ROS

9. Exam levels Problem focused (PF) –affected body area or organ system asthma example: lungs

10. Exam levels, continued expanded problem focused (EPF) –above plus –other symptomatic or related organ systems example: lung exam plus ENT or heart

11. Exam, continued Detailed (D) –extended exam of affected body area and related organ systems exam of lungs, ENT, cardiovascular, and extremities

12. Exam, continued Comprehensive (C) –complete multi-system exam complete exam

13. Basics of E&M coding history physical examination medical decision making time

14. Elements of medical decision-making number of diagnoses and management options to be considered amount and complexity of data reviewed –labs –prior records –consultant reports risk level: complications, morbidity, mortality

15. Diagnoses and decision-making Beware of coding by diagnosis

16. Medical decision-making Level complexityDx/tx options Data reviewed Risk Straight-forwardMinimal LowLimited Low ModerateMultipleModerate HighExtensive High

17. Decision-making examples 1.doing fine, no change 2.check peak flow, adjust medications 3.nebulizer treatment with peak flows before and after, review past levels, add steroid, discuss criteria for urgent care 4.start home nebs, oral steroids; review hospital chart; discuss medication side effects and risks; consider hospitalization, discuss criteria for ER

18. Other factors New vs. established patient –new = not seen within 3 years –documentation requirements stricter (3/3)

19. Other factors time –lesser element –use if counseling > 50% of encounter –document face-to-face time

20. Putting it together: established pts Requires 2 of 3 elements HistoryExamMDM Face-to- face 99211 supervision only Stfrwd5 min. 99212PF Stfrwd10 min. 99213EPF Low15 min. 99214DDModerate25 min. 99215CCHigh40 min.

21. Putting it together:new pts Requires 3 of 3 elements HistoryExamMDM Face-to- face 99201PF Stfrwd10 min. 99202EPF Stfrwd20 min. 99203DDLow30 min. 99204CCModerate45 min. 99205CCHigh60 min.

22. Common errors Undercoding Overcoding

23. Other settings Same system Different specifics

24. Health Maintenance AgeNew ptEstablished pt Less than 1 year9938199391 1-4 years9938299392 5-11 years9938399393 12-17 years9938499394 18-39 years9938599395 40-64 years9938699396 65 and over9938799397

25. Procedures Procedure only visits Combined procedure and E&M visits Modifier -25

26. Modifier 25 Health maintenance visits Reimbursement issues

27. Prolonged services Face-to-face Other

28. Prolonged services Examples

29. How it works in practice Each practice develops their own system Encounter forms--provider marks with: –charge code(s) –diagnoses –procedures/tests/therapies performed

30. What if you get it wrong? undercoding overcoding

31. Summary Code for what you do Document in sufficient detail to justify level Be as specific as possible Include diagnoses appropriate for every service delivered Remember modifiers when needed Keep learning!