namas certified professional medical auditor curriculum
TRANSCRIPT
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Presented by Regan Tyler, CPC, CPC-H, CPC-I, CPMA, CEMC
Senior Consultant & NAMAS Instructor
Primary Care
Agenda
• E/M components
• E/M case examples
• Nurse code 99211
• Incident to & Split/Shared
• Modifier 25 (and other E/M modifiers)
• New Chronic Care Management codes
What Defines The Level of
Evaluation and Management (E/M) Code?
History
Exam
Medical Decision Making
Nature of Presenting Problem
Counseling
Coordination of Care
Time
“KEY” Components
Contributory Factors
CPT clearly demonstrates number of “key components” required
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History
History- Subjective
• Chief complaint – clear, concise statement detailing the reason the patient is presenting today, usually in the patient’s own words
o According to CMS, the CC may be combined with the HPI
• HPI (history of present illness)
• ROS (review of system)
• PFSH (past family social history)
History of Present Illness - HPI
• Location – where is it. (pain in LLQ abdomen)
• Quality – how does is feel – (diffuse-achy, tingling, numb etc.)
• Severity – how bad is it (0 – 10 for pain-adults, 0-3 kids)
• Duration – how long (3 days)
• Timing – when does the symptom occur (worse after meals)
• Context - what happen to caused it (fell while playing basketball twisting his knee)
• Modifying factors - what did the patient do in an attempt to alleviate their symptoms, and the result. (took otc)
• Associated signs and symptoms – what else is bothering the patient. (diarrhea & vomiting)
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Brief HPI
Mr. Jones complains of a worsening sore throat for which he
has been taking Sudafed.
Mr. Jones complains of a worsening QUALITY sore throat
LOCATION for which he has been taking Sudafed MODIFYING
FACTORS
Brief HPI
Sally continues to show improvement over the past 2 months
with her cholesterol on the current regiment of Lipitor.
Sally continues to show improvement QUALITY over the past 2
months DURATION with her cholesterol on the current regiment
of Lipitor MODIFYING FACTORS
Extended HPI
Arnold returns today with worsening low back pain. He
has been taking Advil every 4 hours, and the pain is
rated a 7 out of 10.
Arnold returns today with worsening QUALITY low back
LOCATION pain. He has been taking Advil MODIFYING
FACTORS every 4 hours, and the pain is rated a 7 out
of 10 SEVERITY
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Extended HPI
Patient returns with stable diabetes that he has had for the
past 10 years for which he takes Glucophage. He finds that his
sugar is most unstable just before bedtime
Patient returns with stable QUALITY diabetes that he has had
for the past 10 years DURATION for which he takes Glucophage
MODIFYING FACTORS He finds that his sugar is most unstable
just before bedtime TIMING
Review of Systems-(ROS)
• An inventory of the body systems of the patient to determine if the
patient is experiencing additional signs and/or symptoms
• Expand on remarkable symptoms
• A complete ROS (10+ systems) – Positive or pertinent negative
responses must be individually documented with a statement that
captures the remainder of the required review (e.g., remainder of 10
systems ROS are reviewed and negative”). In the absence of such a
notation, at least ten systems must be individually documented.
Review of Systems
• Constitutional
• Eyes
• Ears, Nose, Mouth, Throat
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Integumentary
• Neurological
• Psychiatric
• Endocrine
• Hematologic/Lymphatic
• Allergic/Immunologic
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Review of Systems
• Complete – inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems.
DG: At least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented.
**For the remaining systems, a notation indicating all other systems are negative is permissible (or something to this effect suggesting 10+ total). In the absence of such a notation, at least ten systems must be individually documented
PFSH
• Past o Current medications
o Past surgeries
o Past illnesses/injuries
• Family o Review of medical events in the patient’s family, including diseases which may be
hereditary or place the patient at risk
• Social o Age appropriate review of past and current activities
Examination
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1995/1997 Guidelines
The documentation of each patient encounter should include:
• Reason for the encounter and relevant history, physical
examination findings and prior diagnostic test results;
• Assessment, clinical impression or diagnosis;
• Plan of care; and
• Date and legible identity of the observer.
Examinations- Objective
• 1995 guidelines o Count the number of systems/areas
o Single system exams are not well-defined…
• 1997 guidelines o Count the number of “elements” or “bullets” performed
o Single system exams are defined
o Harder to meet without templates/macros
Examination Documentation Reminders
• A notation of “abnormal” without elaboration is insufficient documentation.
• Unlike history, portions of examination can not be ‘deferred’
• A brief statement/notation indicating negative or normal findings is sufficient .
• Normal or negative findings must be listed by body area or organ system.
• Page 9 of 2015 CPT states the only difference between an Expanded Problem Focused examination and a Detailed examination is that one is “limited” and the other is “extended”
o You will need to determine which guidelines suit your providers best
and consider local carrier instruction
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Problem
Expanded
Detailed
Comprehensive
1995 - Body Areas 1997 -Elements
1 1 - 5
2 - 7
2– 7 * with 1 detailed
8 + organ systems
6 - 11
12 - 17
18 / 9
Multi - Sys Single - Sys
1 - 5
6 - 11
12 +
All Shaded +
1 Unshaded
Eye/Psych = 9
Body Areas / Organ Systems
Determine Level of Exam
Let’s Apply 1995 Concepts
PHYSICAL EXAMINATION: VITAL SIGNS: Stable, afebrile. GENERAL: Awake, alert and oriented x3. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: Clear to auscultation. ABDOMEN: Soft, minimal amount of tenderness right upper quadrant, no guarding, no rebound, no acute abdomen, stool in vault, no hepatosplenomegaly.
Bullet Page #1
• Bullet #1
• Bullet #2
• Bullet #3
• Bullet #4
• Bullet #5
• Bullet #6
PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 170/75, pulse 96, respirations 16, O2 saturation 97% on room air. Afebrile. GENERAL: Patient is alert and oriented to person, place and time. Is resting comfortably in bed in no acute distress. HEENT: Atraumatic, normocephalic. Pupils equal, round and reactive to light and accommodation. Extraocular movements are intact. Oropharynx is clear and moist. No exudate present. NECK: Supple. No lymphadenopathy. CARDIOVASCULAR: Regular rate and rhythm. Grade 2/6 systolic murmur. No rubs or gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, crackles or rhonchi. ABDOMEN: Positive bowel sounds. Appropriately tender to palpation in right upper quadrant. Nondistended. GENITOURINARY: External genitalia with normal appearance. Bimanual exam is within normal limits with no palpable masses. EXTREMITIES: No erythema, no edema. No calf tenderness.
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Bullet Page #1
• Bullet #1
• Bullet #2
• Bullet #3
• Bullet #4
• Bullet #5
• Bullet #6
PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure is 130/80, heart rate is 82, respiratory rate 16, temperature 98. Saturating 98% on two liter of oxygen. GENERAL: Patient is alert, oriented x3, in no acute distress. He appears somewhat drowsy. He is laying down in 30 degree head-up position in no respiratory distress. HEENT: Positive PERRLA. Sclerae nonicteric. Conjunctiva pink. Oral mucosa moist and I could not evaluate the JVD due to patient's thick neck and large body habitus. No carotid bruits could be appreciated. Thyroid within normal limits. NECK: Supple. CARDIOVASCULAR: Regular rate and rhythm, normal S1-S2. No murmur or gallops could be appreciated. LUNGS: Clear to auscultation bilaterally. No crackles, wheezings, rhonchi was appreciated. ABDOMEN: Normoactive bowel sounds, nondistended, nontender. No organomegaly. EXTREMITIES: Less than 1+ pitting edema in both lower extremities. No clubbing or cyanosis. Has good distal pulses in all four extremities. INTEGUMENTARY: Intact, no rash. NEUROLOGIC: Grossly intact with no focal, sensory, or motor deficits.
Medical Decision Making
Components of MDM
• Medical Decision Making o Number of diagnosis or management
o Amount and/or complexity of data
o Risk of complication
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MEDICAL DECISION MAKING BOX A: Number Of Diagnosis or Management Options (N x P = R)
Problems Number Points Results
Self-limited or minor (stable, improved or worsening) Max = 2 1
Est. problem: stable or improved 1
Est problem: worsening, failing to change 2
New problem: no additional work-up planned Max = 1 3
New problem: additional work-up planned 4
Bring to line A in Final Result for MDM Total
Number of Diagnosis / Problems
Impression:
Shortness of breath
Hypertension
Patient is scheduled for pulmonary consult and started on fast
acting albuterol inhaler. F/U after consult.
Bullet Page #1
• Bullet #1
• Bullet #2
• Bullet #3
• Bullet #4
• Bullet #5
• Bullet #6
MEDICAL DECISION MAKING BOX B: Amount and/or Complexity of Data to be reviewed Points
Review and/or order of clinical lab test 1
Review and/or order of tests in the radiology section of CPT 1
Review and/or order of tests in the medicine section of CPT 1
Discussion of test results with performing physician 1
Decision to obtain old records and/or obtaining history from
someone other than patient 1
Review and summarization of old records and/or obtaining
history from someone other than patient and/or discussion of
case with another health care provider 2
Independent visualization, tracing or specimen itself (not simply
review of report) 2
Bring to line B in Final Result for MDM Total
In order to get credit, the provider must document review & summary
You do not get 2 points if billing the professional component (-26)
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Amount of Data
Chest Pain
Diabetes
Chest X-Ray in the office today was normal. Patient scheduled
for 24-hour Holter monitor. Also ordered fasting A1C as patient
is overdue.
BOX C: Risk of Complication and/or Morbidity or Mortality
Presenting Problems Diagnostic Procedures ordered Management Options Selected
Min
imal
1 self-limited or minor problem
(eg. Cold, insect bite, tinea
corporis
Lab tests requiring venipuncture
EKG/EEG
Urinalysis
Ultrasound, X-RAYS
KOH prep
Rest
Gargles
Elastic bandages
Superficial dressings
Lo
w
2 or more self-limited or minor
problems
1 stable chronic illness
Acute uncomplicated illness or
injury
Physiologic test not under stress
Non-cardiovascular imaging
Superficial needle biopsies
Clinical lab test requiring arterial puncture
Skin biopsies
Over-the-counter drugs
Minor surgery w/ no identified risk
factors
Physical therapy
Occupational therapy
IV fluids without additives
Mo
der
ate
1 or more chronic illnesses w/mild
exacerbation, progression or side
effects of treatment
2 or more stable chronic illnesses
Undiagnosed new problem w/ uncertain prognosis
Acute illness with systemic
symptoms
Acute complicated injury
Physiologic test under stress
Diagnostic endoscopies w/no identified risk
factors
Deep needle or incisional biopsy
Cardiovascular imaging studies w/contrast, no identified risk factors
Obtain fluid from body cavity
Minor surgery with identified risk
factors
Elective major surgery w/o risk
(open, percutaneous, or endoscopic)
Prescription drug management
Therapeutic nuclear medicine
IV fluids with additives
Closed treatment of fracture or
dislocation w/o manipulation
Hig
h
1 or more chronic illnesses w/
severe exacerbation, progression,
side effects of treatment
Acute or chronic illnesses or
injuries that pose a threat to life or bodily function
Abrupt change in neurologic
status
Cardiovascular imaging studies w/contrast
w/ identified risk factors
Cardiac eletrophysiological tests
Diagnostic endoscopies w/indentified risk
factors
Discography
Elective major surgery (open,
percutaneous or endoscopic) w/risk
Emergency major surgery (open,
percutaneous or endoscopic)
Parenteral controlled substances
Drug therapy requiring intensive
monitoring for toxicity
Decision not to resuscitate or to de-
escalate care because of poor
prognosis
Risk
Patient presents today with hypertension, diabetes and
hyperthyroidism. Patient appears stable on current regimen
and no changes are required at this time.
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MEDICAL DECISION MAKING BOX D: Final Result for Complexity of Medical Decision Making: 2 of 3 required
A Number of diagnoses or
management options
≤ 1
Minimal
2
Limited
3
Multiple
≥ 4
Extensive
B Amount and complexity of
data to be reviewed
≤ 1
Minimal
2
Limited
3
Multiple
≥ 4
Extensive
C Risk of complications and/or
morbidity or mortality Minimal Low Moderate High
TYPE OF DECISION MAKING Straight
Forward
Low
Complexity
Moderate
Complexity
High
Complexity
Medical Decision Making
Inguinal Hernia
New Problem, no work up
Diabetes
Not addressed
Hypertension
Not addressed
Robert presented today with acute abdominal pain. The ultrasound reveals a rather
large inguinal hernia that will need surgical intervention. We will schedule him with a
general surgeon first thing in the morning.
Review/order ultrasound
Major surgery without complications
Medical Decision Making
Sore throat
Established Problem, worsening
Cough
New Problem, no work up planned
Patient returns with continued sore throat. Rapid Strep test done in the
office is negative. New productive cough complicating sore throat. Patient
given prescription for Tusslon pearls 250mg, every 4 hours for the next 24.
Will call if symptoms do not improve.
Order/review lab test
Prescription Drug Management
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New Versus Established Patients
A new patient is one who has not received any face to face professional service from the physician/qualified healthcare professional
or
another physician/qualified healthcare professional of the exact same specialty/subspecialty who belongs to the same group practice within the past three years (Check taxonomy codes if unsure)
Medicare regulation states: "Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician."
CPT Code 99211
Typical nurse visits include, patient education, injections, infusions, problem focused evaluations and specimen collection.
Per CPT, “Usually, the presenting problem(s) are minimal. Typically, five minutes
are spent performing or supervising these services.”
General Requirements ◦ Non – Physician must be: ◦ Employee or contractor for physician
Follow physician orders resulting from his/her evaluation of the patient
Be supervised by a physician
• “Because medical necessity is required, vital signs and blood pressure checks
may not be routinely performed at the time of another coded service in order to
bill for a 99211 visit” (e.g.., injections, INRs, etc.)
Page 12 2013 CPT
Incident to
• Follow established patient’s on plan of care already
established by physician
• Cannot see new patients and bill incident to (report under
own ID)
• Cannot see established patients for a NEW problem (report
under own ID)
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Split / Shared Visits
• Patient is seen by both NPP and MD possibly at different
times
• Each provider documents their encounter
• Physician can use NPP’s documentation towards their total
encounter level
Split / Shared Visits
• EXAMPLES OF SHARED VISITS
• 1. If the NPP sees a hospital inpatient in the morning and the physician
follows with a later face-to-face visit with the patient on the same day,
the physician or the NPP may report the service.
• 2. In an office setting the NPP performs a portion of an E/M encounter
and the physician completes the E/M service. If the "incident to"
requirements are met, the physician reports the service. If the “incident
to” requirements are not met, the service must be reported using the
NPP’s UPIN/PIN.
Modifier 25
The following statements are false:
o I can always use this modifier for a new patient.
o I can always use this modifier when I did not plan the procedure.
o I can always use this modifier when the diagnoses are different.
o I can never use this modifier when the diagnoses are the same.
Appropriate Usage:
• “Modifier 25 indicates that on the day of a procedure, the patient's
condition required a significant, separately identifiable E/M service,
above and beyond the usual pre and post-operative care associated with
the procedure or service performed”
Source: WPS Medicare
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E/M Modifiers
Modifier 24: Unrelated E/M during global
Modifier 25: E/M with minor procedure
Modifier 32: Mandated Service
Modifier 57: E/M with major procedure
2015 CPT Changes
• 266 New Codes
• 147 Deleted Codes
• 129 Revised Codes
• Total of 9,951 CPT codes to master!
Evaluation & Management
Chronic Care Management
• 99490 – at least 20 minutes
Complex Chronic Care Management
• 99487 – 60 minutes
• +99489 – each additional 30 minutes
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Evaluation & Management
• Chronic Care Management 99490
• “Patients who receive chronic care management series have
two or more chronic continuous or episodic health
conditions that are expected to last at least 12 months or
until the death of the patient, and that place the patient at
significant risk of death, acute exacerbation /
decompensation, or functional decline. Code 99490 is
reported when, during the calendar month, at least 20
minutes of clinical staff time is spent in care management
activities”
Evaluation & Management
• Complex Chronic Care Management 99487
• The same criteria for CCM is required as well as establishment
or substantial revision of the a comprehensive care plan;
medical, functional and/or psychosocial problems requiring
medical decision making of moderate or high complexity; and
clinical staff care management series for at least 60 minutes,
under the direction of a physician or other qualified health care
professional
• Each add’t 30 minutes reported with add-on code 99489
Evaluation & Management
• Recommend billing CCM and CCCM as soon as the time
threshold has been met.
• Will only be paid once per month to one provider – first one
with their claim in the door gets paid
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Advanced Care Planning
• 99497
• Advanced Care Planning – first 30 minutes
• +99498
• Each additional 30 minutes
Evaluation & Management
• Advanced Care Planning 99497
• “…explanation and discussion of advanced directives such as
standard forms (with completion of forms, when performed) by
the physician; first 30 minutes face-to-face with the patient,
family member(s), and/or surrogate
• Each additional 30 minutes use add-on code 99498
Evaluation & Management
• Advanced Care Planning can be billed on the same day as
other E/M services
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Application of Fluoride
● 99188 Application of topical fluoride varnish by a
or other qualified health care
professional
Cannot be reported if performed by ancillary staff
CMS will not cover
Regan Tyler, CPC, CPC-H, CPC-I, CPMA, CEMC [email protected]
CEU Index# 38868XYH