april 2019 lunch and learn overview of professional and facility … · 2019-04-17 · (problem...

April 2019 Lunch and Learn

Overview of Professional and Facility Evaluation and Management Code Assignment

Objectives

After completing this education participants will:• Have refreshed their knowledge and understanding of the

professional fee and facility evaluation and management code assignment.

• Differentiated the difference between professional and facility evaluation and management codes.

Overview of the Evaluation and Management Section

Evaluation & Management Section

• Codes 99201-99499

• First Section in CPT

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

• Review guidelines at beginning of section

• Notes located beneath heading 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

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)

Encounter Type

Emergency Room Patient - providers will generally use a code in the99281-99285 seriesConsultation - reported using the new or established evaluationand management codes

• Consult is a request for advice or opinion from a provider; a referral transfers complete responsibility of treatment for a specific or suspected problem

• Consulting provider may initiate diagnostic or therapeutic services

Preventative - physical and well-baby visitsNOTE: If an additional problem or issue is identified and treated, an additional E/M code may be applied

Encounter Type

Inpatient• Initial• Subsequent• Consultation

Example

Dr. Smith completed Nena Scott’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

New vs. Established

• New Patient - one who has not received any professional services from the provider or another provider of the same specialty who belongs to the same group practice in the previous three years.

• Established Patient - one who has received professional services from the provider or another provider of the same specialty who belongs to the same group practice in the previous three years.

Professional Fee Evaluation and Management

Key Components of E/M Codes

• Three key components:

– History

– Exam

– Complexity of medical decision making

• New patients

– Three components required

• Established patients

– Two of three components required

Components History

The levels of E/M services are based on four types of history (Problem Focused, Expanded Problem Focused, Detailed, and Comprehensive). Each type of history includes some or all of the following elements:

• Chief complaint (CC); must be present for all

• History of present illness (HPI);

• Review of systems (ROS); and

• Past, family and/or social history (PFSH)

Components of History

Chief Complaint

• Describes the patient’s presenting signs, symptoms, problem, condition, or reason for the visit

History of Present Illness (HPI)

• Chronological description of the patient’s present illness from the first signs and/or symptom or from the previous encounter to the present


Review of Systems (ROS)

• Inventory of body systems obtained by asking a series of questions in order to identify signs and/or symptoms that the patient may be experiencing or has experienced

History of Present Illness Documentation Examples

Location Left Right Proximal Distal

Duration Since this morning 1 week Several Months 48 hours

Modifying Factors Better after eating Relieved by aspirin

Worsens when Took ____ with no relief

Quality Sharp Dull Shooting Throbbing

Severity Pain is 6 on a scale of 1-10

Severe Slight Intolerable

Timing Daily Begin at midnight

Sporadic Nocturnal

Context During exercise Occurred at While running While walking, but not when standing

Associated Signs and Symptoms

Without fever Headache Nausea/vomiting No LOC

1995 Guidelines - History of Present Illness

Chief Complaint New Patient Est Patient Consultation

HISTORY

HPI (History of Present Illness) Location Duration Mod. Factors Quality Severity Timing Context Associated signs & symptoms

Brief (1-3 elements)

Extended(4 or more elements)

16

1997 Guidelines - History of Present Illness Chief Complaint

New Patient Est Patient Consultation

HISTORY

HPI (History of Present Illness) Location DurationMod. Factors Quality Severity Timing Context Associated signs & symptomsOR Status of chronic/inactive conditions 1

2 3

Brief (1-3 elements, or status of

1-2 chronic conditions)

Extended(4 or more elements, or

status of 3 chronic or inactive conditions)


Review of Systems (ROS)

• Inventory of body systems obtained by asking a series of questions in order to identify signs and/or symptoms that the patient may be experiencing or has experienced

Review of Systems

ROS (Review of Systems)

Constitutional Eyes ENMT Card/vasc Neurology GIMusculoskeletal Respiratory GU Hem/Lymph Psych Allergy/Imm Integumentary Endocrine

None

Pertinent toproblem/chief

complaint (1 system)

Extended(2-9 systems

including 1 system pertinent to problem/

chief complaint)

Complete(10 or more systems including

1 system pertinent to problem/ chief complaint)

18


Past, Family, and Social History (PFSH)

• Past illness, operations, injuries, and treatments

• Family history of medical events, diseases, hereditary conditions that may place the patient at risk

• Social history including age and appropriate review of past and current activities (e.g., smoking, alcohol and drug use)

Past, Family, and Social History

PFSH (Past medical, Family and Social History) Past (patient’s illnesses, operation, injuries &

treatments) Family (review of medical events in pt’s family

incl. hereditary disease placing pt at risk) Social (age appropriate review of past & current

activities)* Complete PFSH: 2 Hx areas: a) Established pts. - office visit;

domiciliary care; home care; b) Emergency dept. visit; and, c) Subsequent nursing facility care.

3 Hx areas: a) New patients. - office visit; domiciliary care; home care; b) Consultations; c) Initial hospital care; d) hospital observation; and, e) Comprehensive nursing facility assessments.

None

Pertinent(1 history

area)

CompleteNew or

Consult : 3 history

areasEstablished:

2 historyareas

ProblemFocused

(PF)

ExpandedProblemFocused

(EPF)

Detailed (D)Comprehensive

( C )

20

1995 Guidelines – History Leveling

21


HISTORY

HPI (History of Present Illness) Location Duration Mod. Factors Quality Severity Timing Context Associated signs & symptoms

Brief (1-3 elements)

Extended(4 or more elements)

ROS (Review of Systems) Constitutional Eyes ENMT Card/vasc Neuro GI Musculoskeletal Resp iratory GU Hem/Lymph Psych Allergyimm

Integumentary Endocrine

None

Pertinent to problem

(1 system)

Extended(2-9 systems including 1 pertinent)

Complete(10 or more

systems including 1 pertinent)

PFSH (Past medical, Family and Social History) Past (patient’s illnesses, operation, injuries & treatments) Family (review of medical events in pt’s family incl. hereditary

disease placing pt at risk) Social (age appropriate review of past & current activities)* Complete PFSH: 2 History areas: a) Established pts. - office visit; domiciliary care; home care; b) Emergency dept. visit; and, c) Subsequent nursing facility care.3 History areas: a) New patients. - office visit; domiciliary care; home care; b) Consultations; c) Initial hospital care; d) hospital observation; and, e) Comprehensive nursing facility assessments.

None

Pertinent(1 history area)

CompleteNew or Consult : 3 history areasEstablished: 2 history areas

Problem Focused

(PF)

Expanded Problem

Focused (EPF)Detailed (D)

Comprehensive( C )

Final level of history requires 3 components above met or exceeded

1997 Guideline - History Leveling

22


HISTORY

HPI (History of Present Illness) Location Duration Mod. Factors Quality Severity Timing Context Associated signs & symptomsOR Status of chronic/inactive conditions 1 2 3

Brief (1-3 elements, or status

of 1-2 chronic conditions)

Extended(4 or more elements, or status of 3

chronic or inactive conditions)

ROS (Review of Systems) Constitutional Eyes ENMT Card/vasc Neuro GI Musculo Resp GU Hem/Lymph Psych All/imm Integ Endo

None

Pertinent to problem

(1 system)

Extended(2-9 systems including 1 pertinent)

Complete(10 or more systems

including 1 pertinent)

PFSH (Past medical, Family and Social History) Past (patient’s illnesses, operation, injuries & treatments) Family (review of medical events in pt’s family incl. hereditary disease placing pt at risk) Social (age appropriate review of past & current activities)* Complete PFSH: 2 Hx areas: a) Established pts. - office visit; domiciliary care; home care; b) Emergency dept. visit; and, c) Subsequent nursing facility care.3 Hx areas: a) New patients. - office visit; domiciliary care; home care; b) Consultations; c) Initial hospital care; d) hospital observation; and, e) Comprehensive nursing facility assessments.

None

Pertinent(1 history area)

CompleteNew or Consult : 3 history areas

Established: 2 history areas

Problem-Focused

(PF)

Expanded Problem Focused

(EPF)

Detailed (D) Comprehensive ( C )

Final level of history requires 3 components above met or exceeded

Examination – 1995 Guidelines

• Problem Focused – limited exam of one affected body area or organ system

• Expanded Problem Focused (EPF) – limited examination of the affected body area or organ system and other symptomatic or related organ system(s), typically 2-4 organ systems

• Detailed - extended examination of the affected body area(s) and other symptomatic or related organ system(s), typically 5-7 organ systems

• Comprehensive – general multi-system examination or complete examination of a single organ system (the guidelines state that you need 8 out of the 12 organ systems documented to receive a comprehensive level of exam)

Examination - 1997 Guidelines• Problem Focused Examination – one to five elements identified

in one or more organ system(s) or body area(s). • Expanded Problem Focused Examination – at least six elements

identified in one or more organ system(s) or body area(s). • Detailed Examination – at least six organ systems or body areas.

For each system/area selected, performance and documentation of at least two elements identified is expected. • Alternatively, a detailed examination may include performance

and documentation of at least twelve elements identified in two or more organ systems or body areas.

• Comprehensive Examination – at least nine organ systems or body areas. For each system/area selected, all elements of the examination identified by a bullet should be performed, unless specific directions limit the content of the examination. For each area/system, documentation of at least two elements identified by a bullet is expected.

1995 vs 1997Physical Examination Components

Level of Exam CPT Description 1995 Guidelines 1997 Guidelines

Problem Focused Limited to affected body area or organ system

1 (affected) body area or organ system

1 – 5 bulleted elements

Expanded Problem Focused

Limited exam of affected body area or organ system and other symptomatic or related organ systems

2-7 body areas or organ systems

6 – 11 bulleted elements

Detailed Extended exam ofaffected body area or organ system and other symptomatic or related organ systems

Extended exam (≥ 3 documented findings) of affected body area or organ system + 2-7 additional body areas or organ systems

12 – 17 bulleted elements for two or more systems

Comprehensive

General multi-system exam 8 or more organ systems

18 or more bulleted elements for 9 or more systems

Complete single organ system exam

Not defined See 1997 CMS requirements for individual single system exams

© TrustHCS 2016© TrustHCS 2016

Examination Organ Systems

Constitutional

Eyes

Ears, nose, mouth, and throat

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Musculoskeletal

Skin

Neurologic

Hematologic/Lymphatic/Immunologic

Psychiatric

Body Areas

Head, including the face

Neck

Chest, including breasts and axillae

Abdomen

Genitalia, groin, buttocks

Back, including spine

Right upper extremity

Left upper extremity

Right lower extremity

Left lower extremity

Examination Documentation Guidelines - 1995 and 1997

• Includes body areas and/or organ systems pertinent to the encounter

• Findings of each area or system examined is individually documented

• Finding may be documented as:• Negative or normal

• Positive or abnormal with explanation of finding(s)

• Example – Respiratory: Rales, crackles

27

1995 Guidelines - Examination

EXAMINATION

Body Areas: □1 bodyarea orSystem

□Limitedexam ofAffected

body area + 2-7 body

areas orsystems

□Expandedexam (≥3

documentedelements) of

affected bodyarea

+ 2-7additional

body areas orsystems

□8 or more

OrganSystems

□ Head(w/face)

□ Chest, w/breast &axillae

□ Abdomen □ Back,(w/spine)

□ Neck(thyroid)

□Genitalia/groin/buttocks

□ EachExtremity

Organ Systems:

□ Constitutional□ Eyes□ Ears, nose,

mouth, throat

□ Skin□ Respiratory□ Card/vascular

□ GI□ GU□ Neuro

□ Musculoskeletal□ Hema/lymph /imm□ Psych

ProblemFocused

(PF)

ExpandedProblemFocused

(EPF)

Detailed(D)

Comprehensive(C)

28

Complexity of Medical Decision Making (MDM)

Measured by:• Number of diagnoses or management options• Amount and/or complexity of data• Risk of complications and/or morbidity or mortality

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

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

Medical Decision Making (MDM)MDM Points Table Two out of three must be present to qualify for a given level of MDM

Overall MDM Problem

Points Data

Points Risk

Straightforward Complexity 1 1 Minimal

Low complexity 2 2 Low

Moderate Complexity 3 3 Moderate

High Complexity 4 4 High

Medical Decision Making (MDM)Problem PointsThe “nature and number of clinical problems” are quantified into Problem Points by referring to the following table:

Problems Points

Self-limited or minor (maximum of 2) 1

Established problem, stable or improving 1

Established problem, worsening 2

New problem, with no additional work-up planned (maximum of 1)

3

New problem, with additional work-up planned 4

Medical Decision Making (MDM)

Data PointsThe “amount and complexity of the data reviewed” are quantified by referring to the following table:

Data Reviewed Points

Review or order clinical lab tests 1

Review or order radiology test (except heart catheterization or echo)

1

Review or order medicine test (PFTs, EKG, cardiac echo or catheterization)

1

Discuss test with performing physician 1

Independent review of image, tracing, or specimen 2

Decision to obtain old records 1

Review and summation of old records 2

Contributory ComponentsCounseling and Coordination of Care

• 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 Presenting Problem • Minimal; self-limited or minor, low, moderate, high

Time• Face to Face

• Unit/Floor

Billing Based on Time

Documentation must reflect:• Total length of time for the encounter• Length of time spent coordinating and/or counseling • Issues discussed• Relevant history, exam, and medical decision making

FacilityEvaluation and Management

Facility Evacuation and Management Coding

• Each Facility should develop billing and coding guidelines that reflect the intensity of services for the different levels

• Coding guidelines should be based on facility resources and should be clear to facilitate accurate payments

• Documentation represent information that is clinically necessary for patient care

Example – ER Acuity LevelAcuity Level Level 1 Level 2 Level 3

CPT Code 99281 99282 99283

Description Emergency Department Visit Limited/Minor Problem

Emergency Department Visit Low/Minor Severity

Emergency Department Visit Moderate Severity

Nursing Direct/Indirect Patient Care

Brief Care: • Minimal Nursing

Care/ Involvement

Limited Care Single System: • Limited Nursing

Care

Intermediate: • Brief to Moderate

Exam• Vital Signs• Discussion of

Discharge Instructions (moderately complex)

• EMS/Ambulance

Disposition Discharge (Simple) Discharge (Simple) Discharge (brief to moderate)

Medication None Tetanus IMNo IM, IV or Oral Medications

IM, IV, or oral Medications


General: Interventions

• Vital Signs• No Medications or

Treatment

Referral for Over the Counter Medications

• IV Therapy or Hep Lock• Pulse Oximetry –

Continuous• Single X-ray for Single

Area• Administration of

Prescription Medication• Blood Draw for Labs• Consultations • Multiple Labs

Examples • Insect Bite (uncomplicated)• Rechecks• Check Tb Skin Test• Triaged and Left without

Being Seen

• Sunburn• Ear Pain• Minor Viral Infections• UTI without fever• Simple Trauma (no x-rays)

• Head Injury – without Neurologic Symptoms

• Mild Dyspnea – Not Requiring Oxygen


CPT Code 99284 99285 99291

Description Emergency Department Visit High/Urgent Severity

Emergency Department Visit High Severity

Critical Care, Evaluation & Management, First Hour

Nursing Direct/Indirect Patient Care

Extended Care:• Moderate to Extended• Monitor Vitals• Discussion of Discharge

Instructions – complex, family included

Comprehensive: • 1:1 Nursing• Possibly unstable/guarded

condition• Discussion of Discharge

Instructions – complex, family included

• Multiple Consultations

Critical Care:• 2:1 or Greater Nursing• Possible Altered Levels,

Unstable Vital Signs• Code Blue• Cardiac Massage• Trauma Call

Disposition Discharge (With possible Admission or Transfer)

Discharge/Admit/Transfer Critical Care Admit/Transfer/Expired

Medication • Continuous IV Infusions• More than 2 Nebulizer

• Continuous IV Infusions• Multiple Medication with

Monitoring

• Dopamine, Dobutamine Drip

• Lidocaine Drip• Nitroglycerine Drip• Nipride Drip• TPA/Sterptokinase• Tridil


General: Interventions

• Preparation for more than one special imaging study (CT, MRI,V/Q scan, US)

• Assist PMD with diagnostic/therapeutic procedures (with stable orthostatics with multiple area X-ray/meds)

• Preparation for X-ray -multiple areas

• Multiple blood draw/labs• Lumbar puncture

• Coordination of admission/transfer, or change in living situation

• Cooling/heating blanket• Monitor/stabilize patient

during in-hospital transport and testing (MRI, CT, V/Q scan, US. Vascular studies)

• Conscious sedation

• Multiple parenteral medications requiring constant monitoring

• Multiple Surgical consultants• Arterial Line Placement• Control of Major Hemorrhage• Administration of Blood or

Blood Products• Cut-down• CVP Line insertion• ET tube• Ventilator

Examples • Child w/fever & lab/X-ray • Pediatric sepsis • Blunt/penetrating trauma • MVA multiple injuries

• Severe dehydration : w/multiple IV, tests, and/or labs

• Sepsis/SIRS w/multiple IV/IM med

• Overdose or ingestion

• Acute Failure: renal, hepatic, respiratory, pulmonary edema

• Life-threatening -Hyper/hypothermia

• Major trauma• Shock of all types: septic,

cardiogenic, spinal, hypovolemic, anaphylactic

Thank YouFor Your Time and Attention!

Reference

Association, A. M. (2014). Evaluation and Management Section. In Current Procedural Terminology . American Medical Association.

Green, M. A. (2011). 3-2-1 Code It! Clifton Park, NY: Delmar Cengage Learning.

Optum 360, (2017) Evaluation and Management Services Guidelines Section. In Current Procedural Terminology American Medical Association.

april 2019 lunch and learn overview of professional and facility … · 2019-04-17 · (problem...

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