physician training presented by: la verne jones 1/15/2009 © 2006 the coding network, llc inpatient...

1/15/2009 www.codingnetwork.com© 2006 The Coding Network, LLC

Physician TrainingPresented by: La Verne Jones

INPATIENT SERVICES

1


The Coding Network (TCN)

Quality and Affordability

THE CODING NETWORK is committed to provide cost effective state-of-the-industry procedural and diagnostic coding support to medical groups, academic practice plans, hospitals, ambulatory surgery centers, and billing companies throughout the United States.

2


TCN provides physician & hospital coding,

compliance reviews and training

Avoid costly mistakes and unnecessary audits.

Maximize your revenue. Reduce fixed expenses. Maintain continuity of coverage. Safeguard OIG and CMS compliance. Eliminate coding backlogs. Add new specialists with confidence.

3


TCN is the nation’s leading remote coding service

Each specialty is managed by a national coding expert, with years of coding experience in his specialty.

Our staff of certified coders understand the subtle differences that exist in each specialty.

All coders have years of experience coding exclusively for their specialty.

Since our 1995 establishment, not a single physician has ever paid a penny for recoupments, fines or penalties for a case coded by TCN.

4


TCN’s areas of expertisePHYSICIAN CODING Ambulatory Surgery Centers Anesthesiology Cardiac Catheterization Colorectal Surgery Emergency Medicine Evaluation and Management

Services Gastroenterology General Surgery Gynecology and Gynecologic

Oncology Interventionional Radiology Neurosurgery Ophthalmology Orthopedics Otolaryngology – Head and Neck

Surgery Pain Management

Pathology – Surgical and Anatomic Pediatric Surgery Plastic and Reconstructive Surgery Radiology Surgical Oncology Transplant Surgery Trauma and Burn Urology Vascular Surgery

FACILITY CODING Ambulatory Surgical Centers Emergency Medicine Radiology Inpatient Records Outpatient Ambulatory Coding

5


When TCN codes for you Provide coverage for absent coders due to illness, vacation or

family leave. Eliminate backlogs and/or bottlenecks. Reduce exposure to denials, recoupments and audits. Optimize revenue. Stay on top of coding changes. Comply with all laws and regulations. Receive coding "helpline" access. Receive documentation training. Access to certified experienced coders. Cut overhead by eliminating salaries and benefits. Curtail fixed expenses. Errors and omissions insured. Receive prompt turnaround.

6


Coding compliance reviews

The OIG recommends periodic independent reviews to evaluate your coding for accuracy.

TCN’s coding specialist examines a sample of your coded medical records to validate the procedural and diagnostic coding.

Proper modifier usage and other compliance issues are evaluated and reported.

7


Physician and staff training

Physician and staff training on site at your facility.

Extensive physician-specific training to assist in the proper documentation of patient care.

All courses are specialty specific and include a syllabus for each participant.

8


LA VERNE JONES CCP, CPC

30 years of experience in practice management settings

13 years as facilitator of procedural and diagnostic coding

13 years experience as practice management consultant of HCFA policies

7 years experience as Compliance Officer

9


Course Agenda Components of E&M Services

History Examination Medical Decision-Making Time

Inpatient Categories of Service and Documentation Requirements

Teaching Physician Guidelines10


Let’s get started!

How to use the course workbooks. Lecture – please follow along with the

overheads. Resources & Follow-Up Questions – Please ask me!

11


INPATIENT SERVICES

12


EVALUATION AND MANAGEMENT SERVICES

13



KEY COMPONENTS FOR SELECTION OF LEVEL OF SERVICE

Three (3) key components:

History

Examination

Medical Decision-Making

Key components drive the decision for level of service unless a visit consists predominantly of counseling or coordination of care.

14



KEY COMPONENT #1: HISTORY

The extent of history of present illness, review of systems and past family and/or social history obtained and documented is dependent upon clinical judgment and the nature of presenting problem(s).

History is comprised of some or all of the following elements:

Chief Complaint (CC)

History of Present Illness (HPI)

Review of Systems (ROS)

Past, Family and/or Social History (PFSH)

15


There are four (4) types of history: Problem Focused, Expanded Problem Focused, Detailed and Compre-hensive. To qualify for a given type of history, all three(3) criteria of HPI, ROS and PFSH must be met or

exceeded.

TYPES OF HISTORY HPI ROS PFSH

PROBLEM FOCUSED BriefN/A N/A

1-3

EXPANDED PROBLEM Brief Problem N/AFOCUSED Pertinent

1-3 1

DETAILED Extended Extended 1 4+ 2-9

COMPREHENSIVE Extended Complete 2-3 4+ 10

16


DOCUMENTATION GUIDELINES FOR HISTORY: REVIEW OF SYSTEMS AND PAST FAMILY SOCIAL

HISTORY

A Review of Systems and/or Past, Family and/or Social History obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his own record, or in an institutional setting, or group practice where many physicians share a common record.

The review and/or update may be documented by describing any new ROS/PFSH information or noting there has been no change in the information. The date and location of earlier ROS/PFSH should be noted.

Documentation of Review of Systems and/or Past, Family Social History by University Hospital System or Christus Santa Rosa staff cannot be counted toward the provider’s E&M level.

17


DOCUMENTATION GUIDELINES FOR HISTORY: REVIEW OF SYSTEMS AND PAST FAMILY SOCIAL

HISTORY

If the physician is unable to obtain a history from the patient or other source, the record should describe the patient’s condition/ circumstances which precludes obtaining history, i.e., patient unconscious, patient intubated.

Physicians cannot use “all other systems are negative” as a completion statement for Review of Systems.

Medical students can document in the record but attendings can only

count their documentation of ROS and PFSH. The faculty attending must re-perform or re-document any other work that the medical student has performed.

18


Problem Focused Exam – 1 body area or organ system

Expanded Problem Focused Exam – Limited exam of affected area + 2-7 body areas or organ systems

– Ex: AA0X3, CTAB, Abdomen ND/NT

Detailed Exam – Document 3 or more elements of exam of affected area + 2-7

body areas or organ systems

– Ex: AA0X3, CTAB, Abdomen ND/NT, +BS, no HSM

Comprehensive Exam – 8 or more organ systems

19

KEY COMPONTENT #2: EXAMINATION

There are four (4) types of examinations.


1995 EXAMINATION DOCUMENTATION GUIDELINES

Body Areas:

Head, including the face Neck Chest, including the breasts and axillae Abdomen Genitalia, groin, buttocks Back Each extremity

20


Organ Systems:

Constitutional Eyes Ears, Nose, Mouth, and Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic/Lymphatic/Immunologic

Endocrine system (thyroid)

21


DOCUMENTATION GUIDELINES FOR EXAMINATION

Specific abnormal and relevant negative findings of the examination should be documented. A notation of “abnormal” or “positive” without elaboration is insufficient.

Abnormal or unexpected findings of the examination of any asymptomatic body area(s) or organ system(s) should be described.

A brief statement or notation indicating “negative” or “normal” is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s).

When pelvic or rectal exam for an adult is deferred, document the reason.

The exam is real time. One cannot indicate “no change in exam from previous encounter.”

22


KEY COMPONENT #3: COMPLEXITY OF MEDICAL DECISION-MAKING

Medical decision-making refers to the complexity of establishing a diagnosis and/or selecting a management option. The complexity of the assessment and plan of care for a patient is measured by:

number of possible diagnoses and/or management options

amount and complexity of medical records, diagnostic tests and other data to be obtained, reviewed and analyzed

risk of significant complications, morbidity and mortality

23


KEY COMPONENT #3: COMPLEXITY OF MEDICAL DECISION-MAKING

There are four (4) types of medical decision-making. To qualify for a given type of medical decision-making, two of the three elements in the table must be either met or exceeded.

24


Number of diagnoses or management

options

Amount and/or complexity of data obtained, reviewed, and

analyzed

Risk of complications

and/or morbidity or

mortality

Type of Decision Making

Minimal (1) Minimal or none (1) Minimal (1) Straightforward

Limited (2) Limited (2) Low (2) Low Complexity

Multiple (3) Multiple (3) Moderate (3) Moderate Complexity

Extensive (>4) Extensive (>4) High High Complexity

ELEMENTS

25


26

MEDICAL DECISION MAKING

Number of

Diagnoses

Per Problem 1 Point

3

Each new or established problem for which the diagnosis and/or treatment plan is not evident. 2 plausible differential diagnoses, comorbidities or complications

(not counted as separate problems) clearly stated and supported by information in record: requiring diagnostic evaluation or confirmation

Per Problem 2 Points

A “problem” is defined as definitive diagnosis or, for undiagnosedproblems, a related group of presenting symptoms and/or clinical findings.

Each new or established problem for which the diagnosis and/or treatment plan is evident with or without diagnostic confirmation

CKD, HTN, DM

MEDICAL DECISION-MAKING BOX A.1: DIAGNOSES EXAMPLE


27

3 plausible differential diagnoses, comorbidities or complications (not counted as separate problems) clearly stated and supported by information in record: requiring diagnostic evaluation or confirmation


4 or more plausible differential diagnoses, comorbidities orcomplications (not counted as separate problems) clearly stated and supported by information in record: requiring diagnostic evaluation or confirmation


Total Diagnoses (Box A1) If total is greater than total points for box A2, use in box D.

3

MEDICAL DECISION-MAKING BOX A: DIAGNOSES EXAMPLE


28

MEDICAL DECISION-MAKING BOX A.2: MANAGEMENT OPTIONS

≤ 3 new or current medications per problem

> 3 new or current medications per problem

2

Important Note: These tables are not all inclusive. The entries are examples of commonly prescribed treatments and the point values are illustrative of their intended quantifications. Many other treatments exist and should be counted when documented.

Points

Do not count as treatment option’s notations such as: Continue “same” therapy or “no change” in therapy (including drug management) if specified therapy is not described (record does not document what the current therapy is nor that the physician reviewed it.

0

Drug management, per problem. Includes “same” therapy or “no change” in therapy if specified therapy is described(i.e., record documents what the current therapy is and thatthe physician reviewed it). Dose changes for current medicationsare not required; however, the record must reflect consciousdecision-making to make no dose changes in order to count for coding purposes.

1

Open or percutaneous therapeutic cardiac, surgical or radiological procedure; minor or major

1

Physical, occupational or speech therapy or other manipulation 1


29


Closed treatment for fracture or dislocation 1

IV fluid or fluid component replacement, or establish IV access when record is clear that such involved physician decision-making and was not standard facility “protocol”

1

Complex insulin prescription (SC or combo of SC/IV), hyperalimentation, insulin drip or other complex IV admix prescription

2

Conservative measures such as rest, ice/heat, specific diet, etc. 1

Radiation therapy 1

Joint, body cavity, soft tissue, etc. injection/aspiration 1

Patient education regarding self or home care 1

Decision to admit to hospital 1

Discuss case with other physician 1

Other-specify 1

Total Management Points: If total is greater than total for Box A1, use in Box D.



Drug Management

“Continue present management” but don’t document what current med regimen is = 0 points

PER Problem: Document current regimen and decision to continue or modify:

• 1-3 meds for the problem = 1 point• 4 or more meds for the problem = 2 points

Performing or deciding to perform major or minor surgical procedure = 1 point

30



IV meds order (not just IV saline) = 1 point

Complex insulin Rx or other IV admix Rx = 1 point

Injection/aspiration = 1 point

Dietary counseling or conservative measures (ice, bandages, rest) = 1 point

Counseling on home/self care techniques (example: glucose monitoring) = 1 point

Discuss cases w/other physician (not resident or fellow) = 1 point

Admit patient = 1 point

31


MEDICAL DECISION-MAKING BOX A.2:

Remember that Box A is the number of diagnoses OR management options

- Use the one (A.1 or A.2) with the highest score.

Maximum score for either diagnoses or management options is 4 points.

If you reach 4 points, stop and move onto Box B.

32


33

MEDICAL DECISION-MAKING BOX B: DATA REVIEWED OR ORDERED

1–3 procedures

Table B Data Reviewed or Ordered Point Value

Order and/or review medically reasonable and necessary clinical laboratory procedures. Note: Count laboratory panels as one procedure. >4

procedures

12

Order and/or review medically reasonable and necessary diagnostic imaging studies in Radiology section of CPT.

1–3 procedures >4 procedures

12

Order and/or review medically reasonable and necessary diagnostic procedures in Medicine section of CPT.

1–3 procedures >4 procedures

12

Discuss test results with performing physician. 1

Discuss case with other physician(s) involved in patient’s care or consult another physician (i.e., true consultation meaning seeking opinion or advice of another physician regarding the patient’s care). This does not include referring patient to another physician for future care.

1


34

MEDICAL DECISION-MAKING BOX B: DATA REVIEWED OR ORDERED

Order/review withoutSummary

Order and/or review old records. Record type and source must be noted. Review of old records must be reasonable and necessary based on the nature of the patient’s condition. Practice/facility protocol-driven record ordering does not require physician work. Thus should not be considered when coding E/M services. Perfunctory notation of old record ordering/review solely for coding purposes is inappropriate and counting such is not permitted.

Order/review and summarize

1

2

Independent visualization and interpretation of an image, EKG or laboratory specimen not reported for separate payment.

Note: Each visualization and interpretation is allowed one point.

1

Review of significant physiologic monitoring or testing data not reported for separate payment (e.g., prolonged or serial cardiac monitoring data not qualifying for payment as rhythm electrocardiograms).

1

Total points for Box B. Bring results to box D.


MEDICAL DECISION-MAKING BOX B

For ordering and/or reviewing medically reasonable and necessary lab tests:

1 lab panel = 1 procedure (Example: Chem 7) 1 to 3 procedures = 1 point 4 or more procedures = 2 points

For ordering and/or reviewing medically reasonable and necessary radiology tests:

1 to 3 procedures = 1 point 4 or more procedures = 2 points

For ordering and/or reviewing medically reasonable and necessary medical tests:

Medical tests: EKGs, treadmills, sleep studies, PFTs, EEGs, EMGs 1 to 3 procedures = 1 point 4 or more procedures = 2 points

35


MEDICAL DECISION-MAKING BOX B

Discussing case (during encounter) w/other physician managing patient’s care (PCP) or ordering a consult (referral doesn’t count) = 1 point

Discussing test results w/ performing physician (during encounter) = 1 point

Old Records:

Ordering records (document type and source) = 1 point

Reviewing records (document summary of review findings) = 2 points

36


MEDICAL DECISION-MAKING BOX B:

Document review of significant physiologic monitoring or test data not separately coded/billed for payment (home glucose or BP logs) = 1 point

Independently visualizing and interpreting a radiology image, EKG or lab specimen not separately coded/billed for payment (visualizing and documenting your own interpretation of a chest x-ray already viewed and reported by the radiologist) = 1 point per visualization and interpretation

Note: Can’t double-count (e.g. take a point for reviewing chest x-ray under radiology and take a point for independently visualizing and interpreting same chest x-ray)

37


TABLE OF RISK: BOX C: Use highest level of risk on Table.

38

Minimal • One self-limited or minor problem (e.g., cold, insect bite, venipuncture tinea corporis)

Laboratory tests requiring• Chest x-rays• EKG/EEG• Urinalysis • Ultrasound (e.g., echocardiography)• KOH prep

• Rest• Gargles• Elastic Bandages• Superficial Dressings

Low • Two or more self-limited or minor problems• One stable chronic illness (e.g., well controlled hypertension, non-insulin dependent diabetes, cataract, BPH)• Acute uncomplicated illness or injury (e.g., cystitis, allergic rhinitis, simple sprain)

• Physiologic tests not under stress (e.g., pulmonary function tests) • Non-cardiovascular imaging studies with contrast (e.g., barium enema)• Superficial needle biopsies• Clinical laboratory tests requiring arterial puncture• Skin biopsies

• Over-the-counter drugs• Minor surgery with no • identified risk factors• Physical therapy• Occupational therapy• IV fluids without additives

Level of Presenting of Problem(s) Diagnostic Procedure(s)Management Options

Risk Ordered Selected


TABLE OF RISK: BOX C

39

Moderate • One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment• Two or more stable chronic illnesses• Undiagnosed new problem with uncertain prognosis (e.g., lump in breast)• Acute illness with systemic

symptoms (e.g., pyelonephritis, pneumonitis, colitis)

• Physiologic tests under stress (e.g., cardiac stress test, fetal contraction stress test)• Diagnostic endoscopies with no identified risk factors• Deep needle or incisional biopsy• Cardiovascular imaging studies with contrast and no identified risk factors (e.g., arteriogram, cardiac catheterization)• Obtain fluid from body cavity (e.g., lumbar puncture, thoracentesis, culdocentesis)

• Minor surgery with identified risk factors• Elective major surgery (open, percutaneous or endoscopic) with no identified risk factors• Prescription drug management• Therapeutic nuclear medicine• IV fluids with additives• Closed treatment of fracture or dislocation without manipulation




TABLE OF RISK: BOX C

40

High • One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment• Acute or chronic illnesses or injuries that pose a threat to life or bodily function (e.g., multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure An abrupt change in neurologic status (e.g., seizure, TIA, weakness, sensory loss)

• Cardiovascular imaging studies with contrast with identified risk factors• Cardiac electrophysiological tests• Diagnostic endoscopies with identified risk factors• Discography

• Elective major surgery (open, percutaneous or endoscopic) with identified risk factors• 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




Final Assignment of Medical Decision Making Type

Line A – Use Total Diagnosis Points or the Total Management Option Points from Section A (Tables A.1 and A.2). Line B – Use Total Points from Section B (Table B).

Line C – Use highest level of risk from Section C (Table C).

Choose final Type of Medical Decision Making. Final Type Requires 2 of the 3 MDM Components below be met or exceeded.

41


TABLE D FINAL ASSIGNMENT OF MEDICAL DECISION-MAKING TYPE

42

Number of diagnoses or management options

1 point - Minimal

2 points Limited

4 points Extensive

Amount and complexity of data reviewed or order

≤ 1 pointNone-Minimal

2 points Limited

3 points Multiple

4 points Extensive

Risk Minimal Low Moderate High

Type of medical

decision-making

Straightforward LowComplexity

ModerateComplexity

High Complexity

Final Medical Decision-Making requires 2 of 3 components met or exceeded.

3 points Multiple


WHEN TO USE TIME BASED CODING

In an inpatient setting, when more than 50% of the total visit time by the teaching physician is counseling and/or coordinating the patient’s care, the time used to code must be provided at the patient’s bedside and/or on the patient’s hospital floor or unit.

When coding based on time, the teaching physician may not:

Add time spent by the resident in the absence of teaching physician to face-to-face time with the patient by the teaching physician with or without the resident present.

Count time counseling or coordinating the patient’s care after leaving the patient’s floor or after beginning to care for another patient.

43


WHEN TO USE TIME BASED CODING

In addition to documenting history and/or physical exam provided, the documentation should include:

Total visit time and time spent counseling and coordinating care, and,

Description of the medical decision making and counseling discussion and/or activities coordinated.

Example of documenting support for coding based on time based:

“I spent a total of 45 of 60 minutes on the floor coordinating Mr. Brown’s care and in discussion with Mr. Brown regarding his newly diagnosed lung cancer, prognosis and treatment options. We discussed side effects of medication. We also discussed the possibility of a clinical trial. I have requested that Dr. Jones visit Mr. Brown to discuss the clinical trial.” (99253 Consult)

44


CASE 1: HISTORY 16 year old white male with osteosarcoma presents for

admission for scheduled chemotherapy. First diagnosed in L proximal tibia in July 2008. Had increasing pain (7/10) prior to surgical intervention in July. Has been tolerating treatments – no mucositis, nausea or vomiting, ROS, MSK as per HPI, no decreased ROM. No abnormal weight loss, vision, respiratory, cardiovascular, GI, GU, endocrine normal. FMHx negative for cancer; PMHx, T&A age 2, L tibial intervention July 08. Maintaining B average in school, lives with parents and sibling.

45


CASE 1: HISTORY LEVELING

46

ProblemFocused(FP)

ExpandedProblemFocused(EPF)

Detailed (D) Comprehensive (C)

Final level of history requires 3 components above meet or exceed the same level

Chief Complaint New Patient Est. Patient Consultation

Extended 2-9 system including

PFSH (Past medical, Family and Social History)√ Past (patient’s illness, operation, injuries & treatments)√ Family (review of medical events in pt’s family incl. hereditary disease placing patient at risk√ Social (age appropriate review of past and current activities)

Complete PFSH:2 Hx areas: a) established patient office visit, domiciliary care;home care, b) Emergency dept visit, and c) Subsequent nursing

Pertinent

CompleteNew or Consult

3 history areasEstablished: 2 history areas

(1 History area)None

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.

Complete

10 or moresystems

including pertinent

1 pertinent

None Pertinent

to problem (1 system)

ROS (Review of Symptoms√ Constitutional ENMT Psych

√ Musculo √ GU Allergic/Immunologic Integ √ Card/vac

√ Resp Neuro Endo √ GI Eyes Hem/Lymph

Extended 4 or more elements

Brief (1-3 elements)

HPI (History of Present Illness)

√ Location √ Duration Mod Factors Quality

√ Severity

Timing Context √ Associated signs/symptoms

History


CASE 1: EXAM

Temp 98, pulse 86, RR 20-24, BP 123/60. Head normal; eyes PERRLA, mouth, teeth, throat normal; neck and thyroid normal; normal heart rhythm, s1, s2; lungs normal; abdomen, liver, spleen normal; lymph nodes normal; upper and lower extremities normal ROM; + alopecia, + well healed L tibia scar.

47


Compre-hensive

Each

DetailedExpanded Problem Focused

ProblemFocused

√ Muscu√ Heme /Lymp /ImmPsyc

√ GIGUNeuro

√ Skin√ Resp√ Cardio

Consti tional√ Eyes√ Ears, nose mouth, throat

Organ Systems:

Extremity

Genitourinary /groin /buttocks

√ Neck(thyroid)

8 or more organ systems (can include thyroid)

Expanded exam (3 elements of affected area + 2-7 additional body areas or systems

limited exam of affected area + 2-7 body or systems

1 body area or system

Back(w/spine)

Abdomen

Chest w/Brest & Axilla

√Head(w/face)

Body Areas:

32


If vital signs are taken by UHS/CSR staff, they cannot be counted as constitutional exam.

49


CASE 1: MEDICAL DECISION-MAKING

Hb/Hct 15/42, platelet 376, WBC 10.6, Glu 258, Ca+ 11.5, MTX level 820

Assessment: Osteosarcoma L proximal tibia; proceed with chemotherapy; re-evaluation per prn orders.

50


CASE 1: MEDICAL DECISION-MAKING

Box A.1: # Diagnoses = 2(osteosarcoma, admission for chemotherapy), Limited; Box A.2: # mgmt options = 1, Minimal( Use box A.1 since score is higher than box A.2.)

Box B: Labs = 2 points due to more than four labs, Limited

Box C: Nature of presenting problem = high diagnostic tests ordered = minimal; management options selected = high, High

51


Number of diagnoses or management options

1 point - Minimal

2 points Limited

3 points Multiple

4 points Extensive

Amount and complexity of data reviewed or order

≤ 1 pointNon-Minimal

2 points Limited

3 points Multiple

≥ 4 points Extensive

Risk of complication and/or morbidity or mortality

Minimal Low Moderate High

Type of MDM

Straightforward

LowComplexity

ModerateComplexity

High Complexity

2 of 3 of the above components are met or exceeded.

35


CASE 1: FINAL LEVELING

Code History Exam MDM AverageTime

99221 D D S or L 30

99222 C C M 50

99223 C C H 70

Initial Inpatient Admission: History, Exam, and Medical Decision-Making must meet or exceed the same level in order to assign a specific code (3 out of 3 same level or higher

36


CATEGORIES AND SUBCATEGORIES OF E&M SERVICES

Hospital Observation Discharge Services

99218 - 99220

Hospital Inpatient Services

99221 – 99223 –

Initial Hospital Care

99231 – 99233 – Subsequent Hospital Care99234 – 99236 – Observation or Inpatient

Care Services including

Admission and Discharge

99238 – 99239 – Hospital Discharge Services

Consultations

99241 – 99245 – Office

Consultations99251 – 99255 – Initial Inpatient Consultations

54

99217

Hospital Observation Discharge Services


CATEGORIES AND SUBCATEGORIES OF E&M SERVICES

Critical CareServices

99291 – 99292– Adult

55

99356 – 99357With Direct

Patient Contact

ProlongedServices


99499Unlisted E&M

Service

Newborn Care Service

99460-99463

Delivery/Birthing Room

Attendance and Resuscitation

Services 99464-99465Pediatric Critical

Care Transport99466-99467

Critical Care Service

56

Initial Neonatal and Pediatric Critical

Care99468-99476Initial and Continuing

Intensive Care Services

99477-99480


CATEGORY: Consultation

GENERAL

Service provided by a physician or qualified nonphysician practitioner whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. (Excludes residents, fellows and interns) due to the consultant’s expertise in a specific medical area beyond the requesting provider’s knowledge.

57


Four (4) Requirements for Using Consult Codes

A request for a consultation from an appropriate source and the need for consultation (i.e., the reason for the consultation service) shall be documented by the consultant in the patient’s medical record and included in the requesting physician or qualified NPP’s plan of care in the medical record.

The consultant’s opinion and any services performed or ordered must also be documented in the patient’s medical record. (Render service)

After the consultation is provided, the consultant shall prepare a written report of his findings and recommendations, which shall be provided to the requesting physician to use in the management of and/or decision making for the patient.

58


Note: A request to take care of the problem is a

referral and should be coded with subsequent hospital care codes 99231-99233.

59


Intent is to return the patient to the requesting provider

for ongoing care of the problem. During the service, the consultant may perform or

order diagnostic tests or initiate a treatment plan, including performing emergent procedures.

Additional follow up visits after the initial inpatient consultation are billed using the subsequent hospital care codes (99231-99233).

60


INPATIENT CONSULTATIONS: 99251 - 99255 For new or established hospital inpatients, residents of

nursing facilities or patients in a partial hospital setting. One initial consult per consultant per patient admit. Subsequent services during the same admission are

reported using subsequent hospital care codes (99231-99233) or subsequent nursing facility care codes (99307-99310), including services to complete the initial consultation, monitor progress, revise recommendations, or address a new problem.

61


ACCEPTABLE CONSULT PHRASES

The patient is seen in consultation at the request of Dr. Welby for evaluation of abdominal pain.Dr. Ben Casey has requested consultation on Jane Doe for pre-operative clearance.

62


UNACCEPTABLE CONSULT PHRASES

The patient was referred by Dr. John Smith for treatment of diabetes.Thank you for referring Betty Brown to me for management of her shortness of breath.

63


EXAMPLE DISPOSITION BOXES ON EXAM TEMPLATES

Return to Requesting M.D. with recommendations and treatment optionsReturn to Requesting M.D.’s care after completion of additional diagnostic testing with final recommendations.Return to Requesting M.D.’s care after evaluation of trial of therapeutic regimen.Will follow for GI problems in parallel with PCP if PCP agrees.

64


INPATIENT CONSULTATIONS

CPT99251PF PF SF

HPI1-3

ROS0

PFSH0

EXAM1 BA/OS

MDMStraightfor

ward

99252EPF EPF SF

1-3 1 0 2-7BA/OS

Straightforward

99253D D L

4+ 2-9 1 2-7BA/OS

Low

99254C C M

4+ 10+ 3 8+OS

Moderate

99255C C H

4+ 10+ 3 8+OS

High

66


Observation or Inpatient Hospital Care(Including Admission and Discharge Services)

67

Code History Exam Medical Decision Making

Comments

99234 Detailed or Comp

Detailed or Comp

Straightforward or low

Usually problem(s) requiring admission are of low severity

99235 Comprehensive

Comprehensive Moderate Usually problem(s) requiring admission are of moderate severity

99236 Comprehensive

Comprehensive High Usually problem(s) requiring admission are of high severity

Codes 99234-99236 are used by a provider to report observation or inpatient hospital care services provided to patients admitted and discharged on the same date of service.


Observation or Inpatient Hospital Care(Including Admission and Discharge Services)

Notes: When performed on the same date as the

admission, all other outpatient services provided by the physician in conjunction with that admission are considered part of the initial hospital or observation care.

CPT does not indicate time parameters for the encounter. However, CMS (Medicare) has specific time guidelines. Note discussion on Medicare and Carelink.

67


Observation or Inpatient Hospital Care – Medicare and CareLink

Codes 99234-99236 are used by a provider to report:

Admitting and discharging a patient on the same calendar day for >8 hours but <24 hours, or

Placing a patient under observation and discharging the patient on the same calendar date for >8 hours but <24 hours

68



69

Code

History Exam Medical Decision Making

Comments

99234

Detailed or comprehen

sive

Detailed or comprehensi

ve

Straightforward or

low

Usually problem(s) requiring admission are of low severity

99235

Comp Comp Moderate Usually problem(s) requiring admission are of moderate severity

99236

Comp Comp High Usually problem(s) requiring admission are of high severity



Notes: In addition to meeting the documentation

requirements for history, exam and medical decision-making, documentation in the medical record should include: Statement that the stay for observation care or

inpatient hospital care involved eight hours, but less than 24 hours.

Admission and discharge notes written by the billing provider.

Personal documentation by the billing provider indicating presence and face-to-face services were provided.

70


Hospital Observation Services

Initial observation care:

Codes 99218, 99219 or 99220

Then use discharge code

99217

Then admit as inpatient:

Code 99221-99223)

Admit to Observation

Status*

Subsequent visit by admitting physician or

visit by another provider

Code 99212, 99213, 99214, or 99215

Outpatient consultation: Code

99241, 99242, 99243, 99244, or

99245

Admission & discharged on same calendar date:*Code 99234, 99235 or

99236

Notes:

Prior to observation, patient may have been evaluated at another site of service (e.g. outpatient hospital, office, emergency department, or nursing facility).

72


Hospital Observation Services – Medicare and CareLink

Notes:

Prior to observation, patient may have been evaluated at another site of service (e.g., outpatient hospital, office, emergency department, or nursing facility).

73

In Observation < 8 hours and discharged same calendar date:

Code 99218, 99219 or 99220

In Observation > 8 hours but < 24 hours and discharged

same calendar date: Code 99234, 99235 or 99236

(see slide 15)

In Observation > 24 hours: Code 99218, 99219 or 99220

In Observation > 48 hours: Code 99218, 99219 or 99220

then 99212-99215

When discharged, use observation care

discharge day management: Code

99217

If admitted, use initial hospital visit:

Code 99221, 99222 or 99223

Admit to Observation

Status



Code 99218-9922099217

99218-99220 +99212-99215 +

99217

99218-99220 + 99212-99215 +99221-99223

Type Initial Observation Care

+

Observation Care Discharge Services

Initial Observation Care+

Established Patient, Office or other Outpatient Visit

+Observation Care Discharge

Services

Initial Observation Care+

Established Patient, Office or other Outpatient Visit

+Initial Hospital Visit

Duration of Service

1st calendar day - placed under observation

+ 2nd calendar day - discharged


+2nd calendar day - subsequent

service+

3rd calendar day - discharged


+2nd calendar day - subsequent service

+3rd calendar day - admitted

to inpatient status

Comments Code both services Code all services Code all services

These codes are used to report a patient placed under observation and include initiation of observation status, supervision of care, and periodic assessments.

74



Notes:

Billed only by the physician who admitted the patient to observation and was responsible for the patient during his/her stay.

All other providers should bill the outpatient E/M codes that describe their participation in the patient’s care (i.e., office and other outpatient service codes or outpatient consultation codes)

75


Hospital Observation Services – Medicare and CareLink

Code 99218-99220 99234-99236 99218-99220 + 99217

99218-99220 + 99212-99215 +

99217

99218-99220 + 99212-99215 +

99221-99223

Type Initial Observation Care Observation or Inpatient Care

Services (Including Same

Day Admission and Discharge)

Initial Observation

Care+

Observation Care Discharge

Services

Initial Observation

Care+

Established Patient, Office

or other Outpatient Visit

+Observation

Care Discharge Services

Initial Observation Care

+ Established Patient,

Office or other Outpatient Visit

+Initial Hospital

Visit

Duration of Service

Placed under observation with

discharge on different calendar date

or Under observation <8 hours and discharged on same calendar date

Placed under observation and

discharged on same calendar date

for >8 hours but <24 hours

>48 hours: 1st calendar day - placed

under observation

+ 2nd calendar

day - discharged

>48 hours: 1st calendar day - placed under

observation+

2nd calendar day -

subsequent service

+3rd calendar

day - discharged

>48 hours: 1st calendar day -

placed under observation

+2nd calendar day - subsequent service

+3rd calendar day –

admitted to inpatient status

Comments Do not also code a discharge day service if

observation was <8 hours

Do not also code a discharge day service

Code both services

Code all services

Code all services

76


HOSPITAL OBSERVATION SERVICES – MEDICARE AND CARELINK

Notes: Billed only by the physician who admitted the patient to observation and was responsible for the patient during his/her stay.All other providers should bill the outpatient E/M codes that describe their participation in the patient’s care (i.e., office and other outpatient service codes or outpatient consultation codes).

76


Initial Hospital Observation Services

Code History Exam Medical Decision Making Comments

99218 Detailed or Comprehensive

Detailed or Comprehensive

Straightforward or low Usually problem(s) requiring admission to

observation status are of low severity

99219 Comprehensive Comprehensive Moderate Usually problem(s) requiring admission to

observation status are of moderate severity

99220 Comprehensive Comprehensive High Usually problem(s) requiring admission to

observation status are of high severity

History, exam, and medical decision-making must meet or exceed the same level in order to assign a specific code (i.e., 3 out of 3 same level or higher).



Notes: The descriptors for these codes include the phrase “per day”,

meaning care for the day. Select a code that reflects all services provided during the

date of the service. The observation record for the patient must contain dated and

timed physician’s admitting orders regarding the care the patient is to receive while in observation, and progress notes prepared by the physician while the patient was in observation status. This information is in addition to any record prepared as a result of an emergency department, outpatient clinic, or nursing facility encounter.

In rare instances when a patient is held in observation status for more than two calendar dates, the physician must code subsequent services before the discharge date using outpatient/office visit codes (99212-99215).

78


Observation Care Discharge Services Code 99217 is used to report discharge services of a patient in observation status.

79

History Comments

99217 Observation care discharge day management

Face-to-face time between the attending and the patient


Observation Care Discharge Services

Notes:

Notes: Billed only by the physician who was responsible for observation care during

this stay. Discharge service is billed on the date of the actual visit by the provider . Includes:

Final patient exam Discussion of the hospital stay Instructions for continuing care Preparation of discharge records, prescriptions, and referral forms

All other providers performing a final visit should use outpatient/office visit codes (99212-99215).

Do not bill the hospital observation discharge management code (99217) if patient was

Admitted to inpatient status, use codes 99221-99223. Placed under observation and discharged on the same calendar date, use codes

99234-99236.

80


Hospital Observation During A Global Surgical Period

The global surgical fee includes payment for hospital observation (codes 99217, 99218, 99219, 99220, 99234, 99235 and 99236) services unless specific requirements are met.

Observation services may be paid in addition to the global surgical fee only if both of the following requirements are met:

The hospital observation service meets the criteria needed to justify billing it with modifiers: 24 - Unrelated E/M service by the same physician during a

post-operative period 25 - Significant, separately identifiable E/M service by the

same physician on the same day of a procedure or other service

57 - Decision for major surgery The hospital observation service furnished by the surgeon meets

all the criteria for the hospital observation code billed.

81


How to Use Observation Codes - Examples

Date 9/189/18

Medicare & CareLink9/19 9/20

Admitted to Observation by Provider A on 9/18 at 1AM; seen and discharged by Provider A at 7 AM on 9/18

99234-99236(Provider A)

99218-99220(Provider A)

Admitted to Observation by Provider A on 9/18 at 1AM; seen and discharged by Provider A at 9/18 4PM

99234-99236(Provider A)

99234-99236(Provider A)

83



Admitted to Observation by Provider A on 9/18 at 1AM; seen by Provider B 9/18 at 3 PM; seen and discharged on 9/19 at 7 AM by Provider ANote: Provider A is from a different specialty than Provider B and the service was not a consultation.

99218-99220 (Provider A)

99212-99215 (Provider B)

99218-99220 (Provider A)

99212-99215 (Provider B)

99217(Provider A)

84



Admitted to Observation by Provider A on 9/18 at 1AM; seen by Provider A on 9/19; and, seen and discharged by Provider A on 9/20

99218-99220(Provider A)

99218-99220(Provider A)

99212-99215(Provider A)

99217(Provider A)

Admitted to Observation by Provider A on 9/18 at 1AM; seen by Provider A on 9/19; and, admitted by Provider A to inpatient status 9/20

99218-99220(Provider A)

99218-99220(Provider A)

99212-99215(Provider A)

99221-99223(Provider A)

85


CATEGORY: Hospital Inpatient Services

GENERAL

Care provided to patient admitted to hospital facility.

Four (4) subcategories of Hospital Inpatient Services:

Initial Hospital Care (99221 - 99223) Subsequent Hospital Care (99231 - 99233) Observation or Inpatient Care Services (Including

Admission and Discharge) (99234-99236) Hospital Discharge Services (99238 - 99239)

85


INITIAL HOSPITAL CARE: 99221 – 99223

There is no distinction between new or established patients.

Used only by one admitting physician per admission.

All E&M services provided on the same day are included in initial hospital care and cannot be billed separately.

Frequently disallowed as part of the global surgery package if performed on the day before or the day of a surgical procedure.

86


99221Det/CompDet/CompSF/Low

HPI 4+ROS: 2-9 SystemsPFSH: 1Exam: 2-7 MDM: Low

99222CompCompMod

HPI: 4+ROS: 10 + SystemsPFSH: 3Exam: 8+ SystemsMDM: Moderate

99223CompCompHigh

HPI: 4+ROS: 10+ SystemsPPSH: 3Exam: 8+ SystemsMDM: High

Physicians that participate in the care of a patient but are not the admitting physician of record should bill the inpatient evaluation and management services codes that describe their participation in the patient’s care (i.e., subsequent hospital visit or inpatient consultation).

89


CODING A HOSPITAL ADMISSION THAT OCCURS IN THE COURSE OF AN OFFICE VISIT

88

E/M office visit

code

Admitted patient to the hospital via the office and didn’t see patient in the hospital on the same date

Initial hospital care

code

Admitted patient to the hospital via the office and saw patient in the hospital on the same date

E/M office visit

Code + Initial

Hospital care code

Admitted patient to the hospital via the office and saw patient in the hospital on the following date


SUBSEQUENT HOSPITAL CARE: 99231 - 99233 Physicians can only bill one hospital code per day to encompass all visits for

the patient on a given day.

In a hospital inpatient situation involving one physician covering for another, if physician A sees the patient in the morning and physician B, who is covering for A, sees the same patient in the evening, physician B is typically not paid separately for the second visit. The hospital visit descriptors include the phrase “per day” meaning care for the day.

If the physicians are each responsible for a different aspect of the patient’s care, both visits are paid if the physicians are in different specialties and the visits are billed with different diagnoses.

There are circumstances where concurrent care may be billed by physicians of the same specialty.

Review of medical record, diagnostic studies and changes in the patient’s status (changes in history, physical condition and response to management) since last assessment by the physician.

89


The acuity of the patient’s condition is a key factor in selection of the level of hospital visit. CPT describes the patient’s condition at each level of service as follows.

99231 – usually the patient is stable, recovering or improving.

99232 – usually the patient is responding inadequately to therapy or has developed a minor complication.

99233 – usually the patient is unstable or has developed a significant complication or a significant new problem.

90


93

99231PFPFSF/Low

HPI: 1-3ROS: NonePFSH: NoneExam: 1 BA/System MDM: Low

99232EPFEPFMod

HPI: 1-3ROS: 1- SystemPFSH: NoneExam: 2-7 BA/SystemMDM: Moderate

99233DDHigh

HPI: 4+ROS: 2-9 SystemPPSH: NoneExam: 2-7 BA/SystemMDM: High


OBSERVATION OR INPATIENT CARE SERVICES (INCLUDING ADMISSION AND DISCHARGE SERVICES (99234-99236)

Used to report observation or inpatient hospital care services provided to patients admitted and discharged on the same date.

92

99234Det/CompDet/CompSF/Low

HPI 4+ROS: 2-9 SystemsPFSH: 1Exam: 2-7 BA/SystemsMDM: Low

99235CCMod

HPI: 4+ROS: 10 + SystemsPFSH: 3Exam: 8+ SystemsMDM: Moderate

99236CCHigh

HPI: 4+ROS: 10+ SystemsPPSH: 3Exam: 8+ SystemsMDM: High


HOSPITAL DISCHARGE SERVICES: 99238 – 99239

Includes final exam of patient, discussion of hospital stay, instructions for continuing care to all relevant care givers and preparation of discharge records, prescriptions and referral forms

Less than 30 minutes or greater than 30 minutes. Document the time spent for appropriate code selection.

Only the attending of record can discharge the patient. There may only be one hospital discharge service per patient per hospital stay.

93


CATEGORY: Prolonged Services

PROLONGED SERVICES: 99356– 99357

Used to report prolonged services involving direct (face-to-face) patient contact beyond the usual E&M services in the outpatient or inpatient setting.

CPT 99356-57 are used in addition to the designated E&M service at any level and any other physician services provided at the same session.

Time based codes. Time does not have to be continuous. However, the total duration of time must be considered.

94



Prolonged services codes can be billed only if the total duration of all physician or qualified NPP direct face-to-face service (including the visit) equals or exceeds the threshold time for the evaluation and management service the physician or qualified NPP provided (typical/average time associated with the CPT E/M code plus 30 minutes).

Time spent reviewing charts or discussion of a patient with house medical staff and not with direct face-to-face contact with the patient or waiting for end of a therapy, or for use of facilities cannot be billed as prolonged services.

95



Resident/Fellow time does not count.

The medically necessary reason for prolonged encounter must be documented as well as the total time spent with patient or in review/communication.

96


The medical record must be appropriately and sufficiently documented by the physician or qualified NPP to show that the physician or qualified NPP personally furnished the direct face-to-face time with the patient specified in the CPT code definitions.

The start and end times of the visit shall be documented in the medical record along with the date of service.

97


Do not report prolonged service if it is less than 30 minutes.

Codes 99356-99357 are used to report the total duration of unit time spent by a physician on a given date providing

prolonged service to a patient.

Code 99356 is used to report the first hour of prolonged service on a given date.

98


Code 99357 is used to report each additional 30 minutes beyond the first hour. This code may also be used to report the final 15-30 minutes of prolonged service on a given date. Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately.

The use of the time based add-on codes requires that the primary E&M service have a typical or specified time published in the CPT book.

Use CPT 99356 in conjunction with 99221-99233, 99251-99255, 99304-99310, 90822 and 90829.

99


The following table illustrates the correct reporting of prolonged physician service with direct patient contact in the office setting:

Total Duration of Prolonged Service Code(s)

Less than 30 minutes(less than ½ hour)

Not reported separately.

30 – 74 minutes(½ hr. – 1 hr. 14 min.)

99356 X 1

75 – 104 minutes(1 hr. 15 min. – 1 hr. 44 min.)

99356 X 1 AND 99357 X 1


99356 X 1 AND 99357 X 2


99356 X 1 AND 99357 X 3


99356 X 1 AND 99357 X 4

100


In those E&M services in which the code level is selected based on time (counseling and coordination of care), prolonged services can only be reported with the highest code level in that family of codes as the companion code. In the inpatient setting, prolonged service codes can only be assigned with a level three initial encounter(99223) or subsequent encounter(99233) or a level five consultation (99255).

101


CLINICAL EXAMPLE:

A 34 year old primigravida presents to hospital in early labor. Admission history and physical reveals severe preeclampsia. Physician supervised management for preeclampsia, IV magnesium initiation and maintenance, labor augmentation with pitocin, and close maternal-fetal monitoring. Physician face-to-face involvement includes 40 minutes of continuous bedside care until the patient is stable, then is intermittent over several hours until the delivery.

102


PROLONGED SERVICES:

Threshold Time for Prolonged visit Codes 99356 and/or 99357 billed

with Inpatient Setting Codes.

103


104

120754599306

110653599305

100552599304

18514011099255

1551108099254

130855599253

115704099252

Threshold Time to Bill codes 99356 & 99357

Threshold Time to Bill Code 99356

Typical Time for Code

Code


105

105603099318

110653599310

100552599309

85401099307

Threshold Time to Bill codes 99356 & 99357

Threshold Time to Bill Code 99356

Typical Time for Code

Code


SELECT THE APPROPRIATE CODE BASED UPON THE TYPE OF HISTORY, EXAM AND

MEDICAL DECISION-MAKING RENDERED AND DOCUMENTED. CONSIDER THE IMPACT OF TIME AS APPROPRIATE.

106


CHOOSING EVALUATION AND MANAGEMENT CODES

Identify the category of service.

Identify the subcategory of service.

Determine the extent of history obtained.

Determine the extent of examination performed.

Determine the complexity of medical decision-making.

Determine the approximate amount of intra-service time if counseling or coordination of care is greater than 50%.

107


INITIAL VISITS

Require all 3 key components (History, Exam and Medical Decision-Making).

First time encounters include:

Hospital observation services Initial hospital visits Initial office and inpatient consults

108


SUBSEQUENT VISITS

Require 2 of the 3 key components (History, Exam and Medical Decision-Making).

Subsequent encounters include:

Subsequent hospital visits

109


HOSPITAL OBSERVATION

OUTPATIENTE&M CODES

HISTORY EXAMMEDICALDECISION

PROBLEM TIME

99217

99218 DET-COM DET-COM STRT-LOW LOW

99219 COMPRE COMPRE MODERATE MODERATE

99220 COMPRE COMPRE HIGH MOD-HIGH

3 of 3 Key Components must be met for initial visit

INPATIENT E&M CODES

OBSERVATION CARE DISCHARGE DAY MANAGEMENT

KEY COMPONENTS

110


HOSPITAL ADMISSIONS

INPATIENTE&M CODES


PROBLEM TIME

99221 DET-COM DET-COM COMPRE LOW 30

99222 COMPRE COMPRE MODERATE MODERATE 50

99223 COMPRE COMPRE HIGH MOD-HIGH 70

3 of 3 Key Components must be met for initial visits

INPATIENT E&M CODES

KEY COMPONENTS

111


OBSERVATION OR ADMIT WITH SAME DAY DISHARGE

INPATIENTE&M CODES


PROBLEM TIME

99234 DET-COM DET-COM DET-COMP STRT-LOW

992352 COMPRE COMPRE COMPRE MODERATE

99236 COMPRE COMPRE COMPRE HIGH

INPATIENT E&M CODES

KEY COMPONENTS

112


HOSPITAL VISITS

INPATIENTE&M CODES HISTORY EXAM

MEDICALDECISION PROBLEM TIME

99231 FOCUSED FOCUSED STRT-LOW STABLE 15

99232 EXP/FOC EXP/FOC MODERATE MINOR CMP 25

99233 DETAILED DETAILED HIGH UNSTABLE 35

99238

99239

2 of 3 Key Components must be met for subsequent visits

INPATIENT E&M CODES

HOSPITAL DISCHARGE DAY MANAGENENT LESS THAN 30 MIN.

KEY COMPONENTS

HOSPITAL DISCHARGE DAY MANAGEMENT GREATER THAN 30 MIN.

113


INPATIENT E&M CODES CONTINUATION

INPATIENTE&M CODES


PROBLEM TIME

99251 FOCUSED FOCUSED STRTFWD MINOR 20

99252 EXP/FOC EXP/FOC STRTFWD LOW-MOD 40

99253 DETAILED DETAILED LOW MODERATE 55

99254 COMPRE COMPRE MODERATE MOD-HIGH 80

99255 COMPRE COMPRE HIGH MOD-HIGH 110

3 of 3 Key Components must be met for initial visits

INPATIENT CONSULTATIONS

KEY COMPONENTS

114


MEDICAL NECESSISTY

The CMS Manual, publication 100-4, Chapter 12, 30.6.1 – Selection of Level of Evaluation and Management Service states the following:

“Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code.

It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted.

The volume of documentation should not be the primary influence upon which a specific level of service is billed.

115


MEDICAL NECESSISTY

Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record .

Instruct physicians to select the code for the service based upon the content of the service.

The duration of the visit is an ancillary factor and does not control the level of the service to be billed unless more than 50 percent of the face-to-face time (for non-inpatient services) is spent providing counseling or coordination of care.”

116


MEDICAL NECESSISTY

Medically Necessary Services are services required to:

Diagnose or prevent an illness, injury or condition Treat an illness, injury, or condition Keep condition from getting worse Lessen pain or severity of condition Help improve condition Restore lost skills (rehabilitation)

117


MEDICAL NECESSISTY

Medically Necessary Services:

Are consistent with diagnosis; Meet accepted standards of good medical practice; Can be safely provided.

118


DIAGNOSTIC CODING

ICD codes describe the reason a service (CPT code) was provided.

List the primary diagnosis, condition, problem or other reason for the medical service or procedure.

List secondary diagnoses that impact the medical decisionmaking for the encounter.

Exclude diagnoses that relate to the patient’s previous medical condition or problem and have no bearing on the patient’s present problem.

119


DIAGNOSTIC CODING

Assign all codes to the highest level of specificity (4th or 5th digits).

Code signs and symptoms if a definitive diagnosis has not been determined.

Do not code probable, possible or suspected conditions as definitive diagnoses.

Be specific in describing the condition, illness or disease of the patient. (e.g., renal failure vs. chronic kidney disease, Stage III).

120


DIAGNOSTIC CODING

Distinguish between acute and chronic conditions.

Identify how injuries occur by using E codes.

Use V codes to indicate why a service was rendered when there is no complaint, i.e. routine physical, well baby care, aftercare following surgery, need for prophylactic vaccination, etc.

Avoid unspecified codes when there is a more specific code to describe the patient’s illness, condition or injury.

Diagnoses may be taken from the final assessment or chief complaint.

121


DIAGNOSES

New or established problems

Addressed during the visit

• Qualify the diagnosis (e.g., acute severe, chronic, mild, moderate, etc.).

Co-morbid conditions include conditions that coexist at the time of the visit and influence, require, or affect patient care or treatment.

CPT – Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M service unless their presence significantly increases the complexity of the medical decision-making.

Documentation needs to demonstrate that the comorbidity was a significant influence.

122


DIAGNOSES

Example:

• Assessment 1) CKD – continue present management, 2) Anemia X

• Assessment 1) CKD – continue present management, 2) Anemia secondary to CKD – continue present management

123


DIAGNOSES

Possible code series to consider in addition to co-morbid conditions or complications.

History of cancer (V10) Personal medical history (V11-V15) Family history (V15-V19) Condition influencing health status (V40-V41) Tissue Transplant or artificial device (V42-V44) Post-procedural status (V45)

Must be supported by documentation in the current note.

124


LINKING DIAGNOSIS CODES

125

Assessment

1. Childhood asthma w/ acute exacerbation

2. Allergic rhinitis

Codes

1. 493.02

2. 477.9

E/M Service Established 99232-251. 493.02

2. 477.9

Procedures: Bronchodilation Responsiveness spirometry as in 94010, pre and post- bronchodilator administration

94060 493.02


MEDICAL RECORD DOCUMENTATION

126

Complete Documentation

Correct Medical Coding

Appropriate Reimbursement

The critical factor in determining the level of care:Not what you did….but what you documented!


E&M MODIFIERS

127


MODIFIERS

Modifiers are two-digit additions to CPT codes to indicate that a performed service or procedure has been altered by a specific circumstance but not changed in its definition or code. Some modifiers impact reimbursement while others simply convey information.

128


Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period.

Used to indicate that an E&M service performed during the postoperative period is unrelated to the original procedure.

The diagnosis for the E&M service must support the fact that the service was unrelated.

If the service is unrelated, Medicare will pay for the E&M service with the 24 modifier.

EVALUATION AND MANAGEMENT MODIFIERS

- 24

129


Significant, Separately Identifiable Evaluation and Management Service by

the Same Physician on the Same Day of the Procedure or Other Service.

Reflects that the day of a minor surgical procedure, the patient’s condition required a significant, separately identifiable E&M service above and beyond the other service provided or beyond the usual operative and postoperative care associated with the procedure that was performed.

The term “separately identifiable service” means an additional service that is not part of the surgery or procedure. The E&M service must require additional history, exam, knowledge, skill, work, time, and risk above and beyond that of the surgery or procedure and its pre- and post-procedure components. Moreover, the E&M service should be able to stand alone from the same-day procedure.

- 25

130


Generally used with established patient visits.

A significant, separately identifiable E&M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E&M service to be reported. .

The E & M service may be prompted by the symptom or condition for which the procedure and/or service was provided. Different diagnoses are not required for reporting of the E & M service on the same date.

Initial consultations and additional procedures may be reported without the use of modifier 25.

131


Mandated Services

Used to identify mandated consultation and/or related services (e.g., PRO, third party payer, governmental, legislative, or regulatory requirement).

Generally allowed at 100% since the service is mandated .

Used with second surgical opinions

- 32

132


Decision for Surgery

Indicates initial decision to perform major surgery the same day or next day of the E&M service.

Removes service, normally consultative, from the global surgical package.

Codes with this modifier are reimbursed separately by the carrier.

- 57

133


Increased Procedural Services

When the work required to provide a service is substantially greater than typically required, modifier 22 may be added to the usual procedure code.

Documentation must support the additional work and the reason for it (i.e., increased intensity, time, technical difficulty of procedure, or severity of patient’s condition, physical and mental effort required).

This modifier should not be appended to an E&M Service.

- 22

134

OTHER MODIFIERS


Professional component or interpretation of a diagnostic test or study

- 26

135

OTHER MODIFIERS

- GC

Service performed in part by a resident under direction of a teaching physician


EVALUATION AND MANAGEMENT SERVICES

WITH PROCEDURES

Any specifically identifiable procedure (i.e., identified with a specific CPT code) performed on or subsequent to the date of initial or subsequent Evaluation and Management Services should be reported separately.

The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant separately identifiable E/M service above and beyond other services provided or beyond the usual preservice and postservice care associated with the procedure that was performed. The E/M service may be caused or prompted by the symptoms or condition for which the procedure and/or service was provided. This circumstance may be reported by adding the modifier -25 to the appropriate level of E/M service. As such, different diagnoses are not required for reporting of the procedure and the E/M services on the same date.

136


PERFORMANCE AND/OR INTERPRETATION OF DIAGNOSTIC TESTS

The actual performance and/or interpretation of diagnostic tests/studies ordered during a patient encounter are not included in the levels of E/M services. Physician performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code.

Results are the technical components of a service. Testing leads to results; results lead to interpretation. Reports are the work product of the interpretation of numerous test results.

137


PERFORMANCE AND/OR INTERPRETATION OF DIAGNOSTIC TESTS

The physician’s interpretation of the results of diagnostic tests/studies (i.e., professional component) with preparation of a separate distinctly identifiable signed written report may also be reported separately, using the appropriate CPT code with the modifier -26 appended.

138


DOCUMENTATION EXAMPLES

139


SAMPLE DOCUMENTATION - 99222

Level II Initial Hospital Care

This 42-year old diabetic female Hispanic patient is admitted today with four-day history of fever, chills, harsh cough productive of moderate amounts of greenish and foul-smelling sputum, shortness of breath at rest and general malaise. Onset of symptoms occurred rather suddenly, though the patient admits to a mild dry cough for several weeks, changing to a productive cough over the last four days. Denies rhinorrhea or nasal congestion. Patient fainted today after walking up a flight of steps; says she “could not find my breath and then got dizzy.” Feeling weak and just “really sick.” Temperature taken at home last night 102 degrees. Had TB as a child in her native country in South America. Was apparently treated successfully at that time without sequelae. No history of asthma.

140


ROS: Head: no complaints except for recent dizziness. Ears: no complaints. Eyes: wears glasses. Last exam five years ago in her native country. Nose: denies rhinitis, as above. Throat: extremely sore secondary to deep cough. Resp: Cough, SOB as above. Breasts: has never had mammograms; denies history of nodule/mass. Cardio: patient is hypertensive, controlled with Monopril 20 mg/day. Takes her Bp every other day at local drug store. GI: no NVD. Appetite diminished. GU: no complaints. Last Pap some years ago - normal. Musculoskeletal: admits to general arthralgias with onset of fever. No history of arthritis. Neuro: without complaint. Endo: patient is diabetic; controlled on daily Glucophage 1500 mg/day. Last glucose level taken at home a few days ago by home glucometer. Patient doesn’t remember the result. Admits to being less than compliant in taking the med and monitoring the blood glucose.

141


PMH: Hypertension and diabetes for years. No major surgeries. Usual childhood illnesses. Immunizations: unknown. Allergy: severely allergic to penicillins: hives , no anaphylaxis. FH: Noncontributory to this illness. Mother was nonhypertensive; nondiabetic. Never knew her father and therefore history is unavailable. Three siblings, alive and well.SH: No smoking or drinking. Doesn’t exercise. Married with two children.

142


O: General: febrile-appearing female, short with barrel-shaped chest, lying supine in bed. T: 101.6; P: 72; R: 30, shallow, guarded. Bp: 132/82. Head: normocephalic. No lesions, signs of trauma or fall. Eyes: PERRLA. Sclerae sl. yellow. Ears: Canals clear. TM’s WNL. Nose: mucosa pale. No exudates. Turbinates sl. Congested. Septum deviated to left. Throat: posteropharyngeal wall erythematous. Tonsils small, red without exudates. Tongue geographic, thick. Dentition poor. Gold fillings throughout. Neck: +3 anterior cervical lymphadenopathy. Thyroid not palpable. Chest auscultation reveals LUL clear; LLL with high-pitched rales. RUL nonaudible; RML and RLL some wheezing. Chest percussion reveals dull sounds over RML/RLL but tinny sounds over RUL. Breasts: WNL. No mass or tenderness. Areolae WNL: No discharge. Cardio: Normal S1,S2. No murmur or rub. Abdomen: no hepato-or splenomegaly. Some tenderness over epigastrium. BS active. GU: deferred. Rectal: deferred. Skin: Dry; no petechiae or purpura. Extremities: Warm. No pedal edema. Pulses +2 in upper/lower extremities. No digital clubbing. No CVA tenderness. Neuro: no focal deficits. DTRs +2 upper extremities; +1 lower extremities.

STAT portable chest x-ray ordered. Laboratory tests ordered: SMA-12 including CBC w/diff. STAT ABG. Blood glucose; Hg Alc; UA; sputum culture/sensitivity, and gram stain, AFB x 3. Oximetry reported 90 percent.

143


A: 1. Community acquired pneumonia of LUL. Probably bacterial.2. R/O pneumothorax.3. R/O atypical pneumonitis.4. NIDDM.5. HTN.

P: 1. Patient admitted today to Medical Service ward. 2. Await chest x-ray/ labs. 3. Obtain Pulmonary consult. 4. Begin IV antibiotics – Erythromycin 500 mg q. 6 h. 5. Begin Tylenol for fever. 6. 1500 cal/day ADA diet. 7. Finger sticks before meals. 8. Lispro insulin before meals. 9. Hold Glucophage for now. 10. Resp. isolation. 11. Nasal oxygen 2 liters by nasal cannula.

144


Addendum: Patient now reports she thinks she has visited the ER here about eight months ago for lower respiratory infection, at which time she underwent chest x-ray. Old films to be pulled for comparative review.

(Multisystem-Primary Care Physician)

St. Anthony’s Guide to

Evaluation and Management

Coding and Documentation 145


SAMPLE DOCUMENTATION - 99231

Level I Subsequent Hospital Visit

The patient was admitted three days ago with bleeding gastric ulcer, now stable. Since admission, she has received three units of packed RBCs; hematocrit 29.9, hemoglobin 9.2. Tolerating clear liquids well. She is on H2 blocker, Sucralfate and antacids. No GI complaints at this time. NG tube was removed. Stools remain melanotic.

Blood pressure, pulse, respirations are stable; temperature normal. Abdominal exam is basically unchanged from yesterday.

146


AMENDED CHART NOTES

It is not unlawful to amend a physician’s chart notes to add inadvertently omitted information. Amendments should be made as follows:

Don’t revise a closed note, one that’s already been signed and dated by the physician. Don’t replace an original note with new notes. Instead, add the extra information as an amendment or addendum.

Identify the amendment as an amendment of “late entry.”

Have the physician sign the amendment and date it.

147


AMENDED CHART NOTES

Date it with the date the amendment is made, not the date of the original note. Otherwise, you risk fraud allegations for misrepresentation.

Obviously, amend a note only when the additional work actually was performed and was medically justified. Avoid adding elements to raise the level of service.

Make amendments to notes within a reasonable timeframe. It is questionable whether a physician remembers details of a patient’s care weeks later.

148


TEACHING PHYSICIANGUIDELINES

149


MEDICARE TP ATTESTATION REQUIREMENT

The 11/22/02 revisions to the regulations provide that for E&M services, the TP does not have to duplicate any resident documentation.

The TP must be present during the key portions of the service and personally document his or her presence.

The resident note alone, the TP note alone or a combination of the two may be used to support the level of service billed.

Documentation by a resident of the presence and participation of the TP is not sufficient.

Documentation may be dictated and typed, hand-written or a computer statement initiated by the TP.

150


TEACHING PHYSICIAN ATTESTATION FOR E/M SERVICES

The attending physician who bills for evaluation and management (E&M) services in the teaching setting must, at a minimum, personally document:

His or her participation in the management of the patient; and That he or she performed the service or was physically present during

the critical or key portion(s) of the service performed by the resident (the resident’s certification that the attending physician was present is not sufficient)

You have to include some of your history, exam, assessment, and plan – merely stating “reviewed and agree” is no longer enough

When properly attested, the resident’s documentation and the faculty’s documentation are both considered in determining the E/M level.

Use your attestation to augment/supplement what the resident documented.

151


MEDICARE’S EXAMPLES OF ACCEPTABLE TP NOTES

CMS’ examples of minimally acceptable documentation:

Admitting Note: “I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care.”

Follow-up Visit: “I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note.” or “I saw and examined the patient. I agree with the resident’s note except the heart murmur is louder, so I will obtain an echo to evaluate.”

Initial or Follow-up Visit: “I was present with resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note.

Follow-up Visit: “I saw the patient with the resident and agree with the resident’s findings and plan.

152


MEDICARE’S EXAMPLES OF UNACCEPTABLE TP NOTES

“Agree with above.” followed by legible countersignature or identity;

“Rounded, Reviewed, Agree.” followed by legible countersignature or identity;

“Discussed with resident. Agree.” followed by legible countersignature or identity;

“Seen and agree.” followed by legible countersignature or identity;

“Patient seen and evaluated.” followed by legible countersignature or identity; and

“A legible countersignature or identity alone.

The preceding six and similar statements don’t make it possible to determine whether the TP was present, evaluated the patient, and/or had any involvement with the plan of care.

153


MEDICARE’S SUPERVISION GUIDELINES FOR PROCEDURES PERFORMED WITH RESIDENTS

Minor procedures of <5 minutes: Must be present the entire time

Endoscopies (other than surgical operations): TP must be present for entire viewing including insertion and removal

154


DOCUMENTATION GUIDELINES FOR MINOR PROCEDURES

Procedure name Names of the teaching physician and assistants Pre-operative and post-operative diagnoses, if

different Description of the procedure Post-operative instructions Anesthetic agent, if any Additional information to support the procedure

performed Legible signature(s)

155


DOCUMENTATION GUIDELINES FOR MINOR PROCEDURES

Attestation for minor procedures:

Present for entire procedure.

Presence demonstrated by personal note.

“I was present for the entire bone biopsy performed by Dr. Resident.”

156


MEDICARE SUPERVISION GUIDELINES FOR SPECIFIC PROCEDURES

Time-based procedures billed on TP time only

Critical care Hospital discharge day management Prolonged services Care plan oversight E&M counseling/coordination of care

157


MEDICARE SUPERVISION GUIDELINES FOR SPECIFIC PROCEDURES

Specific complex or high-risk procedures require continual personal TP supervision

Interventional radiologic/cardiology codes Cardiac cath, stress tests, transesophageal

ECG

158


KEY POINTS FOR DOCUMENTING INPATIENT SERVICE

Must be legible. SOAP note must include a chief complaint, ie,

follow-up for gastroenteritis Document time for admissions, discharges, critical

care, time-based coding, and start/stop times for prolonged services.

Resident (if applicable) and faculty must sign. Faculty attestation must show active participation

(“Reviewed and agree won’t do it – your documentation needs to supplement the resident’s note).

Cannot use documentation notes of non-UT Medicine auxiliary staff or mid-levels.

159


COMPLETING FEE TICKET

Select E/M level and any CPT procedure codes.

Select and sequence diagnoses (Diagnoses must be sequenced.)

160



#1 = CC or primary reason for appointment

Code additional diagnoses or co-morbid conditions that coexist at the time of the service and influence, require, or affect patient care or treatment as supported in documentation.

Pay attention to sequencing when providing an E/M service and a procedure in same visit.

Sequencing required to link diagnoses to E/M codes and procedures performed.

161



• Remember ICD-9 codes explain why you performed the service

• If procedures are performed, sequencing is critical since the correct diagnosis code must be linked to the procedure for the procedure to be paid.

Select modifiers

25 modifier is checked or written next to E/M code selected when a procedure is performed (otherwise one of the service codes may not be paid).

Sign fee ticket (paper).

162


IN CLOSING

Avoid reckless disregard for the rules.

Understand the rules of documentation

Avoid using the same level code for all services of the same type (i.e. consultations).

Avoid down-coding which suggests lack of understanding.

Document all requests for consultations.

163


In closing, (con’t)

Avoid use of the word "referral" for consultations.

Evaluate your charge documents annually.

Never bill for services for which you were not present.

Audit your practice every 6 months.

Have a mandatory education program in place for physicians and billing staff.

164


Outpatient Evaluation &. Management CPT Code Criteria

New Patient 99201 99202 99203 99204 99205

Avg time (mins) 10 20 30 45 60 CC: Required CC: Required CC: Required CC: Required CC: Required

Requires all three key HPI: 1-3 HPI: 1-3 HPI: 4+ HPI: 4+ HPI: 4+Components ROS: None ROS: 1 Pertinent ROS: 2-9 ROS: 10+ ROS: 10+

PFSH: None PFSH: None PFSH: 1 Pertinent PFSH: 3 PFSH: 3

PE: 1 BA/OS PE: 2-7 BA/OS PE: 2-7 BA/OS w/detail

PE: 8+OS PE: 8+OS

MDM: Straightforward


MDM: Low MDM: Moderate MDM: High

Established Patient 99211 99212 99213 99214 99215

Avg time (mins) 5 10 15 25 40

174



CC: CC: Required CC: Required CC: Required CC: Required

HPI: HPI: 1-3 HPI: 1-3 HPI:4+ HPI: 4+

Requires two of the ROS: None ROS: None ROS: 1 ROS: 2-9 ROS:10+

three key components PFSH: None PE:

PFSH: None PE: 1 BA/OS

PFSH: 1 PE: 2-7 BA/OS

PFSH: 1 PE: 2-7 BA/OS w/detail

PFSH: 2-3 PE: 8+OS

MDM: MDM: Straightforward


Office Consultation

New or Established 99242 99243 99244 99245

175



Avg time (mins) 15 30 40 60 80

CC: Required CC: Required CC: Required CC: Required CC: Required

HPI: 1-3 HPI: 1-3 HPI:4+ HPI: 4+ HPI: 4+

Requires all three key ROS: None ROS: 1 Pertinent ROS:2-9 ROS: 10+ ROS: 10+

components PFSH: None PFSH: None PFSH: 1 Pertinent PFSH: 3 PFSH: 3

PE: 1 BA/OS PE: 2-7 BA/OS PE: 2-7 BA/OS w/detail

PE: 8+OS PE: +OS




176


Hospital Inpatient Services Evaluation & Management CPT Code Criteria Initial Hospital

Care99221 99222 99223

Avg time (mins) 30 50 70

CC: Required HPI: 4+ ROS: 2-9 PFSH: 1 PE: 2-7 BA/OS w/detail MDM: Low

CC: Required HPI:4+ ROS: 10+ PFSH:3 PE:8+OS MDM: Moderate

CC: Required HPI:4+ ROS: 10+ PFSH: 3 PE: 8+OS MDM: High

SubsequentHospital Care

99231 99232 99233

Avg time (mins) 15 25 35

Requires all three keycomponents

177


Hospital Inpatient Services Evaluation & Management CPT Code Criteria

CC: Required HPI: 1-3 ROS: None PFSH: None PE: 1 BA/OS MDM: Low

CC: Required HPI: 1-3 ROS: 1 Pertinent PFSH: None PE: 2-7 BA/OS MDM: Moderate

CC: Required HPI:4+ ROS: 2-9 PFSH: None PE: 2-7 BA/ OS / detail MDM: High

Initial InpatientConsultation

99251 99252 99253 99254 99255

Avg time (mins) 20 40 55 80 110 CC: Required HPI: 1-3 ROS: None PFSH: None PE: 1 BA/OS MDM: Straightforward

CC: Required HPI: 1-3 ROS: 1 Pertinent PFSH: None PE: 2-7 BA/OS MDM: Straightforward

CC: Required HPI:4+ ROS: 2-9 PFSH: 1 Pertinent PE: 2-7 BA/ OS w/detail MDM: Low

CC: Required HPI:4+ ROS:10+ PFSH:3 PE:8+OS MDM: Moderate

CC: Required HPI:4+ ROS:10+ PFSH:3 PE::8+OS MDM: High

Requires two of thethree key components

Requires all three keycomponents

178


History Components

HPI: History of Present Illness PFSH: Past, family & Social History

Location Timing Quality Context Severity Modifying Factors Duration Associated signs/symptoms

Past medications, illnesses, injuries, operations, hospitalization, allergies, immunizations status Family health status and dx of family members or cause of death Social marital status, current employment/occupational, environment, drugs, alcohol and tobacco use, sexual history

ROS: Review of Systems 2 ROS documented, remainder “all other systems negative” = complete ROS

Constitutional Respiratory Musculoskeletal Psychiatric Allergic/Immunologic Eyes Gastrointestinal Integumentary Endocrine Cardiovascular ENMT Genitourinary Neurological Hematologic/Lymphatic

179


Examination Components

BA: Body Area OS: Organ System

Abdomen GU/groin/pelvic/buttocks Back, Spine Head & Face Chest, Breasts Neck Each Extremity

Constitutional systems Gastrointestinal Musculoskeletal Cardiovascular Genitourinary Neurological Ears Nose Mouth Throat Hematologic/Lymphatic/Immunologic Psychiatric Eyes Integumentary (skin and breast) Respiratory

180


Risk of Complications and/or Morbidity or Mortality

Level of Risk

Category IPresenting Problems

Category IIDiagnostic Procedure(s)

Category IIIManagement Options

Selected

Minimal (1)

One self-limited or minor problem, e.g.

Cold, insect bite, tinea corporis

Laboratory tests requiring venipuncture

Chest X-rays EKG/EEG Urinalysis Ultrasound, e.g., echocardiography KOH prep

Rest Gargles Elastic bandages Superficial dressings

181



Low (2)

Two or more self-limited or minor problems

One stable chronic illness, e.g., well controlled

Hypertension or non-insulin dependent

diabetes, cataract, BPH Acute uncomplicated illness or

injury. e.g., cystitis, allergic rhinitis,

simple sprain

Physiologic tests not under stress, e.g. pulmonary function tests Non-cardiovascular imaging studies

with contrast, e.g., barium enema Superficial needle biopsies Clinical laboratory tests requiring

arterial puncture Skin biopsies

Over the counter drugs Minor surgery with no identified risk

factors Physical therapy Occupational therapy IV fluids without additives

182



Moderate (3)

One or more chronic illnesses with mild exacerbation, progression or side effects of treatment

Two or more stable chronic illnesses

Undiagnosed new problem with uncertain prognosis, e.g., lump in breast

Acute illness with systemic symptoms,

e.g., pyelonephritis, pneumonitis, colitis

Acute complicated injury, e.g., head injury with

brief loss of consciousness

Physiologic tests under stress, e.g. stress test Diagnostic endoscopies with no

identified risk factors Deep needle or incisional biopsy Cardiovascular imaging studies with

contrast and no identified risk factors, e.g. arteriogram,

cardiac catheterization Obtain fluid from body cavity, e.g.

lumbar puncture, thoracentesis, culdocentesis

Minor surgery with identified risk factors

Elective major surgery (open, percutaneous or

endoscopic) Prescription drug management Therapeutic nuclear medicine IV fluids additives Closed treatment of fracture or

dislocation without manipulation

183



High (4)

One or more chronic illnesses with severe

exacerbation, progression or side effects of treatment

Acute or chronic illnesses or injuries that pose a

threat to life or bodily function, e.g., multiple

trauma, acute MI, pulmonary embolus, severe

respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure

An abrupt change in neurologic status, e.g.,

seizure, TIA, weakness or sensory loss

Cardiovascular imaging studies with contrast with identified risk factors

Cardiac electrophysiological tests Diagnostic endoscopies with identified

risk factors Discography

Elective major surgery (open, percutaneous or

endoscopic) with identified risk factors

Emergency major surgery (open, percutaneous

Or endoscopic) Parenteral controlled substances Drug therapy requiring intensive

monitoring for toxicity Decision to not resuscitate or to de-

escalate care because of poor prognosis

184


TrailBlazerHEALTH ENTERPRISE, LLC

EVALUATION AND MANAGEMENTCoding and Documentation Reference Guide

© CP7 codes, descriptions, and other data only are copyright 2007 American Medical Association. All rights reserved. Applicable FARS/DFARS clauses apply.

HPI (History of Present Illness): Characterize HPI by considering either the Status of chronic conditions or the number of elements recorded.

1 condition 2 conditions 3 conditions

Location Severity Timing Modifying factors

1 ) HISTORY

Quality Duration Context Associated signs and symptoms

Status of

1-2 chronic conditions

Status of

1-2 chronic conditions

Status of 3 chronic conditions

Status of 3 chronic conditions

Brief (1-3)

Brief (1-3)

Extended (4 or more)

Extended (4 or more)

ROS (Review of Systems): Constitutional Ears, nose, Gl Integumentary Endo (wt loss, etc.) mouth, throat (skin, breast) Eyes Card/vase GU Neuro Hem/lymph Musculo Psych All/immuno Resp

N/A

Pertinent to problem (1

system)

Extended (Pert and

others) (2-9 systems)

Complete (Pert and

all others) (10 systems)

PFSH (Past, Family, Social History): Past history (the patient's past experiences with illnesses, operations, injuries and treatments) Family history (a review of medical events in the patient's family, including diseases that may be hereditary or place the patient at risk) Social history (an age-appropriate review of past and current activities)

N/A N/A

Pertinent

(1 history area)

"Complete

(2 or 3 history areas)

"Complete PFSH: 2 history areas: a) established patients - office (outpatient) care, domiciliary care, home care; b) emergency department; c) subsequent nursing facility care; and, d) subsequent hospital care. 3) history areas: a) new patients - office (outpatient) care, domiciliary care, home care; b) consultations; c) initial hospital care; d) hospital observation; and, e) initial nursing facility care.

PROBLEM-FOCUSED

EXP. PROBLEM-FOCUSED

DETAILEDCOMPREHENSIVE

Final History requires all 3 components above met or exceeded

HPI (History of Present Illness): Characterize HPI by considering either the Status of chronic conditions or the number of elements recorded.

1 condition 2 conditions OR 3 conditions Location Severity Timing Modifying factors

Quality Duration Context Associated signs and symptoms

185





186

2) EXAMINATION" — CRT Exam Description 95 Guideline Requirements 97 Guideline Requirements CRT Type of Exam

Limited to affected body area or organ system One body area or organ system 1-5 bulleted elements PROBLEM-FOCUSED EXAM

Affected body area or organ system and other symptomatic or related organ systems

2-7 body areas and/or organ systems

6-11 bulleted elementsEXPANDED PROBLEM-

FOCUSED EXAM

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

2-7 body areas and/or organ systems

12-17 bulleted elements for 2 or more systems

DETAILED EXAM

General multi-system8 or more body areas and/or

organ systems18 or more bulleted elements for 9 or

more systems

COMPREHENSIVE EXAM

Complete single organ system exam Not defined See requirements for individual single system exams





187

Instructions for Using Trailblazer’s MDM Coding Method

Coding Medical Decision-Making (MDM) begins with separately coding the three distinct components of MDM. Two of the three components determine the final level of MDM complexity documented in a record of Evaluation and Management (E/M) service. These components are:

1. Number of diagnoses and/or management options.

2. Amount and/or complexity of data reviewed or ordered.

3. Risk of complication and/or mortality.

The TrailBlazer MDM coding method corresponds directly to the components above as follows:

• Section A corresponds to number of diagnoses and/or management options.

• Section B corresponds to amount and/or complexity of data reviewed or ordered,

• Section C corresponds to risk of complication and/or mortality.

Code each component separately using respective Tables A-C, then compare results from Tables A-C to requirements in Table D to determine the overall MDM level.

MEDICAL DECISION-MAKING

Section A

Coding Number of Diagnoses or Management Options – Use the Table A.1 and A.2 on page 2 to determine the numbers of diagnoses or management options.

Note: In all cases, the information in the clinical record (history and physical) must clearly support diagnostic impressions. Diagnostic impressions listed but not supported elsewhere I the clinical record must be included in the problem list for coding purposes.

physician training presented by: la verne jones 1/15/2009 © 2006 the coding network, llc inpatient...

Documents