1 the 99000 e&m codes using dr. quack’s score sheet to understand the evaluation &...

11

The 99000 E&M The 99000 E&M CodesCodes

Using Dr. Quack’s Score Sheet to Using Dr. Quack’s Score Sheet to understand the Evaluation & Management understand the Evaluation & Management CodesCodes

The updated score sheet can be found on The updated score sheet can be found on pages 11 and 12 of pages 11 and 12 of

http://nebraska.aoa.org/documents/ne/2010-05-3RDhttp://nebraska.aoa.org/documents/ne/2010-05-3RD-PARTY-NEWLSETTER.pdf-PARTY-NEWLSETTER.pdf

22

The 99000 E&M CodesThe 99000 E&M Codes

The Quack score sheet we are using The Quack score sheet we are using today can be found on pages 11 and 12 of today can be found on pages 11 and 12 of

http://nebraska.aoa.org/documents/ne/2010-05-3RDhttp://nebraska.aoa.org/documents/ne/2010-05-3RD-PARTY-NEWLSETTER.pdf -PARTY-NEWLSETTER.pdf

The score sheet has been updated from The score sheet has been updated from the hard copy mailed in early May…there the hard copy mailed in early May…there was an omission in the history section (We was an omission in the history section (We can work around it today, however).can work around it today, however).

33

The 99000 E&M CodesThe 99000 E&M Codes

E&M coding is based on 3 key E&M coding is based on 3 key components:components:

1.1. History (There are 4 levels of complexity)History (There are 4 levels of complexity)2.2. Examination (4 levels)Examination (4 levels)3.3. Decision Making (4 levels)Decision Making (4 levels)

First, the level of complexity of each of First, the level of complexity of each of these components is determined.these components is determined.

Then the final level of service is Then the final level of service is determined, based on those levels of determined, based on those levels of complexity.complexity.

44

The 99000 E&M CodesThe 99000 E&M Codes

Levels of service are scored differently for Levels of service are scored differently for New vs. Established patients.New vs. Established patients.For New Patients, the complexity of theFor New Patients, the complexity of the

History, History, Exam, and Exam, and Decision making Decision making

……must all three be considered.must all three be considered.

55

The 99000 E&M CodesThe 99000 E&M Codes

For Established patients, only two of the For Established patients, only two of the three key components must be three key components must be considered. considered. However, it is best to ALWAYS consider However, it is best to ALWAYS consider

Decision Making.Decision Making. THE RESULTING CODE MUST BE THE RESULTING CODE MUST BE

REASONABLE AND NECESSARY. The REASONABLE AND NECESSARY. The Decision Making Score helps assure that is Decision Making Score helps assure that is the case.the case.

66

Key Component #1: HistoryKey Component #1: History

Made up ofMade up ofChief ComplaintChief ComplaintHistory of Present Illness (HPI)History of Present Illness (HPI)Review of Systems (ROS)Review of Systems (ROS)Past, Family, & Social History (PFSH)Past, Family, & Social History (PFSH)

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http://nebraska.aoa.org/do

cuments/ne/2010-0

5-3RD

-PA

RT

Y-N

EW

LSE

TT

ER

.pdf

Link on slides 1 & 4

88

Chief Complaint A brief explanation of why patient is in the office.

Examples of medically necessary: Change in vision, poor vision, blurred vision Eye pain Evaluation of:

cataracts macular degeneration glaucoma

Examples of not medically necessary Routine exam Checkup No complaint Need new glasses

99

1010

History of Present IllnessHistory of Present Illness Made up ofMade up of

LocationLocation [example: “od”, “os”, “ou”, “upper”…][example: “od”, “os”, “ou”, “upper”…] Quality Quality [“sharp”, “dull”, “stabbing”...][“sharp”, “dull”, “stabbing”...] SeveritySeverity [“mild”, “severe”….][“mild”, “severe”….] DurationDuration [“short”, “constant”, “hour or so”…][“short”, “constant”, “hour or so”…] TimingTiming [“morning”, “nighttime”...][“morning”, “nighttime”...] ContextContext [“driving”, “reading”…][“driving”, “reading”…] ModifyingModifying FactorsFactors [“bright light”, “when tired”…][“bright light”, “when tired”…] AssociatedAssociated Signs & SymptomsSigns & Symptoms [“headache”…][“headache”…]

  OR OR ThreeThree Chronic or inactive conditionsChronic or inactive conditions 1.____________1.____________[AMD…][AMD…] 2.____________2.____________[Cataract…][Cataract…] 3.____________ 3.____________ [EBMD…][EBMD…]

1111

1212

Review of SystemsReview of Systems Made up ofMade up of

Constitutional Constitutional (weight loss, etc.)(weight loss, etc.)

Eyes Eyes Ears, Nose, Mouth, Ears, Nose, Mouth,

ThroatThroat Cardiovascular Cardiovascular Gastrointestinal Gastrointestinal Genitourinary Genitourinary Integumentary (skin, Integumentary (skin,

breast)breast)

Musculo-skeletalMusculo-skeletal NeurologicalNeurological Hematologic Lymphatic Hematologic Lymphatic RespiratoryRespiratory EndocrineEndocrine Allergic ImmunologicAllergic Immunologic PsychiatricPsychiatric All others negative (= All others negative (=

9)9)

1313

1414

1515

1616

Past, Family, Social HistoryPast, Family, Social History

1717

1818

http://nebraska.aoa.org/documents/ne/2010-05-3RD-PARTY-NEWLSETTER.pdf

1919

2020

2121

Key Component #2: ExaminationKey Component #2: Examination Made up ofMade up of

AcuityAcuity Adnexae, lids, lacrimal Adnexae, lids, lacrimal

sys, pre-auriclar nodessys, pre-auriclar nodes CorneaCornea IOTIOT Confrontation FieldsConfrontation Fields Conjunctiva, bulbar & Conjunctiva, bulbar &

palpebralpalpebral A/CA/C Retina, vessels, Retina, vessels,

exudates, hemorrhages exudates, hemorrhages (dilated) (dilated)

Ocular MotilityOcular Motility Pupil/Iris, APDPupil/Iris, APD LensLens Disc, Cup, NFL (Disc, Cup, NFL (dilateddilated))

Systemic elements that Systemic elements that briefly assess mental status briefly assess mental status or general constitutionor general constitution

Oriented to time/location & Oriented to time/location & moodmood

General ConstitutionGeneral Constitution

2222

2323

2424

2525

2626

Key Component #3:Key Component #3:Decision MakingDecision Making

Made up ofMade up ofDiagnosis and Management OptionsDiagnosis and Management OptionsData ComplexityData ComplexityRiskRisk

Very Important: Can be used to determine Very Important: Can be used to determine whether the ultimate level of service is whether the ultimate level of service is truly “REASONABLE AND NECESSARY”truly “REASONABLE AND NECESSARY”

2727

2828

2929

3030

3131

3232

3333

Am I Going to Need to Use One of Am I Going to Need to Use One of These Forms For Every 99000 Exam?These Forms For Every 99000 Exam?

Nope. Once you’ve done a number of Nope. Once you’ve done a number of them, you’ll know intuitively what to bill on them, you’ll know intuitively what to bill on almost all of the more common diagnoses.almost all of the more common diagnoses.

Keep the forms available for the unusual Keep the forms available for the unusual situations, however. situations, however.

Now, for some examples………….Now, for some examples………….

3434

Example Case #1Example Case #1

24 YOWM scratched R eye with branch while mowing this morning; blurred vision, mild, scratchy red

eye..

3535

24 yowm scratched R eye with branch while mowing this

morning; blurred vision, mild, scratchy red eye..

3636

3737

3838

3939

mild corneal abrasion 1 1

1

0

4040

4141

Example Case #2Example Case #2

F/U visit: 24 YOWM scratched R eye with branch while mowing yesterday; vision much better, no pain, little redness

4242

F/U visit: 24 YOWM scratched R eye with branch while mowing yesterday; vision much better, no pain, little red

4343

4444

4545

4646

mild corneal abrasion 11

1

0

4747

4848

Example Case #3Example Case #3

67 YOBF c/o blurred VA OU, worse in pm when driving, gradual onset; glare & sun a problem.

4949

67 YOBF c/o blurred VA OU, worse in pm when driving, gradual onset; glare & sun a problem.

5050

5151

5252

5353

ns cataract OU 1 3

0

3

5454

The 99000 E&M CodesThe 99000 E&M Codes

For Established patients, only two of the For Established patients, only two of the three key components must be three key components must be considered. considered. However, it is best to ALWAYS consider However, it is best to ALWAYS consider

Decision Making.Decision Making. THE RESULTING CODE MUST BE THE RESULTING CODE MUST BE

REASONABLE AND NECESSARY. REASONABLE AND NECESSARY. The Decision Making Score helps assure that The Decision Making Score helps assure that

is the case.is the case.

5555

THE RESULTING CODE MUST BE REASONABLE AND THE RESULTING CODE MUST BE REASONABLE AND NECESSARY. NECESSARY. The Decision Making Score helps assure that is the case.The Decision Making Score helps assure that is the case.

5656

Example Case #4Example Case #4

68 YOBF c/o blurred VA OU, Hx cataract, dry AMD, Narrow angle, EBMD; 6 mo evaluation

5757

68 YOBF c/o blurred VA OU, Hx cataract, dry AMD, Narrow angle, EBMD; 6 mo evaluation

CataractEBMDAMDNarrow Angle

5858

5959

6060

6161

EBMD; AMD; Narrow angle

5

1

0

Cataract 13 3

2

6262

THE RESULTING CODE MUST BE REASONABLE AND THE RESULTING CODE MUST BE REASONABLE AND NECESSARY. NECESSARY. The Decision Making Score helps assure that is the case.The Decision Making Score helps assure that is the case.

6363

Example Case #5Example Case #5

Recently suffers constant, severe HA w/ vomiting; dizzyness; noticed he cannot see to the side OU when driving; Has not seen PCP in 20+ years

6464

Recently suffers constant, severe HA w/ vomiting; dizzyness; noticed he cannot see temporally OU

6565

6666

6767

6868

bitemporal heminopsia; swollen disks 2 8

1

2

8

fields?; OCT? 2

6969

7070

These same E&M codes are also used by These same E&M codes are also used by cardiovascular surgeons, cardiovascular surgeons, neurosurgeons, andneurosurgeons, and other specialties that work with life-threatening other specialties that work with life-threatening situations. situations.

ODs must keep the use of the 5 level codes ODs must keep the use of the 5 level codes in perspective, and use only when justified, in perspective, and use only when justified, which will be rarely, if ever, for most OD which will be rarely, if ever, for most OD practitioners. practitioners.

Should an OD Bill a 5 Level Should an OD Bill a 5 Level E&M Code?E&M Code?

7171

Previous recommendations from our Medicare Previous recommendations from our Medicare carrier: Any 5 level code should include: carrier: Any 5 level code should include:

At least one, preferably two, ancillary tests At least one, preferably two, ancillary tests (fields, photos, OCT etc.), and(fields, photos, OCT etc.), andCorrespondence to the PCP, and Correspondence to the PCP, and Correspondence/referral to a tertiary Correspondence/referral to a tertiary provider.provider.

Should an OD Bill a 5 Level Should an OD Bill a 5 Level E&M Code?E&M Code?

7272

The 99000 E&M CodesThe 99000 E&M Codes

Final outcome is based on what is clearly Final outcome is based on what is clearly documenteddocumented in the record. in the record.

If it wasn’t clearly documented in the If it wasn’t clearly documented in the record, auditors assume it wasn’t done.record, auditors assume it wasn’t done.

Caveat: But never make changes to the record once it is Caveat: But never make changes to the record once it is completed. (i.e., never add or alter anything prior to an completed. (i.e., never add or alter anything prior to an audit.)audit.)

7373

For All Patient Record KeepingFor All Patient Record Keeping

You should have on handYou should have on hand A table of you office’s standard abbreviations A table of you office’s standard abbreviations

available for audits.available for audits. A table of signatures (doctors and assistants) A table of signatures (doctors and assistants)

available for audits.available for audits.

Patient records must be signed (legibly, or at Patient records must be signed (legibly, or at least should match the signature table) and must least should match the signature table) and must be dated. be dated.

Electronic signature okay, stamped signatures Electronic signature okay, stamped signatures are not.are not.

7474

Decision MakingDecision Making

Very Important: use Very Important: use Decision Decision MakingMaking to determine whether the to determine whether the ultimate level of service is truly ultimate level of service is truly “REASONABLE AND NECESSARY“REASONABLE AND NECESSARY””

7575

7676

7777

7878

7979

8080

mild corneal abrasion

1 1 1

0

8181