1. INTRODUCTION TO CPT CODING Doctors Hospital Family Practice Residency Program Practice Management

2. Overview of the Course ◦Why Use CPT ◦How CPT code book is broken down ◦Evaluation and Management Codes: 1.STEP #1 to coding E/M: Type of visit 2.STEP #2 to coding E/M: Components of the visit a)Using History to Code b)Using Examination to Code c)Using Medical Decision Making to Code 3.STEP #3 to coding E/M: Determining the final code

3. Why use? ◦Physicians and healthcare providers provide services and perform procedures that need to be documented in a standardized fashion ◦Includes office visits (evaluating a patient – and making a diagnosis) ◦Includes other procedures performed (for example – skin biopsies, injections etc.) ◦Services should be captured and billed appropriately for financial success ◦There should be a standard method for determining the level of services provided ◦Using numbers is the easiest and best way for information to be standardized and passed along to other associated healthcare providers/insurance carriers ◦(sound familiar?)

4. What is CPT? ◦Stands for “Current Procedural Terminology” ◦It is a list of numeric codes that can be used to bill for services or procedures rendered to a patient ◦The CPT is a product of/owned by the American Medical Association (AMA)

5. How is CPT book broken down? ◦Has various sections: 1.E/M (evaluation and management) ◦ These are codes to use to get paid for seeing a patient in the office or hospital setting ◦We will spend most of our time in this course going into detail how to derive the E/M code 2.Anesthesia – codes used to perform anesthesia services 3.Surgery – codes used to perform surgical procedures 4.Radiology – codes used for performing x-rays, reading films, and interventional radiology procedures 5.Pathology/Lab – codes used to make slides/prepare and read specimens 6.Medicine – everything else ◦Has index in the back that will help locate a general area of the CPT code – organized by the name of procedure ◦For example – “Destruction,” “Injection,” “Biopsy” ◦Use the front part to help further specify a code

6. How is CPT broken down? ◦Take some time to Explore the CPT Book now ◦What would the CPT code be for epicondylitis injection of elbow? ◦What would the CPT code be for destruction of an AK by cryotherapy? ◦What would the CPT code be for punch biopsy of one benign skin lesion?

7. E/M codes (evaluation and management) ◦Evaluation and management codes are used for billing for the work done in evaluating and managing a patient: ◦There are various “levels” to consider – based on the complexity of the workup and/or time spent with the patient ◦Level 1 - Low Complexity, typically a nursing visit ◦Level 2 - Problem Focused visit – typically one simple problem ◦Level 3 - Expanded Problem Focused – a typical problem that requires treatment ◦Level 4 - Detailed – typically a more complex problem, or several problems ◦Level 5 – Comprehensive Visit – the most complex visit

8. STEP #1: Type of E/M code ◦The first step of selecting an appropriate E/M code – is to determine the TYPE of visit for E/M code using the following factors: ◦Location (hospital vs. outpatient) ◦ Wellness vs. Illness ◦Wellness visits arranged by age ◦New Vs. Established patients  The new patient is one that has not has an encounter with the practice (or partners) for the last 3 years  The Established patient is one that HAS had an encounter within the previous 3 years ◦Consultation codes (examples:)  Use for Preadmission Testing  Use for OMT Consults from another doc ◦Time allotted ◦Specific Medicare Visits (Medicare wellness, or Medicare PAP) ◦Counseling only visits ◦Transition of Care visits

9. STEP #2: E/M components: ◦The next step is to use the factors listed below to help determine the appropriate E/M code to give to the patient for each visit (*** the stared being the most important) 1. History taking *** 2. Exam complexity *** 3. Medical Decision making *** 4. Counseling given 5. Coordination of Care 6. Nature of the Presenting Problem 7. Time spent seeing the patient ◦This emphasizes the importance of good documentation to help meet the criteria of a specific E/M level visit

10. REVIEW: ◦What are the 3 most important E/M components used to help determine a level of office visit?

11. A) E/M: History ◦The complexity of the visit (the level of E/M coding) is FIRST partially determined by using the following components in the HISTORY taking: ◦Chief Complaint – the nature of the complaint (is it abdominal pain, or a cold) ◦History of Present Illness – the number HPI elements reviewed (pain quality, timing, radiation, palliative, provocative factors etc.) ◦Review of Systems (how many systems reviewed) ◦Past Medical/Surgical/Family/Social history components reviewed (the number of these elements reviewed with the patient) ◦Documentation required for various levels: ◦Problem focused: chief complaint and 1-3 HPI elements ◦Expanded problem focused: Chief complaint, 1-3 HPI elements, 1 ROS element ◦Detailed – Chief complaint, 4-8 HPI elements, 2-9 ROS elements, PFSH: 1 element ◦Comprehensive – Chief complaint, 4-8 HPI elements, 10-14 ROS elements, PFSH: 1 element from each area

12. Chart for E/M: History component: PF = problem focused (2), EPF = expanded problem focused (3), D = detailed (4), C = complex (5)

13. REVIEW: Determine the level of E/M for the following history:  34 y/o presents to office for 3 days of cough. Associated symptoms include congestion and drainage. Mucinex DM does not help. Patient reports no chest pain or palpitations.

14. B) E/M: Examination ◦The level of complexity of the E/M examination component is SECONDLY based on the number of body systems that are EXAMINED during the encounter ◦These systems are clearly outlined by coding criteria ◦With the EXAM component – the provider has an option to follow one of 2 different guidelines ◦The provider can use EITHER the 1995 guidelines/arrangement of systems, or the 1997 guidelines/arrangement of systems ◦1995 – uses whole body systems (Most providers follow the 1995 criteria – since it is simpler) ◦1997 – uses bullets/sections identified as parts of body systems

15. 1995 Arrangement of Organ Systems: ◦Constitutional (e.g., vital signs, general appearance) ◦ Eyes ◦ Ears, nose, mouth, and throat ◦ Cardiovascular ◦ Respiratory ◦ Gastrointestinal ◦ Genitourinary ◦ Musculoskeletal ◦ Skin ◦ Neurologic ◦ Psychiatric ◦ Hematologic/lymphatic/immunologic

16. 1997 Arrangement of Organ Systems:

17. B) E/M: Examination ◦1995 Examination Guidelines: ◦Problem Focused: examination of at least one body organ system ◦Expanded Problem Focused: A limited examination of the affected body area or organ system (2-4 body systems examined) ◦Detailed – An extended exam of the affected body area and other symptomatic or related organ systems (5-7 body systems examined) ◦Comprehensive – General multi-system review (8-12 systems – a full body exam)

18. B) E/M: Examination ◦1997 Examination guidelines: ◦Problem focused: < 6 bullets ◦Expanded problems focused: 6-12 bullets ◦Detailed: 12 or more bullets ◦Comprehensive: at least 2 elements identified by bullets for at least 9 organ systems or body areas

19. REVIEW: Determine the level of E/M for the following examination:  Constitutional: well developed and well nourished and in NAD  ENT: reveals congestion, inflamed turbinates, with posterior pharyngeal cobblestoning, no pharyngeal erythema, mmm  Lungs: CTABL, no w/r/r  Heart: reg, no m/g/r

20. C) E/M: Medical Decision Making ◦Determining an E/M code THIRDLY is based on 2/3 components of DECISION MAKING: 1.The number of diagnoses &/or management options 2.The amount &/or complexity of data (the amount of information that is reviewed) ◦Diagnostic tests (x-rays, labs) ◦Complexity of the data reviewed ◦Consult notes, or directly speaking with a consultant 3.The risks of complications, morbidity or mortality from the diagnosis for the encounter ◦Charts are used to determine the level of the complexity of the decision making based on the 3 components (refer to next slide)

21. Medical Decision Making – Scoring Dx/Mx

22. Medical Decision Making – Data complexity

23. Medical Decision Making – Risk level

24. Medical Decision Making = Final Risk assess (overall risk is the middle column of the 3) S=straightforward, LC = Low complexity MC = moderate complexity, HC = high complexity

25. REVIEW: Determine the level of E/M for the following Medical Decision Making:  45 y/o female smoker reports to the office after visit to the UC for cough 4 days ago. Was dx with pneumonia, placed on antibiotics, but CXR at UC was concerning for lung mass. You look at old reports of CXR done 2 years ago – which was clear. You obtain the CXR records and the report has unfamiliar terminology, so you call the reading radiologist to discuss. Upon reporting the previously normal CXR - He recommends immediate CT of chest for suspicion for cancer. You discuss these things with the patient, order the CT scan, and refer the patient to smoking cessation counseling per her request

26. STEP #3: Determining the final code ◦Once the choices for the level of code are made for each component (history, exam and decision making) – you can use the chart to determine the correct final E/M code ◦The code would be the middle column of the 3 for an established patient ◦The code would be the lower level column for a new patient

27. Final Code selection for E/M

28. References: ◦CPT Standard Edition by AMA ◦“Introduction to Coding” – by Todd Frieze, MD, FACP, FACE, ECNU, CEC; found at: https://www.aace.com/files/pm101_frieze_introcoding.pdf https://www.aace.com/files/pm101_frieze_introcoding.pdf ◦“Pocket Guide to the Documentation Guidelines,” From the American Academy of Family Physicians. 1996. ◦1997 Updates in Coding by the Centers for Medicare and Medicaid Services