icd-9, cpt, e&m coding documentation and compliance …or the in-service for the in-service!!

ICD-9, CPT, E&M ICD-9, CPT, E&M Coding Documentation and Coding Documentation and

ComplianceCompliance……or the in-service for the or the in-service for the

in-service!!in-service!!

……You’ve just seen a patient in your You’ve just seen a patient in your office…office…

……and after the examand after the exam You want to get paid You want to get paid

(After all, you need to pay mortgage, food, etc)(After all, you need to pay mortgage, food, etc) Insurance will pay you if…Insurance will pay you if…

You tell the company what you did…AND…You tell the company what you did…AND… You tell the company why you did itYou tell the company why you did it

Types of “Codes”Types of “Codes”

Procedure codesProcedure codes What I did during the visit What I did during the visit Two TypesTwo Types

CPTCPT Evaluation and ManagementEvaluation and Management

ICDICD Why I did it Why I did it The actual diagnosis codeThe actual diagnosis code

……and these and these mustmust make sense together make sense together

ICD codesICD codes

ICD-9ICD-9

ICD CodesICD Codes ICDICD = = International Statistical Classification of International Statistical Classification of

Diseases and Related Health ProblemsDiseases and Related Health Problems Provides codes to classify diseases and a wide variety Provides codes to classify diseases and a wide variety

of signs, symptoms, abnormal findings, complaints, of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or social circumstances and external causes of injury or disease. disease.

Every health condition can be assigned to a unique Every health condition can be assigned to a unique category and given a code, up to six characters long. category and given a code, up to six characters long.

Easy to understandEasy to understand Allows for global (international) understanding of Allows for global (international) understanding of

informationinformation

ICD-9 ICD-9 (9(9thth version- currently one in use) version- currently one in use)

001-139: Infectious and parasitic diseases001-139: Infectious and parasitic diseases 140-239: Neoplasms140-239: Neoplasms 240-279: Endocrine, nutritional, metabolic and immunity disorders240-279: Endocrine, nutritional, metabolic and immunity disorders 280-289: Blood ad blood-forming organs280-289: Blood ad blood-forming organs 290-319: Mental disorders (used by primary care and psych for research. DSM codes 290-319: Mental disorders (used by primary care and psych for research. DSM codes

are used for clinical billing by psychare used for clinical billing by psych) ) 320-359: Nervous system320-359: Nervous system 360-389: Sense organs360-389: Sense organs 390-459: Circulatory system390-459: Circulatory system 460-519: Respiratory system460-519: Respiratory system 520-579: Digestive system520-579: Digestive system 580-629: Genitourinary system580-629: Genitourinary system 630-676: Complications of pregnancy/childbirth630-676: Complications of pregnancy/childbirth 680-709: Skin and subcutaneous tissues680-709: Skin and subcutaneous tissues 710-739: Musculoskeletal system and connective tissue710-739: Musculoskeletal system and connective tissue 740-759: Congenital anomalies740-759: Congenital anomalies 760-779: Certain conditions originating in the perinatal period760-779: Certain conditions originating in the perinatal period 780-799: Symptoms, signs and ill-defined conditions780-799: Symptoms, signs and ill-defined conditions 800-999: Injury and poisoning800-999: Injury and poisoning E and V codes: External causes of injury and supplemental classification E and V codes: External causes of injury and supplemental classification

ICD-9ICD-9

Can list by disease or symptomCan list by disease or symptom Get better reimbursement for more detailGet better reimbursement for more detail Some insurances will only pay for a certain Some insurances will only pay for a certain

number of visits per diagnosisnumber of visits per diagnosis e.g., diabetese.g., diabetes

Large book with diagnostic codes or can get Large book with diagnostic codes or can get on lineon line

http://www.icd9coding1.com/flashcode/home.jhttp://www.icd9coding1.com/flashcode/home.jspsp

ICD-9 codesICD-9 codes

More detail the better….More detail the better….

Break these down further!Break these down further!

Diseases of the circulatory system Diseases of the circulatory system (390-459) (390-459)

Hypertensive disease (401-405)Hypertensive disease (401-405) (401) Essential Hypertension(401) Essential Hypertension

(401.0) Hypertension, malignant(401.0) Hypertension, malignant (401.1) Hypertension, benign (401.1) Hypertension, benign

(402) Hypertensive heart disease(402) Hypertensive heart disease (403) Hypertensive renal disease(403) Hypertensive renal disease

(403.91) Hypertensive renal disease, unspec., w/ renal (403.91) Hypertensive renal disease, unspec., w/ renal failurefailure

(404) Hypertensive heart and renal disease (404) Hypertensive heart and renal disease (405.01) Hypertension, renovascular, malignant (405.01) Hypertension, renovascular, malignant (405.11) Hypertension, renovascular, benign(405.11) Hypertension, renovascular, benign

Endocrine, nutritional and metabolic diseases, Endocrine, nutritional and metabolic diseases,

and immunity disorders (240-279)and immunity disorders (240-279) diseases of other endocrine glands (250-259)diseases of other endocrine glands (250-259) Note: for 250-259, the following fifth digit can be added:Note: for 250-259, the following fifth digit can be added:

(250.x0) Diabetes mellitus type 2(250.x0) Diabetes mellitus type 2 (250.x1) Diabetes mellitus type 1(250.x1) Diabetes mellitus type 1 (250.x2) Diabetes mellitus type 2, uncontrolled(250.x2) Diabetes mellitus type 2, uncontrolled (250.x3) Diabetes mellitus type 1, uncontrolled(250.x3) Diabetes mellitus type 1, uncontrolled

(250) Diabetes mellitus (250) Diabetes mellitus (250.0) Diabetes mellitus without mention of complication(250.0) Diabetes mellitus without mention of complication (250.1) Diabetes with ketoacidosis (250.1) Diabetes with ketoacidosis (250.2) Diabetes with hyperosmolarity (250.2) Diabetes with hyperosmolarity (250.3) Diabetes with other coma (250.3) Diabetes with other coma (250.4) Diabetes with renal manifestations (250.4) Diabetes with renal manifestations (250.5) Diabetes with ophthalmic manifestations (250.5) Diabetes with ophthalmic manifestations (250.6) Diabetes with neurological manifestations (250.6) Diabetes with neurological manifestations (250.7) Diabetes with peripheral circulatory disorder(250.7) Diabetes with peripheral circulatory disorder (250.8) Diabetes with other nonspecified manifestations(250.8) Diabetes with other nonspecified manifestations (250.9) Diabetes with unspecified complication (250.9) Diabetes with unspecified complication

780-799: Symptoms, signs and ill-780-799: Symptoms, signs and ill-defined conditionsdefined conditions

(780) General symptoms (780) General symptoms (780.0) Alteration of (780.0) Alteration of

consciousnessconsciousness (780.01) Coma, nondiabetic, (780.01) Coma, nondiabetic,

nonhepatic nonhepatic (780.02) Mental status (780.02) Mental status

changes changes (780.09) Semicoma, stupor (780.09) Semicoma, stupor

(780.1) Hallucinations(780.1) Hallucinations (780.2) Syncope(780.2) Syncope (780.3) Convulsions(780.3) Convulsions

(780.31) Seizures, (780.31) Seizures, convulsions, febrileconvulsions, febrile

(780.39) Seizures, (780.39) Seizures, convulsions, otherconvulsions, other

(780.4) Dizziness/vertigo, NOS(780.4) Dizziness/vertigo, NOS (780.5) Sleep disturbance, (780.5) Sleep disturbance,

unspec. unspec. (780.53) Hypersomnia, sleep (780.53) Hypersomnia, sleep

apneaapnea (780.53) Sleep apnea w/ (780.53) Sleep apnea w/

hypersomniahypersomnia (780.58) Movement disorder, (780.58) Movement disorder,

sleep related sleep related (780.6) Fever, nonperinatal(780.6) Fever, nonperinatal (780.7) Malaise and fatigue(780.7) Malaise and fatigue (780.8) Sweating, excessive (780.8) Sweating, excessive (780.9) Other general symptoms (780.9) Other general symptoms

(780.92) Crying, infant, (780.92) Crying, infant, excessive excessive

(780.93) Memory loss(780.93) Memory loss (780.94) Early satiety (780.94) Early satiety

CPTCPT

Current Procedural TerminologyCurrent Procedural Terminology

CPTCPT

CPT = Current Procedural TerminologyCPT = Current Procedural Terminology Code Set accurately describes medical, surgical, and Code Set accurately describes medical, surgical, and

diagnostic servicesdiagnostic services Designed to communicate uniform information about Designed to communicate uniform information about

medical services and procedures among physicians, medical services and procedures among physicians, coders, patients, accreditation organizations, and coders, patients, accreditation organizations, and payers for administrative, financial, and analytical payers for administrative, financial, and analytical purposes. purposes.

The current version is the CPT 2008. The current version is the CPT 2008.

CPTCPT

A CPT code is a five digit numeric code that is used A CPT code is a five digit numeric code that is used to describe medical, surgical, radiology, laboratory, to describe medical, surgical, radiology, laboratory, anesthesiology, and evaluation/management services anesthesiology, and evaluation/management services of physicians, hospitals, and other health care of physicians, hospitals, and other health care providers. providers.

There are approximately 7,800 CPT codes ranging There are approximately 7,800 CPT codes ranging from 00100 through 99499. from 00100 through 99499.

Two digit modifiers may be added when appropriate Two digit modifiers may be added when appropriate to clarify or modify the description of the procedure.to clarify or modify the description of the procedure.

Current Procedural TerminologyCurrent Procedural Terminology

Chapter 1: Evaluation and Management Codes Chapter 1: Evaluation and Management Codes (99201-99499)(99201-99499)

Chapter 2: Anesthesia Codes (00100-01999)Chapter 2: Anesthesia Codes (00100-01999) Chapter 3: Surgery Codes (10040-69990)Chapter 3: Surgery Codes (10040-69990) Chapter 4: Radiology Codes (70010-79999)Chapter 4: Radiology Codes (70010-79999) Chapter 5: Pathology/Laboratory CodesChapter 5: Pathology/Laboratory Codes (80049- (80049-

89399)89399) Chapter 6: Medicine Codes (90281-99199)Chapter 6: Medicine Codes (90281-99199) Appendices: Modifiers, Deleted codesAppendices: Modifiers, Deleted codes

V codes: Supplemental classificationV codes: Supplemental classification

V01 Contact with or exposure to communicable diseases V01 Contact with or exposure to communicable diseases V02 Carrier or suspected carrier of infectious diseases V02 Carrier or suspected carrier of infectious diseases V09 Infection with drug-resistant microorganisms V09 Infection with drug-resistant microorganisms V10 Personal history of malignant neoplasm (i.e. cancer) V10 Personal history of malignant neoplasm (i.e. cancer) V16 Family history of malignant neoplasm V16 Family history of malignant neoplasm V17 Family history of certain chronic disabling diseases V17 Family history of certain chronic disabling diseases V20 Health supervision of infant or child V20 Health supervision of infant or child V21 Constitutional states in development V21 Constitutional states in development V22 Normal pregnancy V22 Normal pregnancy

V codes, contV codes, cont V23 Supervision of high-risk pregnancy V23 Supervision of high-risk pregnancy V24 Postpartum care and examination V24 Postpartum care and examination V25 Encounter for contraceptive management V25 Encounter for contraceptive management V28 Encounter for [antenatal] screening of mother V28 Encounter for [antenatal] screening of mother V29 Observation and evaluation of newborns for suspected V29 Observation and evaluation of newborns for suspected

conditions not found conditions not found V30 Single liveborn V30 Single liveborn V31 Twin birth mate liveborn V31 Twin birth mate liveborn V48 Problems with head neck and trunk V48 Problems with head neck and trunk V49 Other conditions influencing health status V49 Other conditions influencing health status V50 Elective surgery for purposes other than remedying V50 Elective surgery for purposes other than remedying

health states health states V51 Aftercare involving the use of plastic surgery V51 Aftercare involving the use of plastic surgery

V codes, contV codes, cont V56 Encounter for dialysis and dialysis catheter care V56 Encounter for dialysis and dialysis catheter care V57 Care involving use of rehabilitation procedures V57 Care involving use of rehabilitation procedures V58 Encounter for other and unspecified procedures and aftercare V58 Encounter for other and unspecified procedures and aftercare V60 Housing, household and economic circumstances V60 Housing, household and economic circumstances V64 Persons encountering health services for specific procedures not V64 Persons encountering health services for specific procedures not

carried out carried out V65 Other persons seeking consultation V65 Other persons seeking consultation V66 Convalescence and palliative care V66 Convalescence and palliative care V67 Follow-up examination V67 Follow-up examination V68 Encounters for administrative purposes V68 Encounters for administrative purposes V69 Problems related to lifestyle V69 Problems related to lifestyle V70 General medical examination V70 General medical examination V71 Observation and evaluation for suspected conditions not found V71 Observation and evaluation for suspected conditions not found V80 Special screening for neurological eye and ear diseases V80 Special screening for neurological eye and ear diseases V81 Special screening for cardiovascular respiratory and genitourinary V81 Special screening for cardiovascular respiratory and genitourinary

diseases diseases V85 Body mass index V85 Body mass index

Relationship between CPT and ICD-9Relationship between CPT and ICD-9

The critical relationship between an ICD-9 code The critical relationship between an ICD-9 code and a CPT code is that the diagnosis supports the and a CPT code is that the diagnosis supports the medical necessity of the procedure. medical necessity of the procedure.

Since both ICD-9 and CPT are numeric codes, health Since both ICD-9 and CPT are numeric codes, health care consulting firms, the government, and insurers care consulting firms, the government, and insurers have all designed software that compares the codes have all designed software that compares the codes for a logical relationship. for a logical relationship. For example, a bill for CPT 31256, nasal/sinus endoscopy For example, a bill for CPT 31256, nasal/sinus endoscopy

would not be supported by ICD-9 826.0, closed fracture of would not be supported by ICD-9 826.0, closed fracture of a phalanges of the foot. a phalanges of the foot.

Such a claim would be quickly identified and rejected.Such a claim would be quickly identified and rejected.

……trivia for boards…trivia for boards…

Health Care Financing Administration (HCFA)Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS)Common Procedural Coding System (HCPCS)

Diagnosis CodesDiagnosis Codes ICD – 9ICD – 9 Creates medical necessityCreates medical necessity

Level I Level I CPTCPT Updated AnnuallyUpdated Annually

Level II (national)Level II (national) HCPCS (A-V)HCPCS (A-V) Alphanumeric SystemAlphanumeric System

Level III (State)Level III (State) Local Codes (W-Local Codes (W-Z)Z)

E & M CodingE & M Coding

Evaluation and ManagementEvaluation and Management

Most confusing for physiciansMost confusing for physicians

What are E&M Codes?What are E&M Codes? The Evaluation & Management (E&M) codes are a sub-The Evaluation & Management (E&M) codes are a sub-

set of the CPT codes.set of the CPT codes. Can be used by all privileged providersCan be used by all privileged providers Describes:Describes:

Complexity of care provided to a patient for non-procedural Complexity of care provided to a patient for non-procedural visits.visits.

The place of service (inpatient or outpatient)The place of service (inpatient or outpatient) The type of service (new vs. established, consult, preventive, The type of service (new vs. established, consult, preventive,

ER, critical care, etc)ER, critical care, etc) Defined by 3 componentsDefined by 3 components

The patient historyThe patient history The physical examinationThe physical examination Medical decision makingMedical decision making

Why Code?Why Code?

REIMBURSEMENTREIMBURSEMENT Third Party Payers/Insurance AgenciesThird Party Payers/Insurance Agencies Prospective Payment Systems (PPS)Prospective Payment Systems (PPS)

Over coding = FraudOver coding = Fraud Under coding = Lost RevenueUnder coding = Lost Revenue

What Do Coders Look For?What Do Coders Look For?

Professional Coders in your office or from Professional Coders in your office or from insurance companies have been trained to insurance companies have been trained to match documentation in charts to the billing match documentation in charts to the billing informationinformation

It is the It is the ContentContent, not the volume, of , not the volume, of documentation that determines your E&M documentation that determines your E&M code!code!

What Do Coders Look For?What Do Coders Look For? Every patient encounter Every patient encounter should be legibleshould be legible and and

include:include: Date of EncounterDate of Encounter Reason for the visit (chief complaint)Reason for the visit (chief complaint) Appropriate history of present illnessAppropriate history of present illness An exam when necessary or appropriate; i.e. a new patient An exam when necessary or appropriate; i.e. a new patient

(consistency and problem pertinent)(consistency and problem pertinent) Review of lab, x-ray, other ancillary services when Review of lab, x-ray, other ancillary services when

appropriateappropriate AssessmentAssessment Plan of care/Treatment optionsPlan of care/Treatment options Provider signatureProvider signature

Why is Documentation Important?Why is Documentation Important?

The documentation must support the E&M code you The documentation must support the E&M code you select.select.

Your documentation must Your documentation must alsoalso support the medical support the medical necessity of the services providednecessity of the services provided. . The first step is to clearly document the reason for every The first step is to clearly document the reason for every

visit – the visit – the chief complaintchief complaint.. The use of “Follow-up” is insufficient documentation The use of “Follow-up” is insufficient documentation

as it does not indicate medical necessity. as it does not indicate medical necessity. However it is acceptable to document “Follow-up for However it is acceptable to document “Follow-up for

_____”._____”. ““If it isn’t documented, it wasn’t done!”If it isn’t documented, it wasn’t done!”

Patient TypePatient Type

New vs. EstablishedNew vs. Established

ConsultConsult

Inpatient vs. OutpatientInpatient vs. Outpatient

New vs. EstablishedNew vs. Established

New patientNew patient Any patient who has not received professional services, Any patient who has not received professional services,

within the previous 36 months, from a provider within the within the previous 36 months, from a provider within the same group, of the same specialtysame group, of the same specialty

Same group practice: One Federal Tax ID number for all Same group practice: One Federal Tax ID number for all providers, if more than one Federal Tax ID, can consider the providers, if more than one Federal Tax ID, can consider the patient newpatient new

e.g., current practice seen in OLBH ER and Outreach officese.g., current practice seen in OLBH ER and Outreach offices Professional Services: Phone call, prescription, hospital or office Professional Services: Phone call, prescription, hospital or office

visit, etc.visit, etc. Specialty Issue: Optional if one federal Tax ID is shared by Specialty Issue: Optional if one federal Tax ID is shared by

practitioners of other specialties (e.g., surgeon and FP)practitioners of other specialties (e.g., surgeon and FP)

** DO’s and MD’s of the same specialty DO NOT differ even if OMT is offered by the DO** DO’s and MD’s of the same specialty DO NOT differ even if OMT is offered by the DO

Average and Recommended Code Average and Recommended Code DistributionsDistributions

0

10

20

30

40

50

60

99211 99212 99213 99214 99215

MedicareRecommended

The difference in the bell The difference in the bell curves represents loss in curves represents loss in physician income!!physician income!!

Determining the Correct E&M CodeDetermining the Correct E&M Code

There are three key components to consider when selecting the There are three key components to consider when selecting the appropriate E&M:appropriate E&M: History History ExamExam Medical Decision Making (MDM)Medical Decision Making (MDM)

All three componentsAll three components must be documented for a must be documented for a newnew patientpatient (new to clinic or not seen within the past three years). Indicate (new to clinic or not seen within the past three years). Indicate in CC if patient is new.in CC if patient is new.

Only two of the three componentsOnly two of the three components must be documented for must be documented for established patientsestablished patients (seen within the past three years). (seen within the past three years).

E&M selection should E&M selection should nevernever be based on the allotted be based on the allotted time on the appointment schedule!time on the appointment schedule!

Determining the Correct E&M CodeDetermining the Correct E&M Code

To determine the correct level E&M code, To determine the correct level E&M code, consider the complexity of your patient’s consider the complexity of your patient’s condition and your medical decision making, condition and your medical decision making, then support that level of complexity with your then support that level of complexity with your documentation of history and/or exam.documentation of history and/or exam.

Remember: Remember: For a new clinic patient, initial consult, initial inpatient visit or ED For a new clinic patient, initial consult, initial inpatient visit or ED

encounter encounter you must document all three key componentsyou must document all three key components history, exam and your medical decision makinghistory, exam and your medical decision making ..

Defining Levels of E&M ServicesDefining Levels of E&M Services

7 components7 components HistoryHistory ExaminationExamination Medical Decision MakingMedical Decision Making CounselingCounseling Coordination of careCoordination of care Nature of Presenting ProblemNature of Presenting Problem TimeTime

The Medical HistoryThe Medical History

HistoryHistory

Also has several components to determine Also has several components to determine “complexity” or “type”“complexity” or “type” History of Present Illness (HPI)History of Present Illness (HPI) Review of Systems (ROS)Review of Systems (ROS) Past Family and/or Social History (PFSH)Past Family and/or Social History (PFSH)

The extent of history is dependent on clinical The extent of history is dependent on clinical judgment and the nature of the presenting problem.judgment and the nature of the presenting problem.

The four types of History include: Problem focused, The four types of History include: Problem focused, Expanded Problem Focused, Detailed and Expanded Problem Focused, Detailed and Comprehensive.Comprehensive.

History of Present IllnessHistory of Present Illness

History – Chief ComplaintHistory – Chief Complaint

Chief Complaint Chief Complaint RequiredRequired concise statement that describes the symptom, concise statement that describes the symptom,

problem, condition, diagnosis, or reason for the problem, condition, diagnosis, or reason for the patient encounter. patient encounter.

The CC is usually stated in the patient’s own The CC is usually stated in the patient’s own words.words. For example, patient complains of upset stomach, For example, patient complains of upset stomach,

aching joints, and fatigueaching joints, and fatigue Cannot Cannot be the words “follow up” alonebe the words “follow up” alone

History – History of Present IllnessHistory – History of Present Illness

Two types of HPI Two types of HPI BriefBrief, which includes documentation of one to , which includes documentation of one to

three HPI elements. three HPI elements. In the following example, three HPI elements – In the following example, three HPI elements –

location, severity, and duration – are documented: location, severity, and duration – are documented: CC: A patient seen in the office complains of left ear CC: A patient seen in the office complains of left ear

pain. pain. Brief HPI: Patient complains of dull ache in left ear Brief HPI: Patient complains of dull ache in left ear

over the past 24 hours.over the past 24 hours.

History – History of Present IllnessHistory – History of Present Illness

ExtendedExtended, which includes documentation of at , which includes documentation of at least four HPI elements or the status of at least least four HPI elements or the status of at least three chronic or inactive conditions. three chronic or inactive conditions. In the following example, five HPI elements – In the following example, five HPI elements –

location, severity, duration, context, and modifying location, severity, duration, context, and modifying factors – are documented: factors – are documented:

Extended HPI: Patient complains of dull ache in left ear Extended HPI: Patient complains of dull ache in left ear over the past 24 hours. Patient states he went swimming over the past 24 hours. Patient states he went swimming two days ago. Symptoms somewhat relieved by warm two days ago. Symptoms somewhat relieved by warm compress and ibuprofencompress and ibuprofen.

History ComponentsHistory Components LocationLocation

Area of body, localized, unilateral, bilateral, fixed, Area of body, localized, unilateral, bilateral, fixed, migratory, radiation, referredmigratory, radiation, referred

QualityQuality Specific pattern, sharp, dull, throbbing, stabbing, constant, Specific pattern, sharp, dull, throbbing, stabbing, constant,

intermittent, acute, chronic, stable, improving, worseningintermittent, acute, chronic, stable, improving, worsening Laceration as jagged or straightLaceration as jagged or straight Sore throat as scratchySore throat as scratchy

SeveritySeverity Pain scale, “compared to”, observation by physician Pain scale, “compared to”, observation by physician

(discomfort, wincing)(discomfort, wincing) DurationDuration

History ComponentsHistory Components TimingTiming

Onset of problem or symptom and progression, recurrent, comes and Onset of problem or symptom and progression, recurrent, comes and goes, worsens or improvesgoes, worsens or improves

ContextContext Associated with activity, improves with activity, etcAssociated with activity, improves with activity, etc

Modifying factorsModifying factors Steps the patient has taken to alleviate symptoms, what exacerbates Steps the patient has taken to alleviate symptoms, what exacerbates

symptoms, is helped by, is hindered bysymptoms, is helped by, is hindered by Associated signs/symptomsAssociated signs/symptoms

Clinical impressions direct physician questioningClinical impressions direct physician questioning Specific symptoms (weakness, headache with injury)Specific symptoms (weakness, headache with injury) Generalized symptoms, chills, fever, “pertinent positives and negatives”Generalized symptoms, chills, fever, “pertinent positives and negatives”

History GuidelinesHistory Guidelines

HPI mustHPI must be documented by the be documented by the physicianphysician ROS and/or PFSH can be recorded by ROS and/or PFSH can be recorded by

ancillary staffancillary staff Physician must supplement or confirm the Physician must supplement or confirm the

informationinformation If obtained at a prior visit, do not need to re-If obtained at a prior visit, do not need to re-

record. Can review and updaterecord. Can review and update Describe new informationDescribe new information Note date and location of earlier informationNote date and location of earlier information

History GuidelinesHistory Guidelines

If unable to obtain a historyIf unable to obtain a history Describe patient’s medical condition or Describe patient’s medical condition or

circumstance which precludes obtaining a historycircumstance which precludes obtaining a history

Review of SystemsReview of Systems

Review of SystemsReview of Systems DefinitionDefinition

An inventory of body systems obtained through a series of questions An inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms that the patient may be seeking to identify signs and/or symptoms that the patient may be experiencing or has experiencedexperiencing or has experienced

The following “systems” are recognized:The following “systems” are recognized: Constitutional (fever, weight loss)Constitutional (fever, weight loss) - Psychiatric- Psychiatric EyesEyes - Endocrine- Endocrine Ears, nose, mouth throatEars, nose, mouth throat - Neurological- Neurological CardiovascularCardiovascular - Allergic/Immunologic- Allergic/Immunologic RespiratoryRespiratory GastrointestinalGastrointestinal MusculoskeletalMusculoskeletal Integumentary (skin and/or breast)Integumentary (skin and/or breast) Hematologic/LymphaticHematologic/Lymphatic


Three categories of reviewThree categories of review Problem PertinentProblem Pertinent

ROS inquires about the system directly related to the ROS inquires about the system directly related to the problem(s) identified in the HPIproblem(s) identified in the HPI

Both positive responses and pertinent negatives should be Both positive responses and pertinent negatives should be documenteddocumented

In the following example, one system – the ear – is In the following example, one system – the ear – is reviewed: reviewed:

CC: Earache. CC: Earache. ROS: Positive for left ear pain. Denies dizziness, ROS: Positive for left ear pain. Denies dizziness,

tinnitus, fullness, or headache. tinnitus, fullness, or headache.


ExtendedExtended ROS inquires about the system directly related to HPI ROS inquires about the system directly related to HPI

AND a limited number of additional systemsAND a limited number of additional systems 2-9 systems which are documented2-9 systems which are documented

In the following example, two systems – cardiovascular In the following example, two systems – cardiovascular and respiratory – are reviewed: and respiratory – are reviewed:

CC: Follow up visit in office after cardiac catheterization. CC: Follow up visit in office after cardiac catheterization. Patient states “I feel great.” Patient states “I feel great.”

ROS: Patient states he feels great and denies chest pain, ROS: Patient states he feels great and denies chest pain, syncope, palpitations, and shortness of breath. Relates syncope, palpitations, and shortness of breath. Relates occasional unilateral, asymptomatic edema of left leg. occasional unilateral, asymptomatic edema of left leg.

Review of SystemsReview of Systems CompleteComplete

ROS inquires about the system directly related to the ROS inquires about the system directly related to the HPI AND all other body systemsHPI AND all other body systems

At least 10 body systems must be documentedAt least 10 body systems must be documented Those systems w/pertinent +or- responses must be individually Those systems w/pertinent +or- responses must be individually

documented, however for the remaining systems, “all other documented, however for the remaining systems, “all other systems are negative” is permissiblesystems are negative” is permissible

Review of SystemsReview of Systems In the following example, 10 signs and symptoms are In the following example, 10 signs and symptoms are

reviewed: reviewed: CC: Patient complains of “fainting spell.” CC: Patient complains of “fainting spell.” ROS: ROS:

Constitutional: weight stable, + fatigue. Constitutional: weight stable, + fatigue. Eyes: + loss of peripheral vision. Eyes: + loss of peripheral vision. Ear, Nose, Mouth, Throat: no complaints. Ear, Nose, Mouth, Throat: no complaints. Cardiovascular: + palpitations; denies chest pain; denies calf pain, Cardiovascular: + palpitations; denies chest pain; denies calf pain,

pressure, or edema. pressure, or edema. Respiratory: + shortness of breath on exertion. Respiratory: + shortness of breath on exertion. Gastrointestinal: appetite good, denies heartburn and indigestion. Gastrointestinal: appetite good, denies heartburn and indigestion. + episodes of nausea. Bowel movement daily; denies constipation or loose + episodes of nausea. Bowel movement daily; denies constipation or loose

stools. stools. Urinary: denies incontinence, frequency, urgency, nocturia, pain, or Urinary: denies incontinence, frequency, urgency, nocturia, pain, or

discomfort. discomfort. Skin: + clammy, moist skin. Skin: + clammy, moist skin. Neurological: + fainting; denies numbness, tingling, and tremors. Neurological: + fainting; denies numbness, tingling, and tremors. Psychiatric: denies memory loss or depression. Mood pleasant. Psychiatric: denies memory loss or depression. Mood pleasant.

Past Medical HistoryPast Medical History

MedicalMedical

FamilyFamily

SocialSocial

History - PFSHHistory - PFSH

Past HistoryPast History Past experience with illnesses, operations, injuries Past experience with illnesses, operations, injuries

and treatmentsand treatments Family HistoryFamily History

Review of medical events in patients family, Review of medical events in patients family, including hereditary diseaseincluding hereditary disease

Social History Social History Age appropriate review of past and current Age appropriate review of past and current

activitiesactivities


PertinentPertinent review of the history areas directly related to the review of the history areas directly related to the

problem(s) identified in the HPI. problem(s) identified in the HPI. Must document one item from any of the three history Must document one item from any of the three history

areas. areas. In the following example, the patient’s past surgical In the following example, the patient’s past surgical

history is reviewed as it relates to the current HPI: history is reviewed as it relates to the current HPI: Patient returns to office for follow up of coronary artery Patient returns to office for follow up of coronary artery

bypass graft in 1992. Recent cardiac catheterization bypass graft in 1992. Recent cardiac catheterization demonstrates 50 percent occlusion of vein graft to obtuse demonstrates 50 percent occlusion of vein graft to obtuse marginal artery.marginal artery.


CompleteComplete A review of two or all three of the areas, A review of two or all three of the areas,

depending on the category of E/M service. depending on the category of E/M service. Requires a review of all three history areas for Requires a review of all three history areas for

services that, by their nature, include a services that, by their nature, include a comprehensive assessment or reassessment of the comprehensive assessment or reassessment of the patient. patient.

A review of two history areas is sufficient for other A review of two history areas is sufficient for other services. services.


At least one specific item from each of the history At least one specific item from each of the history areas must be documented for the following areas must be documented for the following categories of E/M services: categories of E/M services: Office or other outpatient services, new patient; Office or other outpatient services, new patient; Hospital observation services; Hospital observation services; Hospital inpatient services, initial care; Hospital inpatient services, initial care; Consultations; Consultations; Comprehensive Nursing Facility assessments; Comprehensive Nursing Facility assessments; Domiciliary care, new patient; and Domiciliary care, new patient; and Home care, new patient. Home care, new patient.


Does NOT need to be re-recordedDoes NOT need to be re-recorded Record new information onlyRecord new information only ““No change” PFSH can be documentedNo change” PFSH can be documented

History AlgorithmHistory Algorithm

History TypeHistory Type HPIHPI ROSROS PFSHPFSH

Problem Focused Problem Focused (1 point)(1 point)

BriefBrief NoneNone NoneNone

Expanded Expanded Problem Focused Problem Focused (2 points)(2 points)

BriefBrief Problem Problem pertinentpertinent

NoneNone

Detailed (3 Detailed (3 points)points)

ExtendedExtended ExtendedExtended PertinentPertinent

Comprehensive Comprehensive (4 points)(4 points)

ExtendedExtended CompleteComplete CompleteComplete

Physical ExaminationPhysical Examination

Physical ExamPhysical Exam

Looked at either byLooked at either by Body AreasBody Areas Organ SystemsOrgan Systems

Physical ExamPhysical Exam

Body areas recognized:Body areas recognized: Head (including face)Head (including face) NeckNeck Chest, including breast and axillaeChest, including breast and axillae AbdomenAbdomen Genitalia, groin, buttocksGenitalia, groin, buttocks Back (including spine)Back (including spine) Each extremity (separately)Each extremity (separately)

Physical ExamPhysical Exam Organ systems recognizedOrgan systems recognized

ConstitutionalConstitutional EyesEyes ENT, MouthENT, Mouth CardiovascularCardiovascular RespiratoryRespiratory GIGI GUGU MusculoskeletalMusculoskeletal SkinSkin NeurologicNeurologic PsychiatricPsychiatric Hematologic; Lymphatic; ImmunologicHematologic; Lymphatic; Immunologic

The general multi-system exam should include findings of at The general multi-system exam should include findings of at least 8 of the above 12 organ systemsleast 8 of the above 12 organ systems

Documentation of ExaminationDocumentation of Examination

Make sure you note specific abnormal or Make sure you note specific abnormal or relevant findings of affected body areas or relevant findings of affected body areas or organ systemsorgan systems

Brief statement indicating negative or normal Brief statement indicating negative or normal is sufficient for unaffected or asymptomatic is sufficient for unaffected or asymptomatic systemssystems

Describe abnormal or unexpected findings of Describe abnormal or unexpected findings of asymptomatic areas or organsasymptomatic areas or organs


TypeType Either thisEither this Or thisOr this

Problem Focused (1 Problem Focused (1 point)point)

< 1 organ system/Body area < 1 organ system/Body area 1-5 bulleted elements1-5 bulleted elements

Expanded Problem Expanded Problem Focused (2 points)Focused (2 points)

2-4 Organ Systems/Body 2-4 Organ Systems/Body areasareas

>> 6 Bulleted Elements 6 Bulleted Elements

Detailed Exam (3 Detailed Exam (3 points)points)

5-7 Organ Systems/Body 5-7 Organ Systems/Body AreasAreas

>> 2 bulleted elements 2 bulleted elements from 6 areas orfrom 6 areas or

>> 12 bullets from 12 bullets from >> 2 2 areasareas

Comprehensive Exam Comprehensive Exam (4 points)(4 points)

>> 8 organ systems/body areas 8 organ systems/body areas Complete single system Complete single system examination orexamination or

>> 2 bulleted elements 2 bulleted elements from 9 areasfrom 9 areas


Type of ExaminationType of Examination DescriptionDescription

Problem Focused Problem Focused A limited examination of the affected body area or A limited examination of the affected body area or organ system. organ system.

Expanded Problem Expanded Problem Focused Focused

A limited examination of the affected body area or A limited examination of the affected body area or organ system and any other symptomatic or related organ system and any other symptomatic or related body area(s) or organ system(s). body area(s) or organ system(s).

Detailed Detailed An extended examination of the affected body An extended examination of the affected body area(s) or organ system(s) and any other area(s) or organ system(s) and any other symptomatic or related body areas(s) or organ symptomatic or related body areas(s) or organ system(s).system(s).

Comprehensive Comprehensive A general multi-system examination OR complete A general multi-system examination OR complete examination of a single organ system and other examination of a single organ system and other symptomatic or related body area(s) or organ symptomatic or related body area(s) or organ system(s). system(s).

Physical ExaminationPhysical ExaminationGeneral Multi-System ExaminationsGeneral Multi-System Examinations

TYPE OF TYPE OF EXAMINATION EXAMINATION

DESCRIPTION DESCRIPTION

Problem Focused Problem Focused Include performance and documentation of 1 - 5 Include performance and documentation of 1 - 5 elements identified by a bullet in 1 or more organ elements identified by a bullet in 1 or more organ system(s) or body area(s) system(s) or body area(s)

Expanded Problem Expanded Problem Focused Focused

Include performance and documentation of at least Include performance and documentation of at least 6 elements identified by a bullet in 1 or more organ 6 elements identified by a bullet in 1 or more organ system(s) or body area(s). system(s) or body area(s).

Physical ExaminationPhysical ExaminationGeneral Multi-System ExaminationsGeneral Multi-System Examinations

TYPE OF TYPE OF EXAMEXAM

DESCRIPTION DESCRIPTION

Detailed Detailed Include at least 6 organ systems or body areas. For each system/area Include at least 6 organ systems or body areas. For each system/area selected, performance and documentation of at least 2 elements selected, performance and documentation of at least 2 elements identified by a bullet is expected. Alternatively, may include identified by a bullet is expected. Alternatively, may include performance and documentation of at least 12 elements identified by a performance and documentation of at least 12 elements identified by a bullet in 2 or more organ systems or body areasbullet in 2 or more organ systems or body areas..

Comp.Comp. 1997 Documentation Guidelines for Evaluation and Management 1997 Documentation Guidelines for Evaluation and Management ServicesServices: Include at least 9 organ systems or body areas. For each : Include at least 9 organ systems or body areas. For each system/area selected, all elements of the examination identified by a system/area selected, all elements of the examination identified by a bullet should be performed, unless specific directions limit the content bullet should be performed, unless specific directions limit the content of the examination. For each area/system, documentation of at least 2 of the examination. For each area/system, documentation of at least 2 elements identified by bullet is expected. elements identified by bullet is expected.

1995 Documentation Guidelines for Evaluation and Management 1995 Documentation Guidelines for Evaluation and Management ServicesServices: Eight organ systems : Eight organ systems must must be examined. If body areas are be examined. If body areas are examined and counted, they must be over and above the 8 organ examined and counted, they must be over and above the 8 organ systems. systems.

Exam BulletsExam Bullets ConstitutionalConstitutional

3 vital signs3 vital signs General appearanceGeneral appearance

EyesEyes Inspection of Conjunctiva and LidsInspection of Conjunctiva and Lids Examination of Pupils and Iris (PERLA)Examination of Pupils and Iris (PERLA) Ophthalmoscopic discs and posterior segmentsOphthalmoscopic discs and posterior segments

Ears, Nose, Mouth and ThroatEars, Nose, Mouth and Throat External appearance of Nose and EarsExternal appearance of Nose and Ears Otoscopic ExaminationOtoscopic Examination Assessment of HearingAssessment of Hearing Inspection of Nasal Mucosa/SeptumInspection of Nasal Mucosa/Septum Examination of oropharynxExamination of oropharynx

Exam BulletsExam Bullets

NeckNeck Examination of NeckExamination of Neck Examination of ThyroidExamination of Thyroid

RespiratoryRespiratory Assessment of respiratory effortAssessment of respiratory effort Percussion of ChestPercussion of Chest Palpation of ChestPalpation of Chest Auscultation of LungsAuscultation of Lungs

Exam BulletsExam Bullets CardiovascularCardiovascular

Palpation of PMIPalpation of PMI Auscultation of the HeartAuscultation of the Heart Assessment of Lower Extremity EdemaAssessment of Lower Extremity Edema Examination of Carotid ArteryExamination of Carotid Artery Examination of abdominal aortaExamination of abdominal aorta Examination of femoral pulseExamination of femoral pulse Examination of pedal pulseExamination of pedal pulse

Chest (breasts)Chest (breasts) Inspection of breastsInspection of breasts Palpation of breasts and axillaePalpation of breasts and axillae


Gastrointestinal (abdomen)Gastrointestinal (abdomen) Examination with notation of masses or tendernessExamination with notation of masses or tenderness Examination of liver and spleenExamination of liver and spleen Examination for presence/absence of herniasExamination for presence/absence of hernias Examination of anus, perineum, rectum, including Examination of anus, perineum, rectum, including

sphincter tone, hemorrhoidssphincter tone, hemorrhoids Obtain stool for occult bloodObtain stool for occult blood

Genitourinary (male)Genitourinary (male) Examination of scrotal contentsExamination of scrotal contents Examination of PenisExamination of Penis DRE prostateDRE prostate


Genitourinary (female)Genitourinary (female) Examination of external genetaliaExamination of external genetalia Examination of urethraExamination of urethra Examination of bladderExamination of bladder Examination of cervixExamination of cervix Examination of uterusExamination of uterus Examination of adenexaExamination of adenexa

LymphaticLymphatic Palpation of lymph nodes in Palpation of lymph nodes in twotwo or more areas or more areas Neck, axillae, groin, otherNeck, axillae, groin, other

Exam BulletsExam Bullets MusculoskeletalMusculoskeletal

Examination of gait and stationExamination of gait and station Examination of joints, bones and muscles of one or more of Examination of joints, bones and muscles of one or more of

the following 6 areasthe following 6 areas Head and NeckHead and Neck Spine, ribs and PelvisSpine, ribs and Pelvis Right Upper ExtremityRight Upper Extremity Left Upper ExtremityLeft Upper Extremity Right Lower ExtremityRight Lower Extremity Left Lower ExtremityLeft Lower Extremity

Examination includes…Inspection and/or palpation with Examination includes…Inspection and/or palpation with notation of any misalignment, asymmetry, crepitation, etc; notation of any misalignment, asymmetry, crepitation, etc; range of motion with notation of pain, crepitation; range of motion with notation of pain, crepitation; assessment of stability; assessment of muscle strength assessment of stability; assessment of muscle strength


SkinSkin Examination of skin and subcutaneous tissueExamination of skin and subcutaneous tissue Palpation of skin and subcutaneous tissuePalpation of skin and subcutaneous tissue

NeurologicNeurologic Test cranial nerves with notation of deficitTest cranial nerves with notation of deficit Examination of DTRExamination of DTR Examination of sensationExamination of sensation

PsychiatricPsychiatric Description of judgment and insightDescription of judgment and insight Brief assessment of mental statusBrief assessment of mental status

Medical Decision MakingMedical Decision Making

Determination of Medical Decision Determination of Medical Decision MakingMaking

Based uponBased upon Number of diagnoses or management optionsNumber of diagnoses or management options Amount and complexity of dataAmount and complexity of data Overall riskOverall risk


(MDM) refers to the complexity of determining a (MDM) refers to the complexity of determining a diagnosis and/or the selection of a treatment option. diagnosis and/or the selection of a treatment option.

Measured by documentation of the following:Measured by documentation of the following: Number of diagnoses and/or management options that must Number of diagnoses and/or management options that must

be considered.be considered. Amount and/or complexity of data to be reviewed.Amount and/or complexity of data to be reviewed. Risk of complications, morbidity and/or mortality, and co-Risk of complications, morbidity and/or mortality, and co-

morbidities.morbidities. Four typesFour types

Straightforward, Low Complexity, Moderate Complexity, Straightforward, Low Complexity, Moderate Complexity, and High Complexity.and High Complexity.

Documentation to Support Documentation to Support ComplexityComplexity

Consider the following for riskConsider the following for risk Chronic illness(es)Chronic illness(es)

Well controlledWell controlled Mild exacerbationMild exacerbation Severe exacerbationSevere exacerbation

Acute illnessAcute illness Uncomplicated like allergic rhinitisUncomplicated like allergic rhinitis With systemic symptoms like pneumonitisWith systemic symptoms like pneumonitis

Medical Decision MakingMedical Decision MakingDiagnoses/Management OptionsDiagnoses/Management Options

Max of 4 pointsMax of 4 points

Problem CategoriesProblem Categories Number of Number of ProblemsProblems

Possible Possible PointsPoints

ScoreScore

Self Limited/minorSelf Limited/minor Max of 2Max of 2 11

Established Problem – stable or Established Problem – stable or improvingimproving

11

Established problem – worseningEstablished problem – worsening 22

New problem (no further work up)New problem (no further work up) Max of 1Max of 1 33

New problem (work up needed)New problem (work up needed) 44

Documentation to Support Documentation to Support ComplexityComplexity

Consider the following…Consider the following… Did you order/review labs?Did you order/review labs? Did you order/review X-rays, US, MRIDid you order/review X-rays, US, MRI Did you order/review any other testingDid you order/review any other testing Did you visualize image, tracing, or specimenDid you visualize image, tracing, or specimen Did you review or summarize old recordsDid you review or summarize old records

Must document this on the recordMust document this on the record ……old records reviewed which noted ….old records reviewed which noted ….

Medical Decision MakingMedical Decision MakingAmount and Complexity of DataAmount and Complexity of Data

Max of 4 pointsMax of 4 points

Type of DataType of Data Check if Check if DoneDone

Possible Possible PointsPoints

ScoreScore

Review/Order tests (8xxxx clinical)Review/Order tests (8xxxx clinical) 11

Review/order tests (7xxxx radiology)Review/order tests (7xxxx radiology) 11

Review/order tests (9xxxx medicine)Review/order tests (9xxxx medicine) 11

Discuss test results with performing Discuss test results with performing physicianphysician

22

Independent review of tracing, specimen, Independent review of tracing, specimen, imageimage

22

Decision to obtain medical recordsDecision to obtain medical records 11

Review, summarize old records and/or Review, summarize old records and/or obtain historyobtain history

22

Table of RiskTable of RiskLevel of riskLevel of risk Presenting problem(s)Presenting problem(s) Diagnostics orderedDiagnostics ordered Management optionsManagement options

Minimal (1 Minimal (1 point)point)

One self-limited/minor problem One self-limited/minor problem (e.g., URI)(e.g., URI)

Lab tests requiring venipunctureLab tests requiring venipuncture

CXRCXR

EKGEKG

UrinalysisUrinalysis

RestRest

GarglesGargles

Ace wrapAce wrap

Low (2 points)Low (2 points) 2+self limited/minor problems2+self limited/minor problems

1 stable/chronic illness1 stable/chronic illness

Acute uncomplicated illness/injuryAcute uncomplicated illness/injury

Physiologic tests not under stress (pulm. Function)Physiologic tests not under stress (pulm. Function)

Non-cardiac imaging w/bariumNon-cardiac imaging w/barium

Lab requiring arterial punctureLab requiring arterial puncture

Skin biopsySkin biopsy

Over the counter drugsOver the counter drugs

Minor surgery w/no identified Minor surgery w/no identified riskrisk

PT/OTPT/OT

IV fluids w/o additivesIV fluids w/o additives

Moderate (3 Moderate (3 points)points)

1+chronic illnesses with mild 1+chronic illnesses with mild progression, or side effects of progression, or side effects of treatmenttreatment

2+ stable chronic illnesses2+ stable chronic illnesses

Undiagnosed new problem Undiagnosed new problem w/uncertain prognosisw/uncertain prognosis

Acute illness with systematic Acute illness with systematic symptomssymptoms

Acute uncomplicated injuryAcute uncomplicated injury

Physiologic test under stressPhysiologic test under stress

Diagnostic endoscopy w/no risk factorsDiagnostic endoscopy w/no risk factors

Deep needle or incisional biopsyDeep needle or incisional biopsy

Obtain fluid from body cavityObtain fluid from body cavity

Minor surgery w/risk factorsMinor surgery w/risk factors

Elective major surgery w/no risksElective major surgery w/no risks

Prescription drug managementPrescription drug management

IV with additivesIV with additives

High (4 points)High (4 points) 1+ chronic illness with severe 1+ chronic illness with severe exacerbation or side effects of exacerbation or side effects of treatmenttreatment

Acute/chronic illness that poses a Acute/chronic illness that poses a threat to life/bodily functionthreat to life/bodily function

Abrupt change in neurologic statusAbrupt change in neurologic status

Cardiovascular imaging w/contrast w/risk factorsCardiovascular imaging w/contrast w/risk factors

Cardiac electrophysiological testsCardiac electrophysiological tests

Diagnostic endoscopies w/identified risk factorsDiagnostic endoscopies w/identified risk factors

Elective major surgery w/risk Elective major surgery w/risk factorsfactors

Emergency major surgeryEmergency major surgery

Parenteral controlled substancesParenteral controlled substances

DNR due to poor prognosisDNR due to poor prognosis


The HIGHEST level of ANY ONE of the three The HIGHEST level of ANY ONE of the three aspects of a medical decision making will aspects of a medical decision making will determine the overall level chosendetermine the overall level chosen

Medical Decision MakingMedical Decision MakingFinal Medical Decision MakingFinal Medical Decision Making

2 of 3 rule2 of 3 rule

Decision Decision MakingMaking

Straight Straight ForwardForward

LowLow ModerateModerate HighHigh

Diagnosis Diagnosis &/or &/or Management Management OptionsOptions

Minimal (1)Minimal (1) Limited (2)Limited (2) Multiple (3)Multiple (3) Extensive Extensive ((>> 4) 4)

Amount of Amount of Data Data ReviewedReviewed

Minimal (1)Minimal (1) Limited (2)Limited (2) Multiple (3)Multiple (3) Extensive Extensive ((>> 4) 4)

Table of RiskTable of Risk Minimal (1)Minimal (1) Low (2)Low (2) Moderate Moderate (3)(3)

High (4)High (4)

Defining Levels of E&M ServicesDefining Levels of E&M Services

7 components7 components HistoryHistory ExaminationExamination Medical Decision MakingMedical Decision Making CounselingCounseling Coordination of careCoordination of care Nature of Presenting ProblemNature of Presenting Problem TimeTime

Counseling and Counseling and Coordination of CareCoordination of Care

Discussion with patient or family concerning Discussion with patient or family concerning one or more of the following:one or more of the following: Diagnostic resultsDiagnostic results PrognosisPrognosis Risk & benefits of management optionsRisk & benefits of management options Instruction for managementInstruction for management ComplianceCompliance

Time…as another factorTime…as another factor

Appropriate in cases where counseling and/or Appropriate in cases where counseling and/or coordination of care dominates (>50%) of the coordination of care dominates (>50%) of the patient and/or family encounterpatient and/or family encounter

Documentation requirementsDocumentation requirements Total face to face time or encounterTotal face to face time or encounter Total counseling/coordination timeTotal counseling/coordination time Content of counseling/coordinationContent of counseling/coordination

Time based billing…exampleTime based billing…example

cc: Depressioncc: Depression Hx cc: 59 y/o female w/depression and anxiety. Hx cc: 59 y/o female w/depression and anxiety.

Denies suicidal ideations. Hx ativan use in pastDenies suicidal ideations. Hx ativan use in past Exam: vitals (list)Exam: vitals (list) A/P: Depression. Had long discussion w/patient and A/P: Depression. Had long discussion w/patient and

counseled him on exacerbating factors and treatment counseled him on exacerbating factors and treatment options. Rx ordered (list)options. Rx ordered (list)

Total visit time 25 minutes, counseling time 15 Total visit time 25 minutes, counseling time 15 minutesminutes

Summing Up Your Summing Up Your ServicesServices

Billing the Correct Code…Billing the Correct Code…

The Constants of CodingThe Constants of Coding 3 of 3 rule3 of 3 rule

Go to the lowest componentGo to the lowest component i.e., 2,3,4 = 2i.e., 2,3,4 = 2 3,3,4 = 33,3,4 = 3

Used for new patient, initial consults, initial hospital care Used for new patient, initial consults, initial hospital care and emergency department visitsand emergency department visits

2 of 3 rule2 of 3 rule Go to the middle componentGo to the middle component

2,3,4 = 32,3,4 = 3 3,3,4 = 33,3,4 = 3

Used for established patient, subsequent hospital f/u, f/u Used for established patient, subsequent hospital f/u, f/u consultconsult

New vs. Established PatientNew vs. Established Patient

New PatientNew Patient AllAll key components must meet or exceed the stated key components must meet or exceed the stated

requirements to qualify for a particular levelrequirements to qualify for a particular level Established PatientEstablished Patient

TwoTwo key components must meet or exceed stated key components must meet or exceed stated requirements to qualify for a particular levelrequirements to qualify for a particular level

Documentation RequirementsDocumentation RequirementsNew Patient Office VisitNew Patient Office Visit


Level of Level of ServiceService

HistoryHistory ExaminationExamination Medical Decision Medical Decision MakingMaking

9920199201 Problem focusedProblem focused Problem focusedProblem focused Straight forward Straight forward complexitycomplexity

9920299202 Expanded Expanded problem focusedproblem focused

Expanded Expanded problem focusedproblem focused

Straight forward Straight forward complexitycomplexity

9920399203 DetailedDetailed DetailedDetailed Low complexityLow complexity

9920499204 ComprehensiveComprehensive ComprehensiveComprehensive Moderate complexityModerate complexity

9920599205 ComprehensiveComprehensive ComprehensiveComprehensive High complexityHigh complexity

Established Patient CPT E&M GuidelinesEstablished Patient CPT E&M Guidelines2 of 3 rule2 of 3 rule

CodeCode HistoryHistory Physical ExamPhysical Exam Medical Decision Medical Decision makingmaking

TimeTime

9921199211 Nursing service Nursing service onlyonly

N/AN/A Nursing orderNursing order 55

9921299212 Problem Problem Focused (1)Focused (1)

Problem Problem Focused (1)Focused (1)

Straight forward (1)Straight forward (1) 1010

9921399213 Expanded Expanded Problem Problem Focused (2)Focused (2)

Expanded Expanded Problem Problem Focused (2)Focused (2)

Low Complexity (2)Low Complexity (2) 1515

9921499214 Detailed (3)Detailed (3) Detailed (3)Detailed (3) Moderate ComplexityModerate Complexity 2525

9921599215 Comprehensive Comprehensive (4)(4)

Comprehensive Comprehensive (4)(4)

High Complexity (4)High Complexity (4) 4040

Established Patient CPT E&M GuidelinesEstablished Patient CPT E&M Guidelines2 of 3 rule2 of 3 rule

CodeCode HistoryHistory Physical ExamPhysical Exam Medical Decision Medical Decision makingmaking

TimeTime

9921199211 Nursing service Nursing service onlyonly

N/AN/A Nursing orderNursing order 55

9921299212 Problem Problem Focused (1)Focused (1)


Straight forward (1)Straight forward (1) 1010

9921399213 Expanded Expanded Problem Problem Focused (2)Focused (2)

Expanded Expanded Problem Problem Focused (2)Focused (2)

Low Complexity (2)Low Complexity (2) 1515

9921499214 Detailed (3)Detailed (3) Detailed (3)Detailed (3) Moderate Complexity (3)Moderate Complexity (3) 2525

9921599215 Comprehensive Comprehensive (4)(4)

Comprehensive Comprehensive (4)(4)

High Complexity (4)High Complexity (4) 4040

Inpatient CodesInpatient Codes

Follow 3 of 3 ruleFollow 3 of 3 rule Inpatient Services and ObservationInpatient Services and Observation Inpatient ConsultsInpatient Consults Inpatient follow ups follow the 2 of 3 ruleInpatient follow ups follow the 2 of 3 rule

Other Medical ServicesOther Medical Services

General ConsultantGeneral Consultant

Pre/Post Operative ConsultsPre/Post Operative Consults

Definition of ConsultationDefinition of Consultation

Type of service provided by a physician whose Type of service provided by a physician whose opinion ad advice regarding evaluation and/or opinion ad advice regarding evaluation and/or management of a specific problem is requested management of a specific problem is requested by another physician or other appropriate by another physician or other appropriate source.source.

Consultation ServicesConsultation Services

Documentation MUST includeDocumentation MUST include RequestRequest for consultation documented in the for consultation documented in the

medical recordmedical record ReasonReason for consultation (medical necessity) for consultation (medical necessity) Report- Report- Consultant’s opinion, advice and Consultant’s opinion, advice and

evaluation of the patient (this evaluation of the patient (this MUSTMUST be be communicated back to the requesting physician)communicated back to the requesting physician)

Have separate initial codingHave separate initial coding Follow up visits use established patient visitsFollow up visits use established patient visits

Preoperative ConsultationPreoperative Consultation

Must request opinion or advice regarding a Must request opinion or advice regarding a specific problemspecific problem

Request and need for consult must be Request and need for consult must be documented in the medical recorddocumented in the medical record

Any services ordered or performed must be Any services ordered or performed must be documenteddocumented

Consultant’s opinion, advice and evaluation of Consultant’s opinion, advice and evaluation of the patient must be communicated back to the the patient must be communicated back to the requesting surgeonrequesting surgeon

Preoperative ClearancePreoperative Clearance

ICD-9 diagnosis codesICD-9 diagnosis codes V72.81 Preoperative cardiovascular examinationV72.81 Preoperative cardiovascular examination V72.82 Preoperative op respiratory examinationV72.82 Preoperative op respiratory examination V72.83 Other specified preoperative examinationV72.83 Other specified preoperative examination V72.84 Preoperative examination, unspecifiedV72.84 Preoperative examination, unspecified V72.85 Other specified examinationV72.85 Other specified examination

Must supplement with sigh/symptom/dx codesMust supplement with sigh/symptom/dx codes Must also include surgical indication (eg, cataracts)Must also include surgical indication (eg, cataracts)

Rules for ConsultationRules for Consultation99241-9927599241-99275

Opinion or advise regarding E&M of a specific Opinion or advise regarding E&M of a specific problem is requestedproblem is requested

Documented request from appropriate source is Documented request from appropriate source is required (if patient generated for 99271-99275)required (if patient generated for 99271-99275)

Written report sent to referring provider (a letter for Written report sent to referring provider (a letter for an outpatient)an outpatient)

Initiation of care at time of consult is acceptableInitiation of care at time of consult is acceptable Post-op consult by provider performing pre-op Post-op consult by provider performing pre-op

clearance should use subsequent hospital codes or clearance should use subsequent hospital codes or established office visit codesestablished office visit codes

New outpatient and consultative CPT E&M New outpatient and consultative CPT E&M GuidelinesGuidelines


ConfirmConfirm

ConsultConsult

Initial Initial consultconsult

New New patientpatient

HistoryHistory Physical ExamPhysical Exam Medical Medical Decision Decision MakingMaking

TimeTime

9927199271 9924199241 9920199201 Problem Focused Problem Focused (1)(1)


Straight Straight forward (1)forward (1)

1010

9927299272 9924299242 9920299202 Expanded prob. Expanded prob. focused (2)focused (2)

Expanded prob.Expanded prob.

focused (2)focused (2)

Straight Straight forward (1)forward (1)

2020

9927399273 9924399243 9920399203 Detailed (3)Detailed (3) Detailed (3)Detailed (3) Low Complex Low Complex (2)(2)

3030

9927499274 9924499244 9920499204 Comprehensive (4)Comprehensive (4) Comprehensive Comprehensive (4)(4)

Moderate Moderate Complexity (3)Complexity (3)

4545

9927599275 9924599245 9920599205 Comprehensive (4)Comprehensive (4) Comprehensive Comprehensive (4)(4)

High High ComplexityComplexity

6060

Coding ExamplesCoding Examples

Documentation RequirementsDocumentation RequirementsEstablished Patient Office VisitEstablished Patient Office Visit

Level of Level of serviceservice

HistoryHistory ExaminationExamination Medical decision Medical decision makingmaking

9921199211 Nursing service onlyNursing service only Nursing orderNursing order

9921299212 Problem focusedProblem focused Problem focusedProblem focused Straight forward Straight forward complexitycomplexity

9921399213 Expanded problem Expanded problem focusedfocused

Expanded problem Expanded problem focusedfocused

Low complexityLow complexity

9921499214 DetailedDetailed DetailedDetailed Moderate complexityModerate complexity

9921599215 ComprehensiveComprehensive ComprehensiveComprehensive High complexityHigh complexity

Example 99211Example 99211Non-physician visitNon-physician visit

Patient Calls Advice Nurse with Possible UTIPatient Calls Advice Nurse with Possible UTI Patient brings and drops-off UAPatient brings and drops-off UA Nurse processes UANurse processes UA You (Doctor/PA/NP) review and find UTIYou (Doctor/PA/NP) review and find UTI Nurse calls in antibiotics and documents in ChartNurse calls in antibiotics and documents in Chart

Blood Pressure CheckBlood Pressure Check

Example 99212Example 992124y/o female with fever and ear pain4y/o female with fever and ear pain

Established Patient: 2 of 3 requiredEstablished Patient: 2 of 3 required History: 1-2 HPIHistory: 1-2 HPI Exam: 1-5 elementsExam: 1-5 elements Medical Decision Making: 1 self limited minor Medical Decision Making: 1 self limited minor

problemproblem

Example 99212Example 992124y/o female with fever and ear pain4y/o female with fever and ear pain

HistoryHistory Fever 101Fever 101 Left ear 3 daysLeft ear 3 days

ExamExam Injection with redness and drainage of tympanic membraneInjection with redness and drainage of tympanic membrane Pharynx red, no exudatesPharynx red, no exudates + anterior cervical nodes+ anterior cervical nodes Lungs clearLungs clear Heart rrrHeart rrr

Medical Decision MakingMedical Decision Making OM – Prescription AntibioticsOM – Prescription Antibiotics Fever controlFever control Recheck in 2 weeksRecheck in 2 weeks

Example 99213Example 992134 y/o female with fever and ear pain4 y/o female with fever and ear pain

History: History: 1-3 HPI elements …AND 1-3 HPI elements …AND ROSROS

Exam: 6-11 elementsExam: 6-11 elements Medical Decision Making: Medical Decision Making:

2 self-limited or minor problems …OR2 self-limited or minor problems …OR 1 new problem plus low risk1 new problem plus low risk

Example 99213Example 992134 y/o female with fever and ear pain4 y/o female with fever and ear pain

History: History: Fever and Ear pain for 3 days Fever and Ear pain for 3 days ROSROS

Cough/sinus congestion, sore throat, vomiting and diarrheaCough/sinus congestion, sore throat, vomiting and diarrhea PFSHPFSH

NKA/Immunization/passive smoking/any chronic medsNKA/Immunization/passive smoking/any chronic meds ExamExam

3 vitals (weight, temp, BP)3 vitals (weight, temp, BP) Left TM red, pharynx red, tender nodes, neck supple, lungs clear, heart Left TM red, pharynx red, tender nodes, neck supple, lungs clear, heart

regular, abdomen non-tenderregular, abdomen non-tender Medical Decision Making: Medical Decision Making:

LOMLOM Antibiotics/Fever ControlAntibiotics/Fever Control Recheck in 2 weeksRecheck in 2 weeks Call if worseCall if worse

Example 99214Example 9921458 y/o male at 3 month check up58 y/o male at 3 month check up

Detailed historyDetailed history Extended HPIExtended HPI Extended ROSExtended ROS One element PFSHOne element PFSH

Detailed examDetailed exam 12 exam elements from at least 2 systems12 exam elements from at least 2 systems

Moderate ComplexityModerate Complexity 2 of the following: Multiple dx; Moderate amount 2 of the following: Multiple dx; Moderate amount

and complexity of data; Moderate riskand complexity of data; Moderate risk

Example 99214Example 9921458 y/o male at 3 month check up58 y/o male at 3 month check up

HistoryHistory HTN; DM; DJD; vision exam UTD; (-) HA; (-) SOB; (-) CP; (-) HTN; DM; DJD; vision exam UTD; (-) HA; (-) SOB; (-) CP; (-)

NVDC; (-) Hematochezia; (-) NocturiaNVDC; (-) Hematochezia; (-) Nocturia PFSHPFSH

Unchanged from prior examUnchanged from prior exam Detailed examDetailed exam

12 exam elements from at least 2 systems12 exam elements from at least 2 systems Medical Decision MakingMedical Decision Making

EKG, Pulse Oximetry; UA, Rapid StrepEKG, Pulse Oximetry; UA, Rapid Strep Review of CXRReview of CXR Prescriptions writtenPrescriptions written

Document ProceduresDocument Procedures Document OMMDocument OMM

OMT BillingOMT Billing

OMT codesOMT codes

These are nonallopathic lesions, not elsewhere These are nonallopathic lesions, not elsewhere classified.classified.

CPT codes 98925 – 98929CPT codes 98925 – 98929 ICD codes 739.0 – 739.9 depending on body ICD codes 739.0 – 739.9 depending on body

regionregion Will be discussed at separate lecture in detailWill be discussed at separate lecture in detail

Other Billable ServicesOther Billable Services

Other Billable ServicesOther Billable Services

Injections/ImmunizationsInjections/Immunizations Smoking CessationSmoking Cessation Visit Visit andand procedures procedures

Injections/ImmunizationsInjections/Immunizations

90471 is for first administration90471 is for first administration 90472 is for EACH additional administration90472 is for EACH additional administration Cannot report if patient brings their own Cannot report if patient brings their own

supplysupply Cannot bill 99211 (nursing service) if only Cannot bill 99211 (nursing service) if only

injection giveninjection given Must provide separately identifiable serviceMust provide separately identifiable service

e.g., get vital signse.g., get vital signs

Smoking CessationSmoking Cessation

Document that you told patient to stop Document that you told patient to stop smoking smoking 99406 Greater than 3 minutes, up to 10 minutes99406 Greater than 3 minutes, up to 10 minutes 99407 Greater than 10 minutes99407 Greater than 10 minutes

Other Billable ServicesOther Billable Services Digital Rectal Exam for Prostate Cancer ScreeningDigital Rectal Exam for Prostate Cancer Screening

G0102G0102 Visual Acuity Exam (Snellen Chart)Visual Acuity Exam (Snellen Chart)

9917399173 Needle Sticks!! Needle Sticks!!

96150 – e.g., when an occupational health nurse sees a patient due to 96150 – e.g., when an occupational health nurse sees a patient due to a needle stick he/she can code this encounter as 99499 E/M and a needle stick he/she can code this encounter as 99499 E/M and 96150 CPT with the applicable ICD-9 primary for the wound and a 96150 CPT with the applicable ICD-9 primary for the wound and a secondary ICD-9 code of the External cause.secondary ICD-9 code of the External cause.

Billing an office Visit and a Billing an office Visit and a ProcedureProcedure

Procedure must be a separate service from the Procedure must be a separate service from the evaluation and management serviceevaluation and management service

Modifier 25 should be added to the evaluation Modifier 25 should be added to the evaluation and management service to identify that it is a and management service to identify that it is a separate serviceseparate service

Other Coding OpportunitiesOther Coding Opportunities

ModifiersModifiers 22 Unusual procedural service22 Unusual procedural service 25 significantly, separately identifiable E&M 25 significantly, separately identifiable E&M

service by the same physician on the same day of service by the same physician on the same day of the procedure or other servicethe procedure or other service

e.g., patient comes in with sinus infection – you do e.g., patient comes in with sinus infection – you do OMT “cause it will help” vs. patient coming in OMT “cause it will help” vs. patient coming in specifically for OMTspecifically for OMT

32 Mandated by 332 Mandated by 3rdrd party (HMO) party (HMO) 51 Multiple Procedures51 Multiple Procedures

Other MiscellanyOther Miscellany

Other…Other…

If you see a patient and admit directly to a If you see a patient and admit directly to a hospital, you should submit only the hospital hospital, you should submit only the hospital code.code.

Critical Care CodesCritical Care Codes

Use appropriate E&M code if < 30 minutesUse appropriate E&M code if < 30 minutes 99291 99291

First 30-74 minutes of evaluation and managementFirst 30-74 minutes of evaluation and management 9929299292

Each additional 30 minutes (can round up after 15 Each additional 30 minutes (can round up after 15 minutes)minutes)

e.g., 105-134 minutes = 99291 x 1 and 99292 x 2e.g., 105-134 minutes = 99291 x 1 and 99292 x 2

Prolonged Care CodesProlonged Care Codes

Threshold time is 30 minutes over the time Threshold time is 30 minutes over the time component allotted for the E&M codecomponent allotted for the E&M code OutpatientOutpatient

99354-9935599354-99355 Face to face timeFace to face time

InpatientInpatient 99356-9935799356-99357

Inpatient or outpatient office/floor/unit time without direct Inpatient or outpatient office/floor/unit time without direct patient contactpatient contact

99358-9935999358-99359 e.g., IV running for rehydration in your office for 1 houre.g., IV running for rehydration in your office for 1 hour

Other Coding OpportunitiesOther Coding Opportunities

9905099050 After HoursAfter Hours

9905299052 Services Provided between 11pm and Services Provided between 11pm and 8am8am

9905499054 Sundays/HolidaysSundays/Holidays

9902499024 Post op follow up in Global PeriodPost op follow up in Global Period

9905899058 Office services on Emergent basisOffice services on Emergent basis

9908299082 Unusual Travel (transport/escort)Unusual Travel (transport/escort)

9909099090 Analysis of Data Stored on ComputerAnalysis of Data Stored on Computer

For Further InformationFor Further Information

Evaluation and Management Services Guide - Evaluation and Management Services Guide - AMAAMA

icd-9, cpt, e&m coding documentation and compliance …or the in-service for the in-service!!

Documents

hypertensive disease

icd codes icd

hypertensive renal disease

hypertensive heart disease

v codes

management icd icd

diagnostic codes

dsm codes