Evaluation and Management

Evaluation and Management
Chapter 19 Chapter 19 – Evaluation and Management 1

CPT® CPT® copyright 2010 American Medical Association. All rights reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT® is a registered trademark of the American Medical Association. <Pause>

Objectives Define E/M Differentiate between a new and established patient Identify service location and type Understand the requirements for different levels of service Learn how to properly “level” and E/M service Abstract a provider’s note to arrive at the levels of service In this chapter we will define an evaluation and management service, referred to as an E and M service. We will differentiate between a new and established patient, identify the service location and type, understand the requirements of different levels and categories of service, and we will learn how to find the accurate E and M code by leveling the service.

First Section of CPT® Numerically, it should fall last Brought to the front because this is where most services begin with a patient Most highly utilized codes The Evaluation & Management section is the first section in the CPT® manual, even though numerically should fall in the last section. It is brought forward to the front because this is where most services begin, with the evaluation and management of the patient. Please have your CPT manual open to this section. You may want to have some highlighters in different colors available for you to highlight key and important words and differences as we look at this section.

Evaluate and manage the patient (E/M) Inspection and observation Palpation Auscultation Percussion The evaluation and management section of CPT is used to report visits to medical providers. This is the service where the provider evaluates signs, symptoms, or overall health of a patient and manages any diseases or illness the patient has. These services by the health care provider, whether they are at the hospital, doctor’s office, or other location, are called evaluation and management services, abbreviated as E/M services. Evaluation and management services are not specific to one medical specialty. During an evaluation and management service, the provider will use a variety of methods to evaluate the patient. The provider begins observing the patient to watch behavior and mannerisms. The skin and symmetry of the body are inspected. The provider will then further explore a body system using palpation, auscultation, and/or percussion. Palpation refers examination of the body by touch. Body parts are palpated to look for organ size or condition, or for tenderness. Auscultation is listening to body sounds. A stethoscope can be used to listen to the heart and lungs for sounds. Percussion is creating sounds from tapping on body areas to examine body organs and body cavities. The vibrations of the sounds help identify abnormalities.

ICD-9-CM Coding Primary diagnosis – reason for the visit
Signs and Symptoms Code only if no definitive diagnosis is stated Routinely associated with a disease process should not be coded separately The primary diagnosis for an E/M visit should be the reason the patient is being seen. Sometimes, this is multiple diagnoses, such as hypertension and diabetes, in which case either code could be used for the primary diagnosis unless there are guidelines specific to the disease that specify sequencing rules, such as HIV. Many times, a patient will visit the provider with symptoms, such as a cough or chest pain. When the patient arrives with symptoms and the provider documents a definitive diagnosis, only the definitive diagnosis should be coded. If a symptom is not part of the normal process of the disease, it can be coded in addition to the disease. An example of this would be a patient who visits the doctor for a follow up of hypertension, but also tells the doctor he has knee pain. If the provider evaluations the hypertension and the knee pain, both would be coded. However, if the patient comes in for a follow up of hypertension and complains of headaches, and the provider determines the headaches are due to the high blood pressure, only the hypertension would be coded.

CPT® Coding Select the category or subcategory of service and review the guidelines; Review the level of E/M service descriptors and examples; Determine the level of history; Determine the level of exam; Determine the level of medical decision making; and Select the appropriate level of E/M service. The Evaluation and Management Services Guidelines in CPT® outline six steps to determine the level of an evaluation and management service: 1. Select the category or subcategory of service and review the guidelines; 2. Review the level of E/M service descriptors and examples; 3. Determine the level of history; 4. Determine the level of exam; 5. Determine the level of medical decision making; and 6. Select the appropriate level of E/M service. Steps three through six are referred to as “leveling” an evaluation and management service, or determining the level of service that was provided. We will discuss these steps in detail later in this lecture. The first step is to determine the category or subcategory of service so let’s start there.

Categories and Subcategories
E/M codes are divided into categories representing the type of service, such as office visits, emergency department visits, nursing facility care, etc. Some categories are divided further into subcategories to indicate specific details reflecting the status of the patients as new or established, or inpatient or outpatient. Subcategories are divided into levels, which are assigned a five digit code.

Categories and Subcategories
Category: Office or Other Outpatient Services Subcategory: New Patient Code: 99201 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history A problem focused examination Straightforward medical decision making Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem (s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family. Individual code descriptors provide specific details such as place and or type of service; content of the service provided; nature of the presenting problem; and the time generally required to provide the service. Here we see the category is Office or Other Outpatient Services. The Subcategory is New Patient. The level 1 code is In the descriptor it shows this level of visit requires three key components which are a problem focused history, a problem focused exam, and a straightforward medical decision making. It also shows the typical amount of face-to-face time the provider will have with the patient. In this case, it is 10 minutes.

New vs. Established Patients
New – has not received any face-to-face professional services from the physician, or a physician of the same specialty/subspecialty within the group practice, within the last three years Established – has received face-to-face services in the last three years Some of the categories are divided further into new and established patients. A patient is new if he or she has not received any face-to-face professional services from the physician, or a physician of the same specialty/subspecialty within the group practice, within the last three years. The guidelines in CPT also state the service must be reported by a specific CPT code. An established patient has been seen in the last three years by the same physician, or another physician of the same specialty within the same group practice. One of the key areas in the definition of a new patient is where it states the physician of the same specialty or subspecialty. For example, if a patient sees an internist on a regular basis, but then breaks his leg and sees an orthopedist in the same practice. This patient would be considered new to the orthopedist because the physicians are of different specialties.

Office or Other Outpatient Services
Provided in the physician's office or other outpatient clinic or ambulatory facility New patient Established patient Let’s look at the guidelines for each of the categories. The first category is titled office or other outpatient services. Beneath the title, there are guidelines explaining what these types of services are. The guidelines also give you some information about other services to consider in case there is another subsection you should be looking at. Office or other outpatient services are the type of services that are provided in the physician's office or in an outpatient clinic or other ambulatory facility. The patient is considered an outpatient unless they are admitted into the hospital at which time they are considered inpatient. The guidelines instruct you to go to a different set of codes if you are looking for emergency services, observation care, or inpatient care services. The office and outpatient services are further divided into subcategories for new patient and established patient. We will look at the criteria for new and established patient designation later on. Within new and established, there are specifications for selecting the correct level of visit.

Observation Hospital Observation Services
Patient’s designated or admitted to observation status in the hospital No CPT® guideline on length of observation stay Observation Care Discharge Services If discharge is on date other than date admitted to observation Subsequent Observation Care Patient is seen on a date other than the date of admit or discharge to observation When a patient has a condition that needs to be monitored to determine a course of treatment, he may be admitted to “observation status.” For example, a patient goes to the Emergency Department with severe abdominal pain. While the physician is determining the reason for the pain, the patient is admitted to observation where the physician will continue to run diagnostic tests to determine the cause. The next category of Evaluation & Management codes is used for these hospital observation services. The note underneath Hospital Observation Services tells you these services are provided to patients designated or admitted as observation status in a hospital. It is not necessary the patient be located in an observation area designated by the hospital. Sometimes the patient is still in a bed in the emergency department when the physician puts them into an observation status. There are no guidelines in CPT® limiting how long a patient can stay in observation status. There are codes for observation care discharge, subsequent observation, and initial observation care. For patients admitted and discharged on the same date, you are referred to codes listed in the Hospital Inpatient Services category. The first code listed under hospital observation is observation care discharge services. This code is used to report discharging a patient from observation status if the discharge is on a date other than the date the patient was initially put in observation status. Sometimes a patient can remain in observation for up to three days, depending on the carrier policy. Subsequent Observation Care is used when the patient is seen on a day other than the date of admission or discharge.

Observation Observation Discharge Services (example)
9 p.m. patient seen in ED with concussion and evaluated 10 p.m. patient placed in observation status Remains in observation for 12 hours 10 a.m. following date (day) discharged from observation status Two separate dates for observation admission and discharge Report observation care discharge code for services provided on discharge date Let’s look at an example. A patient is seen in the emergency department for a concussion at 9 pm. After the patient is evaluated, he is put in observation status at 10 pm. The patient is kept in observation for 12 hours. He is discharged from observation status at 10 am the following date. In this case, the admission to observation was on one date of service, and the discharge was on another date of service. The observation care discharge would be coded for the services provided on the discharge date.

Observation Initial Observation Care
Use code from this group when physician initially chooses to place patient into observation If patient admitted to hospital after admission to observation status on the same date – see inpatient hospital care codes Admitted/Discharged same date see If admitted to observation status in the course of another service, all other services are included in the observation status Codes may not be used for post-op recovery The next subcategory for hospital observation services is initial observation care. At the time the physician decides to put the patient in observation status, this would be the group of codes you choose from. The second paragraph gives us a couple of other situations to consider. The guidelines tell us when the patient is admitted to the hospital after being in the observation care status on the same date, look at the notes for the initial hospital care. The guidelines also tell us if the patient is admitted and discharged on the same date, we’re going to want to look at The guidelines throughout evaluation and management assist us in determining whether or not we have selected the correct group of codes. Continuing in the guidelines, we are told when observation status is initiated in the course of another service, all of those services are included in that observation status. If the patient was being evaluated in the emergency department and the physician decides to move the patient into observation status, the physician would not charge for his ED services. He would use only this initial observation care code. The last note under the Initial Observation Care section cautions us that these codes can not be used for post-op recovery. If the patient has a procedure in an outpatient setting and was supposed to be released to home, but instead kept for observation, the observation care would be considered part of the post-op care and included in the surgical package.

Hospital Inpatient Services
Codes used for inpatient facility and partial hospitalization Use codes for admit/discharge on same date Subsequent hospital care codes used for subsequent visits while admitted Includes reviewing medical record, test results, etc The next category of codes is hospital inpatient services. Reading the guidelines, it explains to us that the codes may also be used to report partial hospitalization. This set of codes is used not only for the inpatient facility but also if you're reporting for a partial hospitalization program. This category is further divided into subcategories for initial hospital care and subsequent hospital care. A note under initial hospital care explains this is for the first hospital inpatient encounter by the admitting physician. If there are other initial inpatient encounters by physicians that are not the admitting physician, you would need to look at the initial inpatient consultation codes or subsequent hospital care as appropriate. Sometimes you have an admitting physician who is present in morning, and when the rounds change you may have another physician actually assume care of the patient. In this example, the admitting physician in the morning would report the admit code, and the second physician in the afternoon would report his services either as a consult or a subsequent hospital care depending on the services provided. The idea here is that you can't report two initial hospital care visits in the same day from the same episode. This is a CPT Guideline. For Medicare, however, it is possible to have more than one physician report the initial hospital care. This will be discussed when we look at consultation services. We are also instructed by the guidelines to report – for services where a patient is admitted and discharged as inpatient, or observation, on the same date of service. Subsequent hospital care codes are used for the subsequent visits during the inpatient stay. All levels of subsequent hospital care include reviewing the medical record, test results, and assessing changes in the patient’s status since the last assessment by the physician.

Admit/Discharge Same Day
Observation or Inpatient Care (including admit and discharge services Patient present to ER in morning Admitted to observation at 2 a.m. Patient feeling better by 8 a.m. Lab work is okay; situation resolved Patient discharged Select from codes Finally, we reach the often referred to codes for Observation or Inpatient Care services when the patient is admitted and discharged on the same date of service. An example might be when patient comes into the emergency room with an acute stomach ache, the physician decides to place the patient in observation status to see what's going on. Its 2 AM in the morning and the patient is admitted to observation and made comfortable. The physician orders some labs and the patient gets some rest. By 8 AM in the morning, when the physician comes around to take his rounds, the patient is feeling much better. The situation has resolved, the lab work has come back negative, and the physician decides to release the patient. Because the patient is admitted and discharged on the same date of service, one code would be used from this section.

Hospital Discharge Services
Codes are based on time Includes time spent with the final exam, paper work, writing prescriptions, talking with patient’s family, etc. Parenthetical notes How to code for concurrent care on the discharge date Discharge of a Newborn see code 99463 The next set of codes is the hospital discharge services. Hospital discharge day management codes are billed by the amount of time the physician spends in completing the care of the patient. The final exam, paperwork, writing of the prescriptions, and sitting down with the patient's family members or caregiver giving relevant instructions on how to care for the patient are all included in the discharge day management. Again, at the end of this set of codes, the parenthetical instructions remind us to refer to codes – for admit and discharge on the same date of service. In addition, the parenthetical notes give us instructions on how to bill for concurrent care by another physician on the discharge date. The concurrent care would be reported with codes from the subsequent hospital care codes. The final parenthetical note in this section instructs us to look at CPT® code for discharge services provided to newborns admitted and discharged on the same date of service.

Consultations Consultations Divided by location
Service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or appropriate source Divided by location Office or other outpatient setting consultations use Inpatient consultations use The next category in Evaluation and Management is Consultation Services. Consultation codes are divided by location. If you are coding consultation services performed in an office, or other outpatient setting, you would use – If coding for Inpatient Consultations, you would select from codes – Your CPT coding manual defines a consultation as “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.” Other appropriate sources may be a physician’s assistant or nurse practitioner.

Consultations Consultations (cont.)
Three R’s to meet consultation criteria There must be a request by another physician asking for an opinion The consulting physician needs to render an opinion The consulting physician needs to respond with written report to the requesting physician To qualify as a consultation the documentation has to meet what we call the 3Rs. There must be a request by another physician asking a physician for their opinion; The consulting physician needs to render his/her opinion; and The consulting physician needs to respond with a written report to the requesting physician. So the three R’s to look for when coding consultation services are: Request, Render, and Respond. Follow with me as we continue in the guidelines under consultations. The physician that is consulting can also initiate diagnostic or therapeutic services at the same time or at a subsequent visit. It is necessary to make sure the physician provides a written report back to the requesting physician.

Consultations Patient request of consult for 2nd opinion
Code with office/outpatient visit, home service, domiciliary/rest home codes Requested by insurance company, i.e., Worker’s compensation Use consult code with modifier 32 In the situation where the patient or the patient's family requests the consult, it would be reported with office visit codes, home service codes, or domiciliary/rest home codes. This may occur when a patient wants a second opinion, or wants to have a consultation with specialists rather than their family practitioner. This type of request does not meet the definition of our first R which is request from an appropriate source, so it can not be reported with consultation codes. Another type of consult you may see is one mandated or requested by an insurance company. For instance, in workers compensation cases, there are times when a physician is treating the patient and says the patient is not ready to go back to work. The insurance company may request a second opinion before they decide whether the patient should resume their duties or not. In that type of situation, it would be appropriate to report a consult code and append modifier 32 to indicate it was at the request of the insurance company.

Consultations Consult codes do not distinguish between new/established
Inpatient consult codes Only one consult per admission Use subsequent service codes If subsequent to the completion of the consult the consulting physician assumes responsibility for the patient, the subsequent care would be billed based on the correct place of service. It might be an office visit or hospital visit, or could even be a nursing home facility, etc. It will depend on where the patient is seen. Consultation codes do not distinguish between new or established patients. For inpatient consultation codes, only one consultation should be reported by a consultant per admission. If the consultant visits the patient again during the same admission, the service should be reported with subsequent service codes.

Consultations Medicare: Office Consultations Inpatient Consultations
Report with new and established patient codes Inpatient Consultations Report with initial hospital care codes for the first encounter regardless if performed by the admitting physician. Use Modifier AI for the Principal Physician of Record There is one final note to address on consultations. Medicare no longer recognizes consultations codes. If you are coding for a Medicare patient, you will need to use the new and established patient codes for office consultations, and initial hospital care codes for inpatient consultations. Remember, earlier, we talked about how only the admitting physician should report the initial hospital care code? For Medicare, any physician who consults with the patient on the day of admit should report the initial care code. The principal physician of record should report the initial hospital care code with modifier AI to indicate he is the principal physician of record. This is different rules from the CPT guidelines we discussed earlier. Other payers may allow you to continue to report consultation codes. Make sure you check with individual payers regarding their guidelines.

Emergency Department Does not distinguish between new/established
Facility must be hospital-based and available 24 hours a day Physician direction of EMS emergency care, advanced life support The next Evaluation and Management category is Emergency Department. Emergency department codes do not distinguish between new or established patients. In order for services to qualify as emergency department services, the services must be provided in a facility that is hospital-based and available 24 hours a day. The Insta care and urgent care facilities open after regular office hours are not considered emergency room department services and you wouldn’t use this subsection of codes. Emergency department services will always be provided in a hospital-based facility. Just under the Emergency Department visits is a code for Physician direction of EMS emergency care, advanced life support. There are situations where a physician will direct the emergency care from the emergency department. The patient will be in an ambulance or at a scene. In the process of bringing the patient to the hospital the physician will actually direct the ambulance or rescue personnel on how to provide care to the patient.

Critical Care Services
Critically ill or injured Acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient condition. Services included in critical care described in critical care guidelines. The next category code is critical care services. Critical Care Services are provided to patients in the hospital who are critically ill or injured. They have to meet the criteria of a critical illness or injury as defined in your Critical Care guidelines. The Critical Care Guidelines defines a critical illness or injury as one that “acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.”

Services provided in a critical care unit to a patient who is not considered critically ill are report with other E/M codes. Guidelines contain instructions for coding Pediatric Critical Care Neonatal Critical Care Critical Care and other E/M services may be coded on same date by the same provider. Your guidelines continue on to describe what is involved in critical care. Critical care is usually provided in a critical care area, but not always. Services provided to a patient who is in the critical care unit, but is not considered critically ill, would be reported using other evaluation and management codes. There are also instructions for reporting pediatric critical care and neonatal critical care. This will be further discussed when we reach the Neonatal and Pediatric Critical Care Section. Another important note in your guidelines informs us critical care and other evaluation and management services can be billed on the same date by the same physician.

Guidelines list services inclusive to critical care May not be reported separately Refer back to list to avoid unbundling services Beneficial to highlight each of the CPT® codes listed in the guidelines Now, you may want to get your highlighter. This is a very important section in your guidelines. The next paragraph gives us a lengthy list of what services are considered inclusive to critical care. These services should not be reported separately when provided during the critical care period by the same physician(s) providing the critical care. You will need to refer back to it when coding for critical care to avoid unbundling services or missing opportunities to bill additional services. It may be beneficial to highlight each of the CPT codes listed in this paragraph.

Codes are in time increments Includes the total time spent by the physician on that date of service Doesn’t need to be continuous time Reviewing records/tests, time with family members Time spent off the floor not included The transport of critically ill or critically injured patients over 24 months of age should be reported with the critical care codes. When calculating the time for critical care codes, you include the total amount of time spent by the physician on that date of service, even if it is not continuous. The time spent on the floor unit reviewing patient records and tests, as well as the time spent on the floor or unit with family members to obtain additional information on the patient, is included in the time you report for the critical care. Time spent off of the floor may not be included in this time. Time for services separately billable may not be included in this time.

Time increments Less than 30 minutes use appropriate E/M instead of critical care codes First minutes code 99291 Each additional 30 minutes beyond the initial 74 minutes use 99292 Table in guidelines to help with converting time to critical care code(s) Critical care is billed in time increments. If the total time of critical care is less than 30 minutes, you would bill the appropriate evaluation and management code instead of a critical care code. Code is used to bill the first 30 – 74 minutes. After the first 74 minutes, you bill the add- on code for each additional 30 minutes. Your guidelines provide a great table to help you convert the amount of critical care time to CPT codes.

Nursing Facility Services
Psychiatric residential treatment center Divided into Initial and Subsequent Nursing Facility Discharge & 99316 Similar to hospital discharge – instructions for care, prescriptions, etc. Annual Assessment – 99318 Annual assessment required by law The next category of evaluation and management is Nursing Facility Services. The guidelines pertain to care that is given in a nursing facility as well as services provided to a patient in a psychiatric residential treatment center. Nursing Facility services are divided into initial care and subsequent care. This section does not distinguish between new and established patients. Services performed at other sites of services performed in conjunction with the admission are considered inclusive and included in the Nursing Facility admission. Exceptions to this are hospital discharge and observation discharge services billed on the same date. These services may be reported separately. There are parenthetical instructions telling us to see and for Nursing Facility discharge services. Let’s move now to the Nursing Facility Discharge Services. When a patient is discharged from a nursing facility, all services provided on that date are included in the time used to report the discharge from the nursing facility. Much like discharge from hospital admission, this includes instructions for care, preparation of discharge papers, prescriptions and referral forms in addition to any care given to the patient on that date. The last subcategory under nursing facility is Other Nursing Facility Services. This section includes one code for the annual assessment that is required by law for patients that are in skilled nursing facilities. Every year they have to have a very detailed annual assessment which would be reported with

Domiciliary, Rest Home, or Custodial Care Services
Also includes Assisted Living Physician see patient in one of these types of facilities No medical component Either new patient or established patient The next category of evaluation and management codes are for services provided to patients in domiciliary, rest homes, boarding homes, custodial care services, or assisted living. You may want to make an entry in the alphabetic index in the back of CPT for assisted living. Go to the index to where you would alphabetically locate assisted living, and write in “assisted living” and the codes you would reference. This section of services is used when a physician sees the patient in one of these types of facilities. One of the differences with these types of facilities versus a nursing facility is there is no medical component to the care. The codes are divided into whether the patient is a new patient or an established patient. This category is not to be confused with the services covered by the next category of codes.

Domiciliary, Rest Home, or Home Care Plan Oversight Services
Physician provides oversight of the patient’s care plan Review the case management plan Write new orders Make a new care plan Care plan oversight services are used when the physician provides the oversight of the patient’s care plan. A physician will review the case management plan for the patient and any test results. Although there is not daily nursing care for patients in these types of facilities, the physician will check with the workers to see if they have noticed anything out of order, such as increased disorientation or skipping meals. The patients are typically on medication under the care of their physician and the physician will review what is planned for this patient. The physician may write new orders or will make a new care plan for the patient. This service is billed in increments of time.

Home Services & Prolonged Services
Seen in home by physician Separated by new and established patient Prolonged Services Direct patient contact or without direct patient contact Settings are office/outpatient and inpatient Most are add-on codes Exception is Physician Standby Code Our next category is home services. There aren’t many physicians who do home visits but there are still a few. When the patient is seen in their home by a physician, you would look in this subsection of codes to report the services. Home visit, or private resident codes are divided into subcategories for new and established patients. The next category of codes is Prolonged Services. Prolonged physician services are separated between with direct patient contact and without direct patient contact. They are further subdivided between office or outpatient services and services provided in an inpatient setting. Most of the codes in this section are add-on codes. The only exception is the physician standby services code, which may be reported independently of other codes.

Prolonged Services Guidelines
Physician provides prolonged service with direct face-to-face contact beyond usual service Reported in addition to other physician services Report total duration of face-to-face time; even if time is not continuous Similar to critical care in this manner are used for prolonged service without patient contact Let’s take a careful look at the guidelines so that we can understand how to use these codes appropriately. Prolonged physician service codes are used when a physician provides prolonged service involving direct face-to-face patient contact that is beyond the usual service. The services reported in addition to other physician services including evaluation and management services at any level. Additional appropriate codes should be selected for supplies provided or procedures performed in the care of the patient during this period. The codes for prolonged physician service with direct physician contact are used to report the total duration of face-to-face time spent by a physician, on a given date, providing prolonged services. Even if the time spent on that date is not continuous. This type of service is similar to the critical care in that it's not necessarily going to be time that is spent continuously. The time may be interrupted. Codes – are used to report prolonged physician service without direct patient contact.

Physician Standby Used to report time when a physician is on standby at the request of another physician Only report for more than 30 minutes duration Reported with additional units for each additional 30 minutes Do not report if the period of standby results in the performance of a procedure The last code in this category is for Physician Standby Services. Physician Standby services are used to report time when a patient is on standby at the request of another physician. This service is only reported for more than 30 minutes in duration, and is reported with additional units for each additional 30 minutes. The guidelines for Physician Standby Services say not to use this code if the period of standby ends with the performance of a procedure subject to a "surgical package" by the physician who is on standby. The "surgical package" concept applies to surgical procedures that include the operation itself, local anesthesia, and typical follow-up care. An example would be of a cardiothoracic surgeon standing by during an echocardiography that resulted in emergency open heart surgery. The cardiothoracic surgeon would not code for the standby time.

Case Management & Medical Team Conference
Case Management Services Anticoagulant Management Receive INR testing Alter dosage 99363 for initial 90 days 99364 for each subsequent 90 days Medical Team Conference Requires three healthcare professionals Divided by direct contact or without direct contact The next category is Case Management Services. CPT defines case management as “a process in which a physician or another qualified health care professional is responsible for direct care of a patient and, additionally, for coordinating, managing access to, initiating, and/or supervising other health care services needed by the patient. The first case management section is anticoagulant management. Patients on anticoagulation medication, such as Coumadin, require constant assessment. They are assessed for bruising, asked questions about their diet, and receive INR testing to evaluate the effectiveness or over-effectiveness of the medication. The dosage of the medication is constantly altered. The management of a patient on anticoagulation therapy is reported with for the initial 90 days, and for each subsequent 90 days. This set of codes is used for outpatient services only. The second case management section is Medical Team Conferences. This service is divided by with direct contact with the patient and/or family and without direct contact with the patient and/or family. The Medical Team Conference requires a minimum of three qualified health care professionals from different specialties or disciplines.

Care Plan Oversight Services
Home Health Agency Hospice Nursing Facility Billed on a monthly basis For the amount of time physician spends overseeing care of patient The next category of codes for evaluation and management services is Care Plan Oversight Services. Care Plan Oversight Services are billed on a monthly basis for the amount of time a physician spends overseeing the care of a patient. The location of the patient and the time spent drives the codes selection. The locations include home health agency, hospice, and nursing facility. You may want to go through these codes and highlight the location referenced in each code.

Preventive Medicine Services
Annual Physical Exam Divided by new and established patient and by patient’s age If abnormality is encountered and is significant to require additional work Appropriate code from reported with modifier 25 appended to the office/outpatient code The next category for evaluation and management is Preventive Medicine Services. Preventive Medicine Services are used when a patient is not ill, but coming for an annual physician exam. The codes are divided between new and established patients, and then are selected based on the patient’s age. If the patient presents for preventive medicine service and an abnormality is encountered or a pre-existing problem is addressed, and the abnormality or problem is significant enough to require additional work to perform the key components of a problem-oriented evaluation and management code, the appropriate code from through should be reported in addition to the preventive medicine service. Modifier 25 would be appended to the Office or Outpatient code.

Counseling Risk Factor Reduction and Behavior Change Intervention
For patient without symptoms or established illness No distinction between new and established patient Preventive Medicine, Individual Counseling Behavior Change Intervention Preventive Medicine, Group Counseling Following the new and established patient preventive medicine codes is the subcategory for Counseling Risk Factor Reduction and Behavior Change Intervention. In this subcategory, there is no distinction made between new and established patients. This set of codes is further divided between Preventive Medicine Counseling and Behavior Change Interventions. These services are intended for patients without symptoms or established illnesses. Preventive Medicine Counseling is used when addressing issues on family problems, diet and exercise, substance use, sexual practices, injury prevention, etc. An example of this might be when a patient visits the doctor and is shown how to lift and carry items correctly to protect their back. The patient does not currently have an injury, but wants to be sure they know how to avoid one. Preventive Medicine Counseling services can be reported for the individual with codes – 99404, or for a group with codes & The second section addresses visits for Behavior Change Interventions. Behavior Change Intervention codes are used when a patient is being counseled on behavior, such as tobacco use addiction, or alcohol abuse. This code set is chosen based on the addiction and the time spent counseling.

Non-Face-to-Face Physician Services
Telephone Services Must be provided by a physician Based on amount of time Patient must be established On-Line Medical Evaluation Reported only once for the same episode of care during a 7-day period The next category in evaluation and management includes codes for non-face-to-face physician services. This set of codes addresses advances in technology for the treatment of patients. Non-face-to-face services include telephone services and on-line medical evaluation. The telephone service codes are selected based on the amount of time spent on the phone with the patient. The patient must be an established patient for telephone service codes to be reported. The online medical evaluation is reported only once for the same episode of care during a seven day period. There are a few important details to keep in mind. The services must be provided by a physician. Services for telephone and online evaluation by a non-physician practitioner are reported with codes from the medicine section. If the phone call refers to an E/M visit performed within the previous 7 days, or within the post-op period of a surgery, it can not be reported; and if the phone call results in a visit to the physician within the next 24 hours, or next available urgent visit, it is not reported.

Special Evaluation and Management Services
Basic Life and/or Disability Evaluation Services Work Related or Medical Disability Evaluation Services Specific guidelines under each code The next category in evaluation and management services is Special evaluation and management services. These services include Basic Life and/or Disability Evaluation Services and Work Related or Medical Disability Evaluation Services. There are specific guidelines listed under each code that must be met.

Newborn Care Services Newborn Care Services
Newborn care age 28 days or less Separated by location and by initial or subsequent visits Delivery or Birthing Room Attendance and Resuscitation Services Attendance at delivery at request of delivering physician The next category is Newborn Care Services. Newborn Care Services are separate from other hospital care codes, although they are often provided in the hospital. Newborn care codes are provided to newborns, age 28 days or less. This is the care provided to a newborn typically by a pediatrician to evaluate the health of the newborn. They are separated be location and by initial and subsequent visits. Within Newborn Care Services, there are also Delivery or Birthing Room Attendance and Resuscitations Services. Attendance at delivery should only be used when requested by the delivering physician. If the delivering physician believes there is risk to the newborn, they may request a pediatrician be there for the delivery for immediate attention to the newborn.

Inpatient Neonatal Intensive Care Services Pediatric & Neonatal Critical Care Services
Pediatric Critical Care Patient Transport Inpatient Neonatal and Pediatric Critical Care Initial and Continuing Intensive Care Services Inpatient Neonatal Intensive Care Services and Pediatric and Neonatal Critical Care Services is further divided into: Pediatric Critical Care Patient Transport, Inpatient Neonatal and Pediatric Critical Care; and Initial and Continuing Intensive Care Services.

Pediatric Critical Care Patient Transport
Physician physically present during inter-facility transport of a critically ill patient 24 months of age or less Time: Starts when physician assumes responsibility Ends when receiving facility accepts responsibility Pediatric Critical Care Patient Transport Codes are to be reported when a physician is in physical attendance during the inter-facility transport of a critically ill or critically injured patient 24 months of age or less. The guidelines tell us that face-to-face time starts when the physician assumes primary responsibility of the pediatric patient and ends when the receiving facility accepts responsibility for the patient’s care. If this amount of time is less than 30 minutes, it is not reported with or 99467, but should be reported with the appropriate evaluation and management code. CPT code is for minutes of hands on care and CPT code is for each additional 30 minutes.

Inpatient Neonatal and Pediatric Care Services
Critically ill or injured patients through age five years Includes same procedures listed in critical care codes Guidelines list additional procedures included in this set of codes Inpatient Neonatal and Pediatric Care Services are used to report services provided to critically ill or critically injured patients through age 5. The pediatric and neonatal critical care codes include the same procedures listed as included in the critical care codes & Your guidelines also list additional procedures included in this set of codes. You may want to highlight this paragraph. I took a highlighter, placed a bracket around the paragraph listing the included procedures and wrote “included services” along the side of the bracket. This will be an important paragraph to reference when billing for these services.

Inpatient Neonatal and Pediatric Care Services
Defined by age of patient: Neonates 28 days of age or less Infant or young child 29 days through 24 months of age Young child two through five years of age Inpatient neonatal and pediatric care services are defined by the age of the patient. There are initial and subsequent codes for: Neonates 28 days of age or less, Infant or young child 29 days through 24 months of age; and Young child 2 through 5 years of age.

Initial and Continuing Intensive Care Services
Used to report services to a child who is not critically ill – but requires intensive observation and frequent interventions 99477 used for Initial Hospital Care used for Subsequent Intensive Care Code selection based on the present body weight of the child Finally, in this subsection, we have Initial and Continuing Intensive Care Services. This section of codes is used to report services to a child who is not critically ill, but requires intensive observation, frequent interventions, and other intensive care services. CPT code is used for the Initial Hospital Care. Codes through are used for Subsequent Intensive care and are selected based on the present body weight of the infant.

Evaluation and Management Coding Leveling
Select the category or subcategory of service and review the guidelines; Review the level of E/M service descriptors and examples; Determine the level of history; Determine the level of exam; Determine the level of medical decision making; and Select the appropriate level of E/M service. Now that we have gone through steps one and two, we are ready to look at how to level an E/M services.

E/M Leveling 1995 vs. 1997 Guidelines Seven components to consider
Main difference – exam component Seven components to consider Relates to the level of work performed by the physician History Exam Medical Decision Making Counseling Coordination of Care Nature of Presenting Problem Time The AMA and CMS worked together to come up with guidelines for determining the level of a visit. One set of guidelines came out in 1995, referred to as the 1995 E/M Guidelines. Many specialist disagreed with this method of calculating the level of a visit as they tend to specialize on one area of the body. In 1997, another set of guidelines were released which are more specific to the type of exam being rendered. This set of guidelines is referred to as the 1997 Guidelines. Providers may use either set of guidelines to level an evaluation and management service. In addition, the Medicare carriers and other commercial payers may set their own versions of these guidelines. We are not going to cover both sets of guidelines in this lecture; however, it is important for you to read through both sets of guidelines. The level of visit can be determined by taking into consideration 7 components: History; Exam; Medical Decision Making; Counseling; Coordination of Care; Nature of Presenting Problem; Time.

E/M Leveling Key Components
Generally the influential factors in determining level of service History Exam Medical Decision Making Influential in the level of service unless counseling dominates the encounter Categories/subcategories describe the number of key components required The first three components - History, Exam, and Medical Decision Making- are considered key components. The 7 components relate to the level of work performed by the physician. The key components are generally the influential factors in the level of service, unless counseling dominates the time of the service. Each of the 7 components are referred to in most of the descriptors of the codes in evaluation and management services. A number of categories and subcategories of codes require meeting or exceeding all three key components while others only require two of the three key components. As an example, if you look at code 99201, the description is, “Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components”. When you look at the description is “Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components”. This is something you may want to highlight in your CPT book. Let’s discuss each key component and the contributing components.

History History of Present Illness (HPI)
Chronological description of the patient’s illness Location Quality Severity Timing Context Modifying factors Associated sign and symptoms The patient history is information communicated to the physician by the patient. This information is considered subjective because it comes from the subject. The components of the patient history are the chief complaint, history of present illness, review of systems, and the past, family, and social history. The history of present illness (HPI) is a description of the patient’s illness from the first onset of symptoms to the present. An assessment of the HPI results in either a brief HPI or an extended HPI. A brief HPI consist of up to three elements, and an extended HPI consist of four or more elements. When looking at the HPI, eight elements may be considered or addressed. They are: Location—The location determines the area of the body where the problem, pain, and discomfort occurs. Asking the questions such as “Where does it hurt?” and “Where did it happen?” Quality—The quality of the symptoms may be characterized by the sensation the patient is experiencing. The quality may depict pain as stabbing, throbbing, dull or sharp. Severity—The severity is used to describe the level or degree of the presenting problem. A common gauge of severity uses a scale of one to 10 with one being the lowest and 10 being the highest gauge of pain or severity. It is also possible the severity can be stated as a descriptor such as intense pain. Duration—The duration describes when the symptoms first occurred up to the present encounter. This is often stated in time increments such as hours, days, weeks, and months. Timing—The timing can further describe the signs or symptoms as to whether the problem occurs intermittently or is related to a specific time of day. Context—The context describes the situation surrounding the problem, episode, or condition such as how did it happen. An example would be “I injured my ankle while playing basketball”. Modifying Factors—These are remedies or interventions the patient has done for the specific problem/symptom to relieve the discomfort. A modifying factor can be related to a medication, therapy, dietary modifications. Associated Signs and Symptoms— Are additional problems associated with the symptoms the patient presents with. This information may help in identifying a new disease process or underlying problems related to the existing problem.

History Review of Systems (ROS) Inventory of body systems
Constitutional Eyes Ears, nose, mouth, throat Cardiovascular Respiratory Gastrointestinal Genitourinary Muscloskeletal Integumentary Neurological Psychiatric Endocrine Hematologic/lynphatic Allergic/Immunologic The ROS is an inventory of body systems obtained by asking the patient questions about the signs and/or symptoms the patient is experiencing. CPT identifies 14 elements of a system review. The following is a list of these elements with examples: Constitutional –Patients may report symptoms such as fever, recent weight changes, hot flashes, weakness, fatigue, etc. Eyes – Any questions about glasses or contact lenses, last eye exam, vision, blurring or redness are commonly asked in this area. Ears, nose, mouth, throat – Questions about hearing, tinnitus, sinus congestion, nosebleeds, difficulty swallowing, tenderness of gums are some examples. Cardiovascular – This system consists of the heart, veins, and arteries. Symptoms might include chest pain, tachycardia or high blood pressure or edema Respiratory – The respiratory system focuses on the lungs and the exchange of oxygen throughout the body. Cough, sputum, shortness of breath and wheezing are some of the common complaints Gastrointestinal –Accessory organs such as the liver and spleen are also included in this system. Symptoms including nausea and vomiting, change in bowel habits, food intolerance, and jaundice may be reviewed here. Genitourinary - Symptoms such as difficult or painful urination, stress incontinence, burning and frequency during urination are all common complaints. Female symptoms might include irregularity of menses, pain during intercourse, bleeding unrelated to menses, and/or problems associated with the onset of menopause. Problems such as impotence or a painful injury to the testes are symptoms commonly related in an assessment of the male reproductive organs. Musculoskeletal – The musculoskeletal system focuses on the muscles and bones of the body. Some symptoms are joint pain, arthritis, muscle pain, or pain in movement. Integumentary – The integumentary system refers to the skin and/or breasts. The provider may ask about rashes, irritations, abnormal growths. There may also be a review of self breast examination occurrences and masses, discharge, or tenderness in the breasts. Neurological - Symptoms or conditions relating to the central and peripheral nervous system are referenced here. They might include loss of sensation to a particular body part, loss of consciousness, seizures, and/or aphasia, as well as numbness and tingling. Psychiatric – A psychiatric review might reveal nervousness, mood, insomnia, or depression. Endocrine - This system is comprised of glands and the interaction of hormones. Symptoms usually address the over or under functioning of a gland and its hormones. A physician might ask about thyroid trouble, excessive sweating, thirst, hunger, or urination. Hematologic/lymphatic - Common problems associated with the lymphatic system might be edema and swollen or tender lymph nodes. Symptoms might include problems with easy bruising, frequent infections and fatigue. Allergic/immunologic – This system focuses on the ability of the body to fight disease and its sensitivity to antigens. Questions for this system will focus around environmental allergens, asthma, or urticaria.

History A single element cannot count towards the HPI and the ROS for the same patient encounter Example Knee pain counted as location for HPI Knee pain cannot count as musculoskeletal for ROS The amount of information obtained and documented determines the extent of the review of systems. There are three categories: A problem pertinent ROS is the positive and/or negative responses for at least one system related to the problem. An extended ROS is the positive and/or negative responses for two to nine systems directly related to the problem. A complete ROS is the positive and/or negative responses for all additional body systems related to the problem. At least 10 systems must be individually noted It is important to understand that if an element is counted as a part of the HPI it cannot be counted as an element of the ROS – or vice versa. For example, if part of a patient’s HPI is knee pain (location) we cannot count the knee pain again as part of the musculoskeletal element for the ROS.

History Past, Family and/or Social History (PFSH) Past History
Review of patient’s past illnesses, operations, etc Family History Review of patient’s parents/siblings Social History Review of social factors, marital status, alcohol/drug habits The past, family and/or social history provides a review of the patient’s past medical history, the patient’s family health status, and appropriate age-related social history. The past history includes a review of the patient’s past experiences with illness, operations, injuries, and treatments. It also includes allergies to medications and food. The family history includes a review of the patient’s parents and siblings. The review includes their health status or cause of death, and any hereditary diseases they may have. The social history includes a review of the patient’s external social factors that may have an affect on their health, such as marital status, exercise habits, the use of alcohol or drugs. It will also include developmental information about school, occupation, or living arrangements. Past, family, and/or social history are determined in two levels: Pertinent PFSH, which describes one of the three components Complete PFSH, which describes one from each of the three elements of PFSH patient, family and social history

History History of Present Illness (HPI) Review of Systems (ROS)
Past, Family, and/or Social History (PFSH) Level of History Brief (1-3 elements) No ROS No PFSH Problem Focused Problem Pertinent (1 system) Expanded Problem Focused Extended (4 or more) Extended (2-9 systems) Pertinent (1 history) Detailed Complete (10 or more) (2-3 history areas) Comprehensive Once the level of the history of present illness, review of systems, and past, family, and/or social history is determined, the level of history can be determined using this table.

History CC: Cough HPI: This 2-year-old patient presents with a barking cough occurring at night for the last two days. ROS: The patient has had a runny nose, no ear pain and a slight fever. No complaints of chest pain. PFSH: The patient is up to date on all immunizations and currently takes Zyrtec daily. No known allergies to medications. Let’s look at an example. Here in the HPI, we have three elements. It is a barking cough which gives us quality, it occurs at night which gives us timing, and has been for the last two days, which is duration. For the Review of Systems, the systems reviewed are ears and nose, which count as one together, constitutional for the fever, and respiratory for the chest pain. So we have three components for the review of systems. For the past medical, family, and social history, the provider has reviewed the past medical, giving us one component.

Past, Family, and/or Social History (PFSH) Level of History Brief (1-3 elements) No ROS No PFSH Problem Focused Problem Pertinent (1 system) Expanded Problem Focused Extended (4 or more) Extended (2-9 systems) Pertinent (1 history) Detailed Complete (10 or more) (2-3 history areas) Comprehensive Now, we use the grid to put it all together. We had 3 for the HPI, 3 for the review of systems, and 1 for the past, family, and social history. To reach the level of history, we must meet or exceed all components.

Past, Family, and/or Social History (PFSH) Level of History Brief (1-3 elements) No ROS No PFSH Problem Focused Problem Pertinent (1 system) Expanded Problem Focused Extended (4 or more) Extended (2-9 systems) Pertinent (1 history) Detailed Complete (10 or more) (2-3 history areas) Comprehensive The highest level of history we meet or exceed all components for is expanded problem focused. So we have an expanded problem focused level of history.

Exam Examination – may be body areas or organ systems Body Areas
Head, including face Neck Chest, including breasts Abdomen Genitalia, groin, buttocks Back, including spine Each extremity The next key component to consider is the examination. The exam may be of body areas or organ systems. The following body areas are recognized: Head, including the face; Neck; Chest, including breasts and axilla; Abdomen; Genitalia, groin, buttocks; Back, including spine; and each extremity.

Exam Examination (cont) Organ Systems Eyes
Ears, nose, mouth and throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic/lymphatic/immunologic The following organ systems are recognized: Eyes; Ears, nose, mouth and throat; Cardiovascular; Respiratory; Gastrointestinal; Genitourinary; Musculoskeletal; Skin; Neurologic; Psychiatric; Hematologic/lymphatic/immunologic.

Exam Problem Focused – a limited examination of the affected body area or organ system. 1 body area or organ system Expanded Problem Focused – a limited examination of the affected body area or organ system and other symptomatic or related organ system(s). 2 – 7 body areas or organ systems – limited exam Detailed – an extended examination of the affected body area(s) and other symptomatic or related organ system(s) 2 – 7 body areas or organ systems – detailed exam Comprehensive – a general multi-system examination or complete examination of a single organ system 8 or more body areas or organ systems OR complete single organ system The levels of E/M services recognize four types of examination and can be determined again by using a table.

Exam Constitutional: Vital Signs: Resp: 26. Temp: Weight: 41 lbs. HEENT: PERRLA Ears negative. Nares wet with clear rhinorrhea. Throat red and swollen. Respiratory: No Rhonchi or rales. Skin: Negative Let’s continue with our 2-year-old patient. Here we have five organ systems reviewed. One is Constitutional, two is the eyes, three is ears, nose, and throat, four is respiratory, and five is skin.

Exam Problem Focused – a limited examination of the affected body area or organ system. 1 body area or organ system Expanded Problem Focused – a limited examination of the affected body area or organ system and other symptomatic or related organ system(s). 2 – 7 body areas or organ systems – limited exam Detailed – an extended examination of the affected body area(s) and other symptomatic or related organ system(s) 2 – 7 body areas or organ systems – detailed exam Comprehensive – a general multi-system examination or complete examination of a single organ system 8 or more body areas or organ systems OR complete single organ system We have five elements that were examined. Looking at our chart, both the expanded problem focused and the detailed exams have two to seven systems. The difference in the exams is one is detailed and one is limited. For this chart, we will say the exam is limited. This gives us an expanded problem focused exam.

Medical Decision Making
Thought process of the physician throughout the visit Three elements to consider Number of management options Minimal, limited, multiple, extensive Amount and/or complexity of date to be review Minimal or none, limited, moderate, extensive Risk of complications, morbidity, and/or mortality Minimal, low, moderate, high The last key component is medical decision making and it consists of the thought process of the physician throughout the visit. You can follow along in your CPT book by referencing Table 1 Complexity of Medical Decision Making. When determining the level of medical decision making, three elements are taken into consideration: Number of Diagnoses or Management Options, Amount and Complexity of Data to be Reviewed, and the Risk of Significant Complications, Morbidity, and Mortality. The number of diagnoses or management options is based on the number of diagnoses to consider, along with the status of the diagnoses or suspected diagnoses. The levels of diagnoses or management options include minimal which is a self-limited or minor problem, established stable or resolved problem. There is limited which is one to two established problems that are stable, improved, or resolving. There is multiple which is two to three problems worsening or exacerbated or a new problem with no additional work-up planned. And there is extensive which is three or more diagnoses, or a new problem with additional work-up planned. The amount and complexity of data to be reviewed involve the type of data and the review of the data. Types of data include diagnostic testing, old medical records, and history from a source other than the patient. Levels of Amount and Complexity of Data to be reviewed include: Minimal or none, Limited, Moderate, Extensive The assessment of risk is based on the risk of significant complications, morbidity, and/or mortality, as well as co morbidities associated with the patient’s presenting problems, the diagnostic procedures and/or the possible management options.

# of dx or mgmt options Amt and/or complexity of data Risk of Complications Type of Decision Making Minimal Minimal or none Straightforward Limited Low Low complexity Multiple Moderate Moderate complexity Extensive High High complexity This table mirrors Table 1 in CPT and reflects the four types of medical decision making. The highest level of risk in any one category determines the overall level of risk component, not the overall MDM level. To qualify for a given type of decision making, two of the three elements in the table must be met or exceeded. Once you have determined the level of diagnoses or management options, data to be reviewed and the level of risk, you can use the table below to determine the level of medical decision making.

CC: Cough HPI: This 2-year-old patient presents with a barking cough occurring at night for the last two days. ROS: The patient has had a runny nose, no ear pain and a slight fever. No complaints of chest pain. PFSH: The patient is up to date on all immunizations and currently takes Zyrtec daily. No known allergies to medications. Constitutional: Vital Signs: Resp: 26. Temp: Weight: 41 lbs. HEENT: PERRLA Ears negative. Nares wet with clear rhinorrhea. Throat red and swollen. Respiratory: No Rhonchi or rales. Skin: Negative A&P: Croup – use cold air humidifier, return to clinic if this has not resolved by next week. In the grid for Medical Decision Making, you must meet or exceed two of the three columns to meet the level of medical decision making. This gives us a straightforward medical decision making.

# of dx or mgmt options Amt and/or complexity of data Risk of Complications Type of Decision Making Minimal Minimal or none Straightforward Limited Low Low complexity Multiple Moderate Moderate complexity Extensive High High complexity In the grid for Medical Decision Making, you must meet or exceed two of the three columns to meet the level of medical decision making. This gives us a straightforward medical decision making.

E/M Leveling Contributing Components
Counseling: risk factor reduction, patient/family education Coordination of Care: arrange follow up treatment not typically provided by the provider, eg., physical therapy Nature of Presenting Problem: Taken into consideration in the medical decision making portion of the encounter Time: If counseling/coordination of care dominates more than 50 percent of encounter, time may be considered as the controlling factor Once you have selected the level of history, exam, and medical decision making, you can select the level of service. Within each level of visit there are requirements for that level. As we discussed earlier, the codes will tell you if two of three components or three of three components are required. There are additional components that may affect the level of service. These include Counseling or Coordination of Care, Nature of Presenting Problem, and Time. Counseling refers to providing professional advice and/or instruction. CPT® lists the following activities as counseling: risk factor reduction, patient and family education, discussion and education of the importance of treatment compliance, education on disease or injury management, discussion regarding prognosis, discussion of diagnostic findings and risk and benefit analysis of management options. Providers often spend time arranging for follow-up treatment, care, consultations and other services not typically provided by the provider making these arrangements. The time spent in these endeavors is considered coordination of patient care with outside agencies and providers. A presenting problem is a disease, condition, illness, injury, symptom, sign, finding, complaint or other reason for encounter with or without a diagnosis being established at the time of the encounter. The levels of the nature of the presenting problem are taken into consideration in the medical decision making portion of the encounter. The final and most significant contributing factor is time. In instances where counseling and coordination of care dominates more than 50 percent of the encounter, time may be considered the controlling factor in determining the level of service. Time is also a consideration when the provider spends time with parties who have assumed responsibility for the care of the patient. This would include family members, foster parents, or a legal guardian responsible for the decision making of the patient. The extent of the counseling and/or coordination of care must be described in the medical record. Time is also the controlling factor in selecting from one of the following services: Hospital discharge services, Patient transport, Critical care services, Prolonged services, Standby Services, Care plan oversight services If the service is time-based, the documentation in the medical record must state the actual total time spent face-to-face with the patient and the amount of time spent counseling and/or coordinating care. If time is not documented, it would indicate the service took less than 30 minutes. The only exception would be for “hospital discharge.”

Determine the Level of E/M
Established patient office visit table HISTORY Problem focused Expanded problem focused Detailed Comprehensive EXAM MDM Straightforward Low Moderate High LEVEL OF VISIT 99212 99213 99214 99215 Now that we have the level of history, exam, and medical decision making, we can put it all together and determine the level of the visit. For our visit, we had an expanded problem focused history, an expanded problem focused exam, and a straightforward medical decision making.

Category: Office or Other Outpatient Services Subcategory: Established Patient Descriptors: “…which requires at least 2 of these three components.” Now, look in CPT. Find the Category for Office or Other Outpatient Visits. Remember, in the beginning, we said that Office or Other Outpatient Visits were divided into subcategories for New and Established Patients. For this lecture, we will say this is an established patient. You will see in the descriptors of each of the levels that an established patient requires two of the three key components mentioned.

Established patient office visit table HISTORY Problem focused Expanded problem focused Detailed Comprehensive EXAM MDM Straightforward Low Moderate High LEVEL OF VISIT 99212 99213 99214 99215 Looking back at our table, two of the three components meet the level required for a So our level of evaluation and management service for this office visit is a level 3 Established patient office visit which is a

Modifiers Modifier 24 Unrelated evaluation and management service by the same physician during a postoperative period. Modifier 25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service. Modifier 32 Mandated Services Modifier 57 Decision for surgery The most common modifiers used on E/M services are Modifiers 24, 25, 32, and 57. Modifier 24 is appended to the E/M service when they are seen for an unrelated E/M service by the same physician in the post-operative period. Because the services is unrelated to the surgery, it would not be considered part of the global package, and would be separately payable. Modifier 25 is appended to the E/M service when it is performed with a surgery or service that is separately identifiable from the E/M service. The two services can have the same diagnosis code, but they must be separately identifiable. When a provider performs a surgery, the work involved in evaluating the patient pre-surgery is included in the payment for the surgery. Only if work is done outside of the normal evaluation of a patient for that surgery is it separately payable. If you are in doubt of whether the service is separately identifiable, make two notes from it. Pull all of the documentation related to the surgery out of the note, and see if there is enough left for the E/M service. Modifier 32 is appended to services required by a third party, such as a court mandate, or workers’ compensation. Modifier 57 is used when the decision for a surgery is made during the global period. If the patient sees the provider, and the provider decides to perform a major surgery that day, or the next day, a modifier 57 would need to be appended to the E/M visit to show that is when the decision was made. Otherwise, the E/M would be considered part of the global package and not separately payable.

E/M Leveling Many factors to consider when determining a level of Evaluation and Management Service. Be sure to Review the Guidelines and code descriptions. As you can see, determining the level of an evaluation and management service has many factors. Constant review of the CPT guidelines, and practice, will help you with selecting the appropriate code.

Evaluation and Management

Similar presentations

Presentation on theme: "Evaluation and Management"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

Evaluation and Management

Similar presentations

Presentation on theme: "Evaluation and Management"— Presentation transcript:

Similar presentations

About project

Feedback