1. Continuity Clinic Coding Patient Encounters II EPISODE 2 Determining the “level” of the encounter

2. Continuity Clinic Objectives Understand the basic rules: –Physician payment rules –Basic CPT and ICD coding rules Be familiar with the 3 criteria for selecting the correct EM Code

3. Continuity Clinic The “Art” of CPT Coding First select the code based on the “feel” of the visit (not check-up) – how complex, how much time Then validate your code using a E/M tool (E/M = evaluation and management)

4. Continuity Clinic The “Art” of CPT Coding The “Feel” –99211 = nurse visit –99212 = easy, brief problems –99213 = average, usual problems –99214 = “oh no!” –99215 = after visit you think “I just ran a marathon” Why should you care? –> $40 difference between level 3 and 4!

5. Continuity Clinic 99212 Typical Scenarios Diaper rash OM recheck and resolved Otitis externa Thrush

6. Continuity Clinic 99213 Typical Scenarios Fever and pharyngitis UTI-cystitis URI and Otitis Mild LRI’s Moderate Injury *Most acute uncomplicated problems

7. Continuity Clinic 99214 Typical Scenarios Chronic or Multiple problems –Headaches, abdominal pain –Fatigue, anorexia –Asthma, diabetes School and Behavioral Problems –ADHD return visits Acute Complicated Illnesses –Fever without focus –Influenza

8. Continuity Clinic 99215 Typical Scenarios Diabetes complicated by illness Headaches with vomiting Disabling abdominal pain Fatigue and anorexia in adolescent Fever without focus for more than 60 days Initial evaluation for ADHD

9. Continuity Clinic The Science of Coding Three Criteria for selecting the correct E/M Code: –History –Physical Examination –Medical Decision Making For established patients, must have 2/3 areas at same level to qualify (3/3 for new patients)

10. Continuity Clinic Levels of History Level of HistoryChief ComplaintHPIROSPFSH Problem Focused -level 2- Required1-3 elementsNot required Expanded Problem Focused -level 3- Required1-3 elements1 systemNot required Detailed -level 4- Required4+ elements or 3+ chronic elements 2-9 systems1 element Comprehensive -level 5- Required4+ elements or 3+ chronic elements 10 systems2 or 3 elements

11. Continuity Clinic What Constitutes the Elements of the History? History of Present Illness (HPI) Review of Systems (ROS) Past, Family, Social History (PFSHI) Location, quality, severity, duration, timing, context, modifying factors, associated signs and symptoms Constitutional, eyes, ENT, CV, respiratory, GI, GU, musculoskeletal, integumentary (includes breast), neurological, psychiatric, endocrine, hematologic/lymphatic, allergic/immunologic Past – experience with illnesses, operations, injuries and treatments, allergy hx, medications taken prior to visit Family – medical history including hereditary diseases, current illness in family Social – age appropriate review of activities, drug use, education, sexual history, day care status

12. Continuity Clinic Levels of Physical Exam Level of Physical Exam 1995 Guidelines1997 Guidelines Problem Focused -level 2- 1 body area or organ system 1-5 bullets in 1 or more organ systems Expanded Problem Focused -level 3- 2-4 body areas/organ systems including affected area 6-11 bullets in one or more organ systems/body areas Detailed -level 4- 5-7 body areas/organ systems including affected area 12 or more bullets in two or more organ systems/body areas Comprehensive -level 5- 8 or more organ systems General multi system exam: 2 bullets from 9 different organ systems Either the 1995 guidelines or 1997 guidelines may be used, but most general pediatricians use the 1995 guidelines as the 1997 guidelines were written with specialists in mind.

13. Continuity Clinic Body Areas/Organ Systems in the PE 1995 Guidelines1997 Guidelines Body Areas: abdomen; back including spine; chest, including breast and axillae; GU/groin/buttocks; head, including face; each extremity; and neck Organ Systems: CV, constitutuional; ears/nose/mouth/throat; eyes; GI; GU; hematologic/lymphatic/ immunologic; musculokeletal; neuro/psych; respiratory, skin General multi-system exam: CV; chest/breasts; constitutional; ears/nose/throat; eyes; GI; GU; hematologic/lymph/immuno; respiratory, musculoskeletal; neck; neuro; psychiatric; skin Single system exam: constitutional; CV; GI; GU; lymphatic; neck; neuro; psych; respiratory; skin

14. Continuity Clinic Criteria for Selecting the Correct EM Code History and Physical form the 1 st two of the key criteria in coding. In the next set of slides and the conclusion of the trilogy “Coding”, we will discuss medical decision making as the third component.