© 2010 delmar, cengage learning chapter 9 cpt evaluation and management

© 2010 Delmar, Cengage Learning

Chapter 9

CPT Evaluationand Management


E/M Section

• Codes 99201–99499• First section in CPT• Review guidelines at beginning section

• Apply applicable notes


E/M Coding Tips

• Notes located beneath headings and/or subheadings apply to all codes in heading or subheading

• Parenthetical notes located below a specific code apply to that code only– Unless the note indicates otherwise


E/M Overview

• Introduced in 1992• Between three and five levels of service

• Reflects amount of work involved in providing health care to a patient


Levels of Service

• Organized according to:– Place of service

• Physical location where health care is provided to patients (e.g., office, hospital, home, nursing facility)

– Type of service• Type of health care services provided to patients (e.g., new or initial encounter, follow-up or subsequent encounter, consultation)


Example

• Dr. Miller completed Jennifer Sullivan’s history and physical on the first day of her inpatient admission– Place of service: hospital– Type of service: initial care– E/M category: hospital inpatient services

– E/M subcategory: initial hospital care


E/M Section Guidelines

• Located at beginning of section

• Includes:– Classification of E/M services– Definitions of commonly used terms– Unlisted service– Special report– Clinical examples– Instructions for selecting level of E/M service


Classification of E/M

• Categories (e.g., office, outpatient visits, consultations)

• Subcategories (e.g., new and established patients)

• Five-digit numerical codes (99201–99499)

(continued)


Classification of E/M

• Code descriptions include:– Place and/or type of service– Content of service– Detailed history and examination– Nature of presenting problem– Time required to provide service


E/M Key Terms

• New patient• Established patient• Concurrent care• Unlisted service• Special report• Clinical examples (Appendix C)


Levels of E/M Service

• When selecting, require key components of history, examination, and medical decision making

• Contributory components include counseling, coordination of care, nature of presenting problem, and time


Key Components

• Three components:– Extent of history– Extent of examination– Complexity of medical decision making

• New patients– Three components required

• Established patients– Two of three components required


Extent of History

• Includes:– History of present illness (HPI)– Review of systems (ROS)– Past/Family/Social history (PFSH)

• Four types:– Problem-focused– Expanded problem-focused– Detailed– Comprehensive


Extent of Examination

• Four types:– Problem-focused– Expanded problem-focused– Detailed– Comprehensive


Complexity of Medical Decision Making

• Measured by:– Number of diagnoses or management options

– Amount and/or complexity of data– Risk of complications and/or morbidity or mortality

(continued)


Complexity of Medical Decision Making

• Documentation includes:– Ancillary test results (e.g., laboratory)

– Known diagnoses– Opinions of other physicians– Planned course of action– Review of previous records


Medical Decision Making

• Four types of complexity:– Straightforward– Low– Moderate– High


E/M Code Selection

Select E/M code based on extent of history and examinationand complexity of medical decision making

History Problem-focused

Expandedproblem-focused

Expanded problem-focused

Detailed Compre-hensive

Examina-tion

Problem-focused

Expandedproblem-focused

Expanded problem-focused

Detailed Compre-hensive

MedicalDecisionMaking

Straight-forward

Lowcomplexity

Moderate complexity

Moderate Complexity

High Complexity

Go to appropriate E/M category/subcategory andselect code based on this information

Current Procedural Terminology © 2008 American Medical Association. All rights reserved.


Contributory Components

• Counseling and/or coordination of care components “drive” CPT code selection only when they dominate the encounter.


Counseling

• Diagnostic results• Prognosis• Risks and benefits of treatment options

• Instructions for treatment and/or follow-up

• Compliance with treatment options• Risk factor reduction• Patient and family education


Nature of the Presenting Problem

• Five types:– Minimal– Self-limited or minor– Low severity– Moderate severity– High severity


Time

• Face-to-face time– Amount of time office or outpatient care provider spends with patient and/or family

• Unit/Floor time– Amount of time provider spends at patient’s bedside and managing patient’s care on unit/floor


Billing According to Length of Time

• Document:– Total length of time for the encounter

– Length of time spent coordinating and/or counseling

– Issues discussed – Relevant history, exam, and medical decision making


Code 99211

• Nurse visit• Reported when ancillary personnel provide E/M services

• Document chief complaint and description of service provided


Hospital Observation Services

• Subcategories– Observation care discharge services– Initial observation care

• Discharge services– Final examination of patient– Discussion of hospital stay– Instructions for continuing care


Initial Observation Care

• Reported for patients who are admitted for observation services on one date and discharged from observation status on a different date


Hospital Inpatient Services

• Subcategories– Initial hospital care– Subsequent hospital care– Observation or inpatient care services

– Hospital discharge services


Hospital Discharge Services

• Includes:– Final examination of patient– Discussion of hospital stay – Instructions for continuing care– Preparation of discharge records, prescriptions, and referral forms


Consultations

• Consultation criteria• Subcategories

– Office or other outpatient services– Initial inpatient consultations

• Preoperative clearance


Pediatric Critical Care Patient Transport

• Definition• Interfacility transport• Critical illness or injury


Critical Care Services

• Physician directly delivers medical care to critically ill or injured patient– Manages life-threatening conditions– Single or multiple vital organ system failure

• Does not have to be provided in a critical care unit

• May be continuous or interrupted

(continued)



• Includes the following procedures:– Blood gases– Chest x-rays– Gastric intubation– Information data stored in computers– Cardiac output measurements– Pulse oximetry

(continued)



• Includes the following procedures:– Temporary transcutaneous pacing– Vascular access procedures– Ventilatory management


Inpatient Neonatal and Pediatric Critical Care

• Neonate• Low birth weight

– Less than 1500 grams (g)


Nursing Facility Services

• Includes:– Nursing facility (NF)– Skilled nursing facility (SNF)– Intermediate care facility (ICF)/Mentally retarded

– Long-term care facility (LTCF)– Psychiatric residential treatment facility


Prolonged Services

• Reported in addition to an E/M service at any level

• Physician’s services involving patient contact that are considered beyond the usual service in either an inpatient or outpatient setting

(continued)


Prolonged Services

• Reported only when time is greater than 30 minutes

• Time must be documented


Physician Standby Services

• Physician spending a prolonged period of time without patient contact waiting for an event to occur that will require the physician’s services

(continued)


Physician Standby Services

• Standby types:– Operative– Pathology– Diagnostics– Obstetrics– Pediatrics


Case Management Services

• Physician is responsible for:– Direct care of patient– Coordinating and controlling access to or initiating and/or supervising other health care services needed


Care Plan Oversight Services

• Cover physician’s time while supervising a complex and multidisciplinary care treatment program for a specific patient under the care of a home health agency, hospice, or nursing facility


Preventive Medicine Services

• Routine examinations or risk management counseling for children and adults who exhibit no overt signs or symptoms of a disorder while presenting to the medical office for a preventive medical physical

• Wellness visits• Risk factors


Newborn Care

• Service provided in a variety of health care settings, hospitals, birthing centers, and homes that include:– History and examination of normal infant

– Attendance at delivery and initial stabilization of newborn

– Newborn resuscitation


Counseling Risk Factor Reduction

• Preventive Medicine Counseling (99401-99404)

• Used for promoting health and preventing illness and injury

(continued)


Counseling Risk Factor Reduction

• Intervention should address family problems, diet and exercise, substance use, injury prevention, and dental health

• No illness should be present with these codes


Behavior Change Intervention

• Behavior Change Intervention (99406-99409)

• For patients who have behavior that is considered an illness, itself

• Smoking and tobacco cessation• Alcohol and/or substance abuse


Non-Face-to-Face Physician Service

• Telephone Service (99441-99443)

• E/M service provided by a physician using the telephone

(continued)


Non-Face-to-Face Physician Service

• Code is not reported if service ends with decision to see patient within 24 hours or within seven days of a previously completed procedure

• Provided to an established patient


Special E/M Services

• Provided to:– Establish baseline information prior to issuance of life or disability insurance certificates

– Examine a patient with a work-related or medical disability problem

© 2010 delmar, cengage learning chapter 9 cpt evaluation and management

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