Webcast Session I An Introduction to Evaluation and Management (EM) Coding Accurate Coding for Evaluation and Management (EM) Services A webcast designed.

Webcast Session I An Introduction to Evaluation and Management (EM) Coding Accurate Coding for Evaluation and Management (EM) Services A webcast designed for headache and migraine specialists Presenters Stuart B. Black, MD American Headache Society (AHS) Sheila J. Madhani, MA, MPH, CCS-P MARC Associates October 9, 2007

Goals Introduction to CPT EM codes
Review of CPT coding guidelines and practices Application of CPT coding guidelines and practices to clinical scenarios relevant to headache specialists

What Will We Discuss? Importance of accurate coding
CPT codes vs. ICD codes Components of EM codes Types of EM codes How to properly select and report EM codes/services Use of modifiers Clinical examples Coding resources

Importance of Accurate Coding
Full and fair description of services provided Avoid over-coding (fraud and abuse) and under-coding (not reporting all the services you have provided) Improve quality of patient care

CPT codes vs. ICD codes

CPT codes vs. ICD codes CPT codes
CPT is an acronym for Current Procedural Terminology CPT codes are published by the American Medical Association and are used by CMS and many private insurers to report physician services A CPT code is a five digit numeric code that is used to describe medical, surgical, radiology, laboratory, anesthesiology, and evaluation/management services There are approximately 7,800 CPT codes ranging from through 99602 Two digit modifiers may be appended when appropriate to clarify or modify the description of the procedure

CPT codes vs. ICD codes ICD
ICD stands for International Classification of Diseases It is a coding system used to code signs, symptoms, injuries, diseases, and conditions

CPT codes vs. ICD codes Relationship between CPT and ICD
Both types of codes must be reported on claims to Medicare and many private insurers CPT code Describes medical procedure or service ICD code Describes clinical condition of patient to support the medical necessity of the procedure or service

CPT codes vs. ICD codes ICD-9-CM ICD-10 ICD-10-CM
Diagnosis coding classification system used in the delivery of patient care ICD-10 Used to track mortality data ICD-10-CM Currently under development

Components of EM codes

Components of EM codes All EM services follow a similar format
Unique code number Place and/or type of service Content of service Nature of the presenting problem Time typically associated with service

Components of EM codes Ex , Office or other outpatient visit, est. patient Unique code number 99213 Place and/or type of service Office or other outpatient visit¹ Content of service Expanded problem focused history Expanded problem focused examination Medical decision making of low complexity Nature of the presenting problem Usually, the presenting problem(s) are of low to moderate severity Time typically associated with the procedure Physicians typically spend 15 minutes face-to-face with the patient and/or family ¹ Includes hospital outpatient

Categories of EM codes

Categories of EM codes Physicians use EM codes to report professional services Documentation in the medical record must support the EM code and ICD-9 code(s) submitted Submitting a code that is not supported by documentation may be considered fraud

Categories of EM codes Office or other Outpatient Services, New Patient Office or other Outpatient Services, Established Patient Hospital Inpatient Services, Initial Hospital Care Hospital Inpatient Services, Subsequent Hospital Care Office or Other Outpatient Consultations, New or Established Patient Inpatient Consultations,

Categories of EM codes Levels of service
Within each category there are various codes representing the different levels of service Increased levels of service reflect the increased levels of time, intensity, and complexity of the service Ex. Office or other outpatient visit, new patient 99201 – Level 1 99202 – Level 2 99203 – Level 3 99204 – Level 4 99205 – Level 5

How to properly select and report EM codes/services

5 Steps to Selecting Appropriate EM codes/services
Step 1.- Type of Service: What type of service is the patient receiving? (office visit, consultation etc.) Step 2.- New or Established: If this is an office visit, is this a new or established patient? Step 3.- Key Components: What level of the key components (history, examination, medical decision making) have been met or exceeded Step 4.- Time: Will time determine the level of E/M service? Step 5.- Documentation: Document! Document! Document!

Step 1: Type of Service What type of service is the patient receiving (office visit, consultation etc.)? Common EM services performed by headache specialists Office/Outpatient Services 99214 2005 Medicare utilization by neurologists: 1,768,059 Consultation Services 99244 2005 Medicare utilization by neurologists: 519,888

Step 1: Type of Service When is a consultation a consultation?
A type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source Not a Consultation Ongoing management of the patient by the consultant physician

Step 1: Type of Service When is a consultation a consultation?
CMS Transmittal 788 – effective 1/17/06 To bill for a consultation, there must be documentation of the request If there is no request, an outpatient/office visit (new or established) should be reported “…a consultation request may be verbal however the verbal interaction identifying the request and reason for a consult shall be documented in the patient’s medical record by the requesting physician or qualified NPP, and also by the consultant physician or qualified NPP in the patient’s medical record.” (CMS Transmittal 788)

Step 1: Type of Service When is a consultation an office visit?
Transfer of care A transfer of care occurs when a physician requests another doctor to assume the care of the patient for a specific condition Once a transfer occurs consultations can no longer be reported Established patient EM codes must be reported

Step 2: New or Established Patient?
CPT differentiates between new and established patients (office/outpatient) New patients More physician work Greater documentation requirements Higher reimbursement

Step 2: New or Established Patient?
Is this a new or established patient? New patient: one who has not been seen by the physician or another physician of the same specialty who belongs to the same group within the past 3 years Established patient: one who has been seen by the physician or another physician of the same specialty who belongs to the same group within the past 3 years

Step 3: Key Components There are six components that are used to define the level of an E/M service History Examination Medical Decision Making Counseling Coordination of Care Nature of Presenting Problem Time

Step 3: Key Components The three key components must be considered and supported by documentation in the medical record before selecting a code History Examination Medical decision making

Step 3: Key Components History
Elements Chief complaint History of the present illness (HPI) Review of symptoms Past medical, family, and social history (PFSH) Levels Problem focused Expanded problem focused Detailed Comprehensive

Chief complaint “A chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter, usually stated.” American Medical Association. Current Procedural Terminology CPT Chicago, Ill: AMA press;2007

History of Present Illness (HPI) Must be performed by physician HPI Elements Levels Problem Focused Expanded Problem Focused Detailed Comprehensive Location Quality Severity Duration Timing Context Modifying factors Associated signs or symptoms Brief (1-3 elements) Extended (4 or more elements)

Review of Systems (ROS) Can be performed by medical extender ROS Levels Problem Focused Expanded Problem Focused Detailed Comprehensive Constitutional (wt loss etc) Eyes ENT, Mouth Respiratory Cardiovascular GI GU MS Neuro Integumentary Endocrine Hem/lymph Allergy/Immun Psychiatric All others negative None Problem specific (1 system) Extended (2-9 systems) Complete (Greater than 10 systems or some with all others negative)

Past Medical, Family, and Social History (PFSH) Can be performed by medical extender PFSH Levels Problem Focused Expanded Problem Focused Detailed Comprehensive Pertinent At least 1 item from at least 1 history. Complete Specifics of at least 2 history areas documented. All 3 for new patient. None

Summary Elements Problem Focused Expanded Problem Focused Detailed Comprehensive HPI History of Present Illness Brief (1-3 elements) Extended (4 or more elements) ROS Review of Systems None Problem Specific Complete PFSH Past Medical, Family and Social History Pertinent

Step 3: Key Components Physical Examination
The level of exam is determined by the number of body areas or organ systems documented Levels Problem focused Expanded Problem Focused Detailed Comprehensive

CPT Descriptors For Four Levels of Physical Examination Problem focused - A limited examination of the affected body area or organ system(s) Expanded problem focused - A limited examination of the affected body area or organ system and other symptomatic or related organ system(s) Detailed - An extended examination of the affected body area or organ system and other symptomatic or related organ system(s) Comprehensive A general multi-system examination or a complete examination of a single organ system American Medical Association. Current Procedural Terminology CPT Chicago, Ill: AMA press;2007

Documentation guidelines for physical examination 1995 Guidelines (general exams) 1997 Guidelines (specialty exams) Single system (specialty) examination Neurological – recommended for headache specialists General multisystem examination

1997 Guidelines – Neurological  Measurement of any 3 of 7 vital signs  General appearance of the patient  Ophthalmoscopic examination  Examination of carotid arteries  Auscultation of heart  Examination of peripheral vascular system  Higher cortical functions  Cranial nerves  Sensation  Muscle strength  Muscle tone  Deep tendon reflexes  Coordination  Gait and station Constitutional Eyes Cardiovascular Neurological

Summary Level of Exam 1997 Single Organ System Problem focused 1-5 elements Expanded Problem Focused At least 6 elements Detailed At least 12 elements Comprehensive Perform all elements Document all elements in Constitutional Eyes Musculoskeletal Neurological Document 1 element in Cardiovascular

Step 3: Key Components Medical Decision Making (MDM)
What is medical decision making (MDM)? MDM refers to the complexity of establishing a diagnosis and/or selecting a management option Of the three key components of EM, MDM is the most challenging to meet and document

How is MDM measured? Number of diagnoses or management options Number of possible diagnoses Number of options that must be considered Amount and/or complexity of data to be reviewed Amount and/or complexity of medical records, diagnostic tests and/or other information that must be obtained, reviewed and analyzed Risk of complications and/or morbidity or mortality The risk of significant complications, morbidity and/or mortality associated with the patient’s presenting problem The risk of comorbidities associated with the patient’s presenting problem The risk of the diagnostic procedure(s) and/or the possible management options

What are the different levels of MDM? Straightforward Low complexity Moderate complexity High complexity

Summary Number of diagnoses or management options Amount and/or complexity of data to be reviewed Risk of complications and/or morbidity or mortality Type of decision making (Level of MDM) Minimal Minimal or None Straightforward Limited Low Low Complexity Multiple Moderate Moderate Complexity Extensive High High Complexity

Step 3: Key Components Choosing an appropriate level of EM service based on key components New patient, office/outpatient and office consultations You must meet or exceed ALL of the requirements to qualify for a particular level of an EM service Established patient, office/outpatient You must meet or exceed 2 out of the 3 requirements to qualify for a particular level of an EM service

Step 3: Key Components Summary
New Patient – Office/OP (3 out of 3) Code History Exam Medical Decision Making 99201 Problem focused Straightforward 99202 Extended problem focused 99203 Detailed Low complexity 99204 Comprehensive Moderate Complexity 99205 High Complexity

Office or other Outpatient Consultation (3 out of 3) Code History Exam Medical Decision Making 99241 Problem focused Straightforward 99242 Extended problem focused 99243 Detailed Low complexity 99244 Comprehensive Moderate Complexity 99245 High Complexity

Established Patient – Office/OP (2 out of 3) Code History Exam Medical Decision Making 99211 Minimum services; Physician not required 99212 Problem focused Straightforward 99213 Extended Problem Focused Low complexity 99214 Detailed Moderate Complexity 99215 Comprehensive High Complexity

Step 4: Time Time is included in the definition of levels of EM services Ex. “99213 Office or other outpatient visit…physicians typically spend 15 minutes face-to-face with the patient and/or family.” This time is considered average time that may be higher or lower depending on specific circumstances

Step 4: Time In certain circumstances the three key
components (history, physical examination and MDM) are not the controlling factor in determining the level of an EM service

TIME Step 4: Time In certain circumstances is the controlling factor
in determining the level of an EM service

Step 4: Time Time determines the level of E/M service when counseling and/or coordination of care dominate (> 50%) the encounter Counseling and coordination is separate from the history, physical exam and medical decision making More common scenario for headache specialists The extent of counseling and/or coordination of care must be documented in the medical record independent of the three key components

Step 4: Time Counseling patient and/or family
Diagnostic results, impressions, and/or recommended diagnostic studies Prognosis Risks and benefits of management (treatment options) Instructions for management (treatment) and/or follow-up Importance of compliance with chosen management (treatment) options Risk factor education Patient and family education American Medical Association. Current Procedural Terminology CPT Chicago, Ill: AMA press;2007

Step 5: Documentation General Principles of Medical Record Documentation¹ Medical record complete and legible The documentation of each patient encounter includes: Reasons for the encounter and relevant history, physical examination findings and prior diagnostic test results; Assessment, clinical impression or diagnosis; Plan for care; and Date and legible identity of the provider If not documented, the rationale for ordering diagnostic and other ancillary services easily inferred ¹ 1997 EM Guidelines, Centers for Medicare and Medicaid Services (CMS)

Step 5: Documentation General Principles of Medical Record Documentation¹ Past and present diagnoses accessible Appropriate health risk factors identified Patients progress and response to changes in treatment included CPT and ICD-9 codes supported by documentation ¹ 1997 EM Guidelines, 1997 EM Guidelines, Centers for Medicare and Medicaid Services (CMS)

Use of modifiers

Use of Modifiers What is a modifier? Why use modifiers?
Modifiers indicate that a service was altered in some way from the stated CPT descriptor without changing the definition Why use modifiers? When you need to communicate something unusual about the service to Medicare What is the impact of modifiers? Modifiers can maintain, reduce or increase reimbursement levels for a service

Use of Modifiers Common modifiers for EM services
-21: Prolonged evaluation and management services Only can be used with the highest level EM service -25: Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service Appropriate documentation for the need of the EM service should be recorded in the patient’s medical record -52: Reduced services Should not be used if there is a code at a lower level that describes the service provided

Clinical examples

Case #1 – History (HPI, ROS, PFSH)
32 year old woman with PMH of “TTH”. Onset of H/A age 14. H/A associated with vomiting, photophobia & dysfunction. 8 year history of chronic daily headaches. Taking Vicodan daily (4-6/D) for 5 years; was taking Butalbital before Vicodan. Disability for 2 years. New onset: “visual blurring” OD; Numbness in RUE; Transient Confusion

Case #1 Level of Care Physical Exam Diagnosis
99241?; 99242?; ?; ?; 99245? 99201?; 99202?; 99203?; 99204?; 99205? Physical Exam Exam: 23 Bullets BP 210/105; Pulse 72 Irreg.; RR 15; General Exam: Otherwise WNL Neurological Exam Higher Cortical Function; Cranial Nerves; Motor; Coordination; Gait; Reflexes Sensation; All WNL Diagnosis 1. Migraine with aura; 2. Chronic Daily H/A; 3.Medication Overuse Headache; 4. Hypertension; 5. R/O Cardiac Arrthymia; 6. R/O CNS Mass Lesion; 7. R/O Cerebral Vascular Disease (TIA, Cerebral Emboli, Infarct) Complexity of Data Reviewed Reviewed 22 pages of prior records; Head Ct without contrast (2004); CT cervical spine (2004) Ordered MRI Head with contrast; Lab; EKG; Cardiology Consult; Hospital Care? Risk Risk of Presenting Problem: Minimal?; Self Limited or Minor?; Low severity?; Moderate severity? High severity? Risk of Management Options?; Risk of Diagnostic Procedures?

Case #1 Pre-service Reviewed the medical history form completed by the patient and vital signs obtained by clinical staff Intra-service A comprehensive History A comprehensive neurological exam > 23 Bullets Medical Decision Making Number of Diagnoses or Treatment Options >4 Amount / Complexity of Data Reviewed > 4 Using Table of Risk: “One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment” “An abrupt change in neurologic status, e.g. seizure, TIA, weakness, sensory loss” “Drug therapy requiring intensive monitoring for toxicity”

Case #1 Post-service Complete the medical record documentation
Provide necessary post evaluation care and coordination of care The Level of Care would be because History and Exam were Comprehensive and MDM was High Complexity. This would not be a Consultation or 99245 because the referral requires a transfer of care for further E /M.

29 year old woman with PMH of MH without aura. Established Pt. Hospitalized 2 years ago due to medication overuse headache; took Fiorocet daily for 3 years; now on Topamax; limits abortive triptan to 2 days per week. Is Bipolar; Has insomnia; Had “Syncopal Spell” one day ago with loss of bladder control; struck head . New onset vertigo.

Office Visit: 99212?; 99213?; 99214?; 99215? Physical Exam Exam: 23 Bullets BP 130/80; Pulse 72 regular RR 16; Bruise on R frontal area from trauma when fell; General Exam: Otherwise WNL Neurological Exam Awake, alert, coherent. Memory/intellect intact No aphasia or dysarthria CN’s: WNL; Motor exam wnl Coordination intact; Gait; no ataxia; Reflexes: wnl; Sensation: intact Diagnosis 1.Migraine with aura; 2. Medication overuse headache by history; 3. Bipolar disorder; 4. Sleep disorder; 5.Syncope; 6. Head trauma due to #5; 6. R/O vasovagal syncopy; 7. R/O seizure; 8. New onset Vertigo Complexity of Data Reviewed Reviewed 1.Current chart; 2. Hospital records; 3. All current meds Ordered 1.Lab; 2.Repeat MRI of head; 3.EEG; 4.EKG Risk Risk of Presenting Problem: Minimal?; Self Limited or Minor?; Low severity?; Moderate severity? High severity? Risk of Management Options?; Risk of Diagnostic Procedures?

Case #2 Pre-service Reviewed the medical history form completed from the patient, vital signs obtained by the clinical staff Intra-service Obtained a comprehensive history including a review of all medications for possible drug interactions. Compared status to last visit. Performed comprehensive neuro exam. Considered relevant data, options, and risks; formulated a diagnosis; developed a treatment plan. Discussed diagnosis, treatment options and risks with patient and family. Ordered and arranged diagnostic testing. Medical Decision Making Number of Diagnoses or Treatment Options list 5 established Dx. & 2 R/O Dx . Amount / Complexity of Data Reviewed >4 Using the Table of Risk: “One or more chronic illness with severe exacerbation, progression, or side effects of treatment” “An abrupt change in neurologic status, e.g.. seizure, TIA, weakness, sensory loss” “Drug therapy requiring intensive monitoring for toxicity”

Case #2 Post-service Complete medical record documentation. Provide necessary communication and coordination of care. Respond to testing results and revise treatment plan. The level of care would meet the criteria for because not only 2 out of 3 but 3 out of 3 requirements were met; a comprehensive History, Exam and High Complexity MDM

33 year old woman; 10 year history of MH without aura. Established pt. Hospitalized at another clinic 5 years ago because of MOH. Did well until 4 mo ago; recurrent daily “migraine” with 7 days a week of OTC use & triptans bid 4 days a week. On Inderal for headache and BP control. New onset stress; crying; not sleeping. C/O difficulty “Coping”.

Office Visit: 99212?; 99213?; 99214?; 99215? Physical Exam Exam: 12 Bullets BP 160/90; Pulse; 90 Regular; RR 17; Pt appeared depressed; crying Neurological Exam MS. Awake, alert, coherent; affect flat; judgment impaired; intellect and memory intact; no dysarthria/aphasia; CN disc flat OU, 3,6,7,12 intact: Motor: Coordination: Gait: intact Diagnosis 1.Migraine without aura; 2. New Onset Chronic Daily Headache; 3.Medication Overuse Headache (OTC, Triptans); 4. Hypertension; 5. New Onset Depression; 6. R/O acute CNS lesion Complexity of Data Reviewed 1.Records including prior medication history reviewed; 2. Patient has had no recent lab; studies ordered to include CBC, SMA, Sed rate, Thyroid profile; 3. Repeat MRI? ; 4. Will Discuss meds, clinical change, with PCP (Time spent with patient: 35 minutes) Risk Greater than 50% of the time was spent in coordination of care 1.Discussed prognosis if not treated; 2. Discussed Risk of Medication Overuse; 3. Discussed Risk and benefits of treatment options; 4. Discussed Risk of non-compliance; 5. Discussed tests ordered and future tests if need; 6. Discussed instructions for treatment and follow-up.

Case #3 Pre-service Reviewed the medical history form completed by the patient and vital signs obtained by the clinical staff. Discussed new symptoms with the NP. Intra-service An extended problem focused history including current meds for headache control and antihypertensive meds. Discussed new onset daily headaches and depression. Discussed risk of using triptans with hypertension and use of Inderal in depression Performed an extended problem focused examination including mental status Medical Decision Making Number of Diagnoses or Treatment Options > 4 Amount / Complexity of Data Reviewed > 2 Using the Table of Risk: “One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment” “Prescription drug management”

Case #3 Post-service Complete medical record documentation
Provide coordination of care and review with PCP; consider Psych consult The H & P are Extended Problem Focused. The CPT level of care would be However, since greater than 50% of time was spent in Counseling and Coordination of Care, if that criteria were used, the level of care would be coded as The counseling and discussion included prognoses, risks and benefits of treatment options, instructions for treatment and follow up, importance of compliance, risk factors of current course, and risk factor reduction with proper management.

Coding resources

Coding resources American Headache Society (AHS)
AHS’s Headache Coding Corner American Medical Association CPT-related resources Centers for Medicare and Medicaid Service (CMS) Evaluation and Management Services Guide 1997 Documentation Guidelines for Evaluation and Management Services

Next AHS Coding Webcast
Don’t forget to register for our next Webcast: Understanding Medical Decision Making (MDM) on October 16. To register please go directly to:

Thank You The American Headache Society thanks you for your participation. We will now take questions. Please contact American Headache Society (AHS) headquarters for further information: or

Webcast Session I An Introduction to Evaluation and Management (EM) Coding Accurate Coding for Evaluation and Management (EM) Services A webcast designed.

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Webcast Session I An Introduction to Evaluation and Management (EM) Coding Accurate Coding for Evaluation and Management (EM) Services A webcast designed.

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