Choosing the Proper Levels OfEvaluation & Management Services Presented by: David Klein, CPC, CHC
Telling the StoryIt’s not Just Documentation that tells the Story…Everything we do in Practice Tells a Story, for example: Cervical Sprain/Strain indicates whiplash injury -59 modifier indicates separate site/organ system was treated Our fee schedule reflects how we value our skills Level 1 Established Patient Exam indicates a problem that will likely self resolve
Introduction Evaluation and Management – E/M codes Office or Other Outpatient Services 99201 – 99215 E/M codes are the most scrutinized codes by third party payers when it comes to levels of service provided and utilization guidelines. One of the most common mistakes when billing E/M codes are inappropriate coding due to misinterpretation of descriptions and definitions. The key components and how they determine the level of service.
Terminology New Patient - A new patient is one who has not received professional services from a provider or another provider of the same specialty who belongs to the same group practice within the past 3 years. Established Patient - A patient who has received professional services within the past 3 years from the provider or another provider of the same specialty who belongs to the same group practice. Chief Complaint - A concise statement from the patient describing the symptom, problem, condition, diagnosis, or other factor that identifies the reason for the visit.
Concurrent Care - When more than one provider provides services to a patient on the same day. Payment for concurrent care is determined by establishing medical necessity for services performed by more than one provider. Counseling - A discussion with the patient and/or family regarding diagnoses, test results, medication management, care instructions, prognosis, or other factors related to the patient’s condition. History of Present Illness - A chronological description of the development of the patient’s present illness, or problem from onset to present. This must be documented by the provider and not ancillary staff. Medical Decision Making - The process for describing the outcome of the visit, through consideration of the nature of the presenting problem, diagnoses, treatment and/or management options, diagnostic tests and procedures ordered, complexity of the condition and risk for complications.
Morbidity - The quality or state relative to a disease process. Mortality - The number of deaths in a given time or place. Nature of Presenting Problem - A disease, condition, illness, injury, sign, finding or complaint for which the patient is being seen. The five types are: Minimal – Services may not require the presence of a provider, however, services are rendered under a provider’s supervision. Self-Limited or Minor – A problem that typically runs a definite course, is transient in nature, and not likely to permanently alter health status. Low Severity – A problem in which the risk of morbidity without treatment is considered to be low; there is minimal risk of mortality without treatment; and full recovery is expected. Moderate Severity – A problem for which the risk of morbidity without treatment is moderate; there is moderate risk of mortality without treatment or there is some uncertainty of the prognosis or potential for functional impairment. High Severity – A type of problem in which the risk of morbidity and/or mortality without treatment is high to extreme. There exists a high probability of severe or prolonged functional impairment.
Past History - A review of the patient’s own medical history related to trauma, illness, previous surgeries and hospitalizations, including medications, allergies and other pertinent information. Social History - A review of events and activities describing the patient’s lifestyle, eg. marital status, education, employment, sexual history, substance use or other relevant social factors. Review of Systems - An inventory of the body systems acquired through a series of questions asked to the patient. The review of systems helps define possible management options. Face to Face Time - This includes only the time the provider spends face to face with the patient obtaining the history, performing the examination and counseling the patient and/or family. Consultations – Services provided by a provider whose opinion or advice is requested for a specific condition or problem by another provider or an appropriate source.
The Seven Components of E/M » History * » Examination * » Medical Decision Making * » Counseling » Coordination of Care » Nature of Presenting Problem » Time * Key Components
HistoryFour Types: • Problem Focused • Expanded Problem Focused • Detailed • ComprehensiveComponents that determine the extent of history obtained: 1. Chief Complaint/History of Present Illness: • Location, Quality, Severity, Duration, Timing, Context, Modifying Factors, Associated Signs and Symptoms 2. Review of Systems: • Constitutional, Eyes, Ears/Nose/Throat/Mouth, Cardiovascular, Respiratory, Gastrointestinal, Genitourinary, Musculoskeletal, Integumentary, Neurological, Psychiatric, Endocrine, Hematologic/Lymphatic, Allergic/Immunologic 3. Past, Family, Social History: • Past History, Family History, Social History
History CC/HPI = 8 Elements ROS = 14 Systems PFSH Brief 1-3 Elements Problem Pertinent Extended 2-9 Systems Complete 10+ Systems Pertinent 1 AreaExtended 4 or More Complete 2/3 or 3/3After Determining which level of each history component is applicable, choosethe overall level of history:HPI + ROS + PFSH = Level of HistoryBrief N/A N/A Problem FocusedBrief Problem Pertinent N/A Expanded Problem FocusedExtended Extended Pertinent DetailedExtended Complete Complete Comprehensive
Examination 1995 GuidelinesFour Types: Problem Focused – A limited examination of the affected body area or organ system. Expanded Problem Focused – A limited examination of the affected body area or organ system and other symptomatic or related organ system(s). Detailed – An extended examination of the affected body area(s) and other symptomatic or related organ system(s). Comprehensive – A general multi-system examination or a complete examination of a single organ system.
Medical Decision MakingThe complexity of establishing a diagnosis and/orselecting a management option is measured by thefollowing 3 elements: 1. The number of possible diagnoses and/or number of management options that must be considered. 2. The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed. 3. The risk of significant complications, morbidity and/or mortality, as well as co morbidities associated with the patient’s presenting problem(s), the diagnostic procedure(s) and possible management options.
Table of RiskLevel of Diagnostic Procedures Management Options Presenting Problem(s) Risk Ordered Selected One self limited or minor problem; Lab test requiring venipuncture Rest eg. cold, insect bite, tinea corporis Chest x-rays Gargles Minimal EKG, EEG Elastic Bandages Urinalysis Superficial Dressings Two or more self limited or minor Physiologic tests not under stress Over the counter drugs problems. eg. pulmonary function tests Minor surgery with no identified risk One stable chronic illness, eg. well Non-cardiovascular imaging studies factors Low controlled hypertension, NIDD with contrast, eg. barium enema Physical therapy Acute, uncomplicated illness or Skin biopsy Occupational therapy injury eg. simple sprain, cystitis. Clinical laboratory tests requiring IV fluids without additives arterial puncture One or more chronic illnesses with Physiologic test under stress eg. Minor surgery with identified risk mild exacerbation, progression, or cardiac stress test fetal contraction factors. side effects of treatment. stress test. Elective major surgery with no Two or more stable chronic Diagnostic endoscopies with no identified risk factors. illnesses. identified risk factors. Prescription drug management.Moderate Undiagnosed new problem with Deep needle or incision biopsy. Therapeutic nuclear medicine. uncertain prognosis, (lump in breast). Obtain fluid from body cavity, eg. Closed treatment of fracture or Acute complicated injury, eg. head lumbar puncture, thoracentesis etc. dislocation without manipulation. injury with brief loss of consciousness. One or more chronic illnesses with Cardiovascular imaging studies with Elective major surgery with identified severe exacerbation, progression, or contrast with identified risk factors. risk factors. side effects of treatment. Cardiac electrophysiological tests. Emergency major surgery. Acute or chronic illnesses or injuries Diagnostic endoscopies with Parenteral controlled substances. High that may pose a threat to life or identified risk factors. drug therapy requiring intensive bodily function, eg. progressive Discography. monitoring for toxicity. severe rheumatoid arthritis, acute MI, Decision not to resuscitate or to etc. escalate car because of poor prognosis
Four Types of Decision Making: – Straight Forward – Low Complexity – Moderate Complexity – High Complexity Determine the type of decision making by choosing which levels of risk qualify for each element of medical decision making. Two out of three elements must be met or exceeded to qualify for any given level of decision making.Number of DX Amount and/or Risk of ComplicationsOr Management + Complexity of Data + and/or Morbidity or = Type ofOptions to be Reviewed Mortality Decision MakingMinimal Minimal/None Minimal Straight ForwardLimited Limited/Low Low Low ComplexityMultiple Moderate Moderate Moderate ComplexityExtensive Extensive High High Complexity
Office or other outpatient services New Patient 99201-99205 For a new patient, all three key components must be met or exceeded to qualify for a particular level of service. The overall level of service is selected based on the performance and documentation of history, examination, and medical decision making. Code 99201 99202 99203 99204 99205 Expanded Problem History Problem Detailed Comprehensive Comprehensive Focused Focused Expanded Problem Examination Problem Detailed Comprehensive Comprehensive Focused Focused Medical Low Moderate Straightforward Straightforward High ComplexityDecision Making Complexity Complexity Typical Time Spent Face to 10 Minutes 20 Minutes 30 Minutes 45 Minutes 60 Minutes Face
Office or other outpatient services Established Patient 99211-99215 For an established patient, two of the three key components must be met or exceeded to qualify for a particular level of service. The overall level of service is selected based on the performance and documentation of history, examination, and medical decision making. Code 99211 99212 99213 99214 99215 Expanded Problem History Minimal Problem Detailed Comprehensive Focused Focused Expanded ProblemExamination Minimal Problem Detailed Comprehensive Focused Focused Medical Moderate High Decision Minimal Straightforward Low Complexity Complexity Complexity MakingTypical TimeSpent Face to 5 Minutes 10 Minutes 15 Minutes 25 Minutes 40 Minutes Face
Office or Other Outpatient Services 99201 – 99215 Office or other outpatient service E/M codes are reported for patients presenting to a physician’s office, outpatient hospital or other type of ambulatory facility. When counseling and/or coordination of care dominates more than 50% or the total time spent face to face with the patient, time may be the controlling factor in determining the level of service. The documentation must include how much time was spent for the visit and how much time was spent counseling/coordinating care. Code 99211 may not require the presence of a provider. Any established patient visit encounter in which the provider is directly involved in the care of the patient should be coded as a 99212 at a minimum.
When Can You Bill for E/M Services?In most cases, the following scenarioswarrant an E/M service:• New Patient Exam• Re-Examinations• Exacerbations• Patient Presents with New Condition** If CMT also performed then a modifier is necessary – see next slide
25 Modifier• 25 Modifier - According to the AMA: “Significant, separately Identifiable Evaluation and Management Service by the Same Physician on the same day of the procedure or other service: 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 the other service provided… The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date.”
For More Information: Contact David KleinPhone: 888-306-1256 Email: email@example.com www.paydc.com