The first edition of Physicians’ Current Procedural Terminology appeared in 1966, and the book was subsequently revised in 1970, 1973, and 1977. Since 1984, the Physician’s Current Procedural Terminology has been updated and revised annually. CPT uses a five digit system for coding services rendered by physicians, plus two digit add-on modifiers or separate five-digit numbers representing the modifiers to indicate complications or special circumstances. The International Classification of Diseases (ICD) had its beginnings in England during the 17 th Century. The United States began using ICD toward the 19 th Century to report causes of death and prepare mortality statistics. Hospitals started using ICD in 1950 to classify and index diseases. ICD-9 code numbers have from three to five digits.
CPT is the systematic listing of procedures PERFORMED BY PROVIDERS. Unless otherwise specified, it is assumed that the Provider performed the procedure or service and reimbursement is paid with that assumption. There is one exception to this rule, Office visit 99211, a Level I patient encounter, can be done by medical staff qualified to do the task as long as it is supervised by a physician. This is a common code used for those coming in for a BP check, injection or minimal service usually performed by a physician’s assistant (RN, LPN, others). Coding must be correct if claims are to be paid promptly. Every individual diagnosis and procedure or service must be assigned correct and complete code numbers. Two coding systems are used in physicians’ offices; International Classification of Diseases, Ninth Revision (ICD-9) for diagnosis. Physicians’ Current Procedural Terminology (CPT) to identify services. A Provider can use any code he/she is qualified to do.
To facilitate understanding of the coding system it is helpful to dissect the code itself. In this case we use as an example the code related to the evaluation and management of a new patient. As you can see the first two numbers identify the section where the code is located. The third number allows you to define your search while the fourth number specifies what type of code is used. Normally for E & M codes the fourth number will identify whether the services are been provided to a new or established patient. The last code relates to the complexity of the encounter.
Most procedures are stand alone definitions of the services offered. Regardless, based on the complexity of the services offered, additional components have been added to the code system to assist Providers in the definition of the most appropriate service. Some of the most common components identify characteristics such as age, time and size. On the other hand, the person coding services must be aware that these components may not have anything to do with the key components of evaluation and management.
The levels of E/M services encompass the wide variations in skill, effort, time, responsibility and medical knowledge required for preventing, or diagnosing and treating illness or injury, and promoting optimal health. Codes for E/M services are categorized by the place of service (e.g., office or hospital) or type of service (e.g. critical care or preventive medicine services). The narrative for most of the E/M services recognize seven components. But before we discuss these seven components and how they are to be used it will be helpful to define the types of E/M Codes.
New Patient – has not received services from Provider or another Provider of the same specialty who belong to the same Group within the past three years. Established Patient – has received services from Provider or another Provider of the same specialty who belong to the same Group within the past three years.
There are three components (history, examination and medical decision making are the most often used components to define the levels of E/M services. Information regarding at least two, and occasionally all three, must be documented in the patient’s record to justify the selected code. Counseling and Coordination of care need not be provided on every visit. However, when counseling and coordination of care takes up more than 50% of the time, time then becomes the determining factor is selecting the proper code. Time must be indicated in the record whenever this factor is used to determine the level of service.
Problem focused – chief complaint, brief history or present illness/problem Expanded Problem Focused – chief complaint, brief history or present illness/problem, problem-pertinent system review Detailed – chief complaint, extended history or present illness/problem, problem-pertinent system review extended to include a review of a limited number of additional systems, and pertinent past, family and/or social history directly related to the patient’s problem Comprehensive– chief complaint, extended history or present illness/problem, review of systems that are directly related to the problem identified in the history of present illness, plus a review of all additional body systems, and complete past, family and social history.
CC – concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other reason for the encounter. Usually stated in the patient’s words. HPI – chronological description of patient’s condition. A brief HPI consist of three elements while an extended HPI is at least four elements . location quality severity associated signs/symptoms timing context duration modifying factors ROS – inventory of body systems obtained through a series of questions. Problem pertinent requires review of one system. Extended involves two to nine systems . Complete is at least 10 systems . Constitutional symptoms (e.g., fever, weight loss) Eyes Ears, nose, mouth, throat Cardiovascular Respiratory Gastrointestinal Genitourinary Neurological Intergumentary (Skin/breast) Musculoskeletal Psychiatric Hematologic/Lymphatic Allergic/Immunologic Endocrine PFSH- Pertinent is at least one item. Complete is at least two of the three items must be documented. PFSH consists of a review of three areas: - past history – past experiences with illness, injuries, treatments & surgeries - family history – review of medical events in family, including disease that may be hereditary or place patient at risk - social history – age appropriate review of past and current activities
Problem focused - examination limited to the affected body area or organ system. One to five elements. Expanded Problem Focused – limited examination of the affected body area or organ system and other symptomatic or related organ system. At least six elements. Detailed – extended examination of the affected body area (s) and other symptomatic or related organ system(s). At least twelve elements in two or more organ systems. Comprehensive – general, multisystem examination or complete single organ operating system examination. For each area/system at least two elements or minimum of nine systems and two elements of each system selected.
See attachment “General Multi System Examination” for a complete list!!
Straightforward – minimal number of possible diagnosis or management options; minimal data to be reviewed (if any), minimal risk or complication or morbidity/mortality Low Complexity – limited number of possible diagnosis or management options; limited data to be reviewed, low risk or complication or morbidity/mortality Moderate Complexity – multiple number of possible diagnosis or management options; moderate amount of data to be reviewed and moderate risk or complication or morbidity/mortality High Complexity – extensive number of possible diagnosis or management options; extensive amount of data to be reviewed and high risk or complication or morbidity/mortality
Minimal – problem that may not require the presence of the Provider, but service is provided under the Provider’s supervision Self-limited or minor – transient problem, and low probability of permanently altered state; or good prognosis with management/compliance Low Severity – problem that has a low risk of morbidity or little, if any, risk of mortality without treatment; full recovery is expected without functional impairment Moderate Severity – problem that carries a moderate risk of morbidity or mortality without treatment; uncertain outcome or increased probability of prolonged functional impairment High Severity – problem that has a high to extreme risk of morbidity or mortality without treatment; or high probability of severe, prolonged functional impairment
Counseling – Discussions wit patient or family regarding: Diagnostic results Prognosis Risks and benefits of management (treatment) options Instructions for management (treatment) or follow-up Importance of compliance with chosen management (treatment) options Risk factor reduction Patient and family education Coordination of care – contact with other Providers on behalf of the patient. If no patient encounter included then a case management code should be used Time – only a guideline except in appropriate counseling. Used only when counseling or coordination represents more than 50% of the time spent with the Provider (face to face)
Number of components required (history, exam, and medical decision making). Key Phrases to code selection appear in bold face. If more than 50% of the service involves counseling or coordination of care, then time is used to determine the code selected. A presenting problem is a disease, condition, illness, injury, symptom, sign, finding, or complaint.
Use these codes if the patient has not been seen by the physician, or any member of the group who is of the same specialty, within the past three years. Consider assigning the appropriate critical care code instead of these codes if the physician provided constant attention to a critically ill patient. Consider assigning the appropriate consultation code instead of these codes when an opinion or advice was provided about a patient for a specific problem at the request of another physician or other appropriate source. Report only the appropriate initial hospital care, hospital observation or comprehensive nursing facility assessment code if the patient is admitted to the hospital or a nursing facility on the same day to the office visit. Do not consider the time spent by other staff (e.g., nurse, nurse practitioner or physician assistant as part of face-to-face time. Use a case management code when coordination of care involved other providers or agencies but did not involve a patient encounter on that day. Report additionally prolonged services codes 99354-99355, as appropriate, for E/M services that exceed 30 minutes of the typical time specified in the code narrative. Only the direct physician-patient (face-to-face) contact should be used to determine the prolonged service code. The time must be clearly documented in the medical record. (Some third party payers may allow reporting of prolonged services with only modifier-21 and the highest level of E/M service code. Be sure to verify the reporting requirements of the individual payer). Add modifier – 25 or 09925 to report that a separately identifiable E/M service was performed by the same physician on the same day as a procedure or service. Only the content associated with the separate E/M service should be considered when determining the correct level of service. Add modifier – 57 or 09957 to indicate that the decision to perform surgery was made at this visit. For Medicare, the decisions must be to perform major surgery (surgery with a 90-day post-operative period). Report separately the codes for the diagnostic tests or studies performed.
Use these codes if the patient has been seen by the physician, or any member of the group who is the same specialty, within the pat three years. These codes also apply to preoperative medical evaluation services rendered by the primary care physician at the request of the surgeon. Consider assigning the appropriate critical care code instead of these codes if the physician provided constant attention to a critically ill patient. Consider assigning the appropriate consultation code instead of these codes when an opinion or advice was provided about a patient for a specific problem at the request of another physician or other appropriate source. Report only the appropriate initial hospital care, hospital observation or comprehensive nursing facility assessment code if the patient is admitted to the hospital or a nursing facility on the same day as the office visit. Do not consider the time spent by other staff (e.g., nurse, nurse practitioner or physician assistant) as part of face – to – face time. Use a case management code when coordination of care involved other providers or agencies but did not involve a patient encounter on that day. Report additionally prolonged services codes 99354 – 99355, as appropriate, for E/M services that exceed 30 minutes of the typical time specified in the code narrative. Only the direct physician-patient (face-to-face) contact should be used to determine the prolonged service code. The time must be clearly documented in the medical record. (Some third party payers may allow reporting of prolonged services with only modifies-21 and the highest level of E/M service code. Be sure to verify the reporting requirements of the individual payer). Add modifier-24 or 09924 to indicate that an E/M service performed during the postoperative period was not related to the prior procedure. The claim should show a different diagnosis from that for the surgery. Add modifier-25 or 09925 to report that a separately identifiable E/M service was performed by the same physician on the same day as a procedure or service. Only the content associated with the separate E/M service should be considered when determining the correct level of service. Add modifier-57 or 09957 to indicate that the decision to perform surgery was made at this visit. For Medicare, de decision must be to perform major surgery. Report separately the codes for the diagnostic tests or studies performed.
Modifiers permit the Provider to indicate circumstances in which a procedure as performed differs from that described by its usual five digit code. Providers and coders must keep present that not all modifiers may be used with every CPT. Applicable modifiers are usually found at the beginning of each section.
-21 can only be used on the highest code in a category E/M 99205 99215 99245 99255 No specific payment amount attached. -22 Services are greater than those usually performed. Report should be included. -24 Used only on E/M code. Must be for condition or problem not related to the operation performed by surgeon 0-90 days preceding the visit -25 Used only on E/M code. Patient’s condition must warrant significant separate service. Most frequently used to bill office visit in conjunction with preventive medicine in the same day. -26 Used to indicate the professional component when technical component is billed by another Provider. If whole service is provided -26 is not needed.
If a patient comes into the office requiring emergency care and the Provider bills for the office visit, suturing of the laceration, and the surgical tray most insurance carriers will only pay for the suturing. However, if the office visit is coded as an emergency, most carriers may reimburse for the office visit. 99203 = $ 94.68 12001 = $141.69 99070 = $ N/A 99058 = $N/A $236.37
If multiple lacerations are repaired with the same technique and are in the same anatomic category, the Provider should add up the total length of all the lacerations and report one code to obtain maximum reimbursement. Coding these lacerations individually will result on the first laceration been paid at full price with the second and third laceration been down coded or pay at a fraction of the cost. 12011 = $150.06 12013 = $164.86/82.43 12013 = $164.86/N/A 12015 = $245.51 $232.49 $245.51
Legible by a common person Completeness include: Reason for encounter and relevant history Physical examination findings Prior diagnostic test results Assessment, clinical impression, or diagnosis Plan for care Date and legible identity of the observer Rationale for ordering tests documented unless easily inferred Past and present diagnoses should be accessible Health risks factors should be identified Patient’s progress, response to and changes in treatment should be documented
S = subjective statements of symptoms and complaints in the patient’s own words, chief complaint O = data from physical examination, x-rays, laboratory and other diagnostic tests A = assessment of subjective and objective parts of the chart note P = Diagnostic and therapeutic plan and instructions to the patient
Billing training coding e&m
Billing Training Principles of Coding Taino Consultants Inc. Jose I. Delgado, Ph.D., CAPPM
Background CPT = What you did ICD – 9 = Why you did it
Current Procedural Terminology (CPT) Six Major Sections Evaluation and Management 99201 to 99499 Anesthesiology 00100 to 01999, 99100 to 99140 Surgery 10000 to 69999 Radiology, Nuclear Medicine and Diagnostic Ultrasound 70000 to 79999 Pathology and Laboratory 80000 to 89999 Medicine 90700 to 99199
Coding StructureMedicine Or E&M Type LevelSection of Code of Code 99202
Components of Codes Age Specific 42831 Adenoidectomy, age 12 or over Time 99291 Critical care, initial …; first hour Size 11420 Excision, benign lesion; 0.5 cm or less Each additional 15786 Abrasion, single lesion 15787 Each additional 4 lesions or less “e.g.” 25600 Treatment of closed distal radial fracture (e.g. Colles or Smith type) () Parenthesis 25111 Excision of a ganglion (dorsal or volar) Et seq – “and following” 14060 Adjacent tissue transfer or rearrangement, eyelids, nose, ears, and/or lips; defect, 10 sq cm or less. 14061 Defect 10.1 sq cm to 30.0 sq cm (for eyelid, full thickness, see 67961 et seq)
Evaluation and Management (E & M) Codes Office Visits Hospital Visits Consultations Emergency Department
Components of an E & M Visit History Examination Medical Decision Making Nature of Present Illness Counseling Coordination of Care Time
1. History Problem focused Expanded Problem Focused Detailed Comprehensive
Elements of History Chief Complaint (CC) History of Present Illness (HPI) Review of Systems (ROS) Past, family and/or social history (PFSH)
History - Elements RequiredType ofHistory HPI ROS PFSH______Brief N/A N/A Problem FocusedBrief Problem N/A Expanded Problem Pertinent FocusedExtended Extended Pertinent DetailedExtended Complete Complete Comprehensive
2. Examination Problem focused Expanded Problem Focused Detailed Comprehensive
General Multi-System ExaminationLevel of Exam Perform and DocumentProblem Focused One to five elementsExpanded Problem At least six elements FocusedDetailed At least two elements identified from each of six areas/systems or at least 12 elements identified in two or more areas/systemsComprehensive At least two elements identified from each of nine areas/systems
Elements of ExaminationSystem/Body Area Elements of ExaminationsConstitutional - Measurement of any three of the following seven vital signs: 1. Sitting or standing blood pressure 2. Supine blood pressure 3. Pulse rate and regularity 4. Respiration 5. Temperature 6. Height 7. Weight (may be measured and recorded by ancillary staff) - General appearance of patient (e.g., development, nutrition, body habitus, deformities, attention to grooming)Eyes - Inspection of conjunctivae and lids - Examination of pupils and irises (e.g., reaction to light and accommodation, size and symmetry) - Ophthalmoscopic examination of optic discs (e.g., size, C/D ratio, appearance) and posterior segments (e.g., vessel changes, exudates, hemorrhages)Ears, Nose, Mouth, - External inspection of ears and nose (e.g., overall appearance, Throat scars, lesions, masses) - Otoscopic examination of external auditory canals and tympanic membranes - Assessment of hearing (e.g., whispered voice, finger rub, tuning fork) - Inspection of nasal mucosa, septum and turbinates - Inspection of lips, teeth and gums - Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx
3. Medical Decision Making Straightforward Low Complexity Moderate Complexity High Complexity
Elements of Decision MakingNumber of Amount and/or Risks ofDiagnoses or complexity of Complications Type ofManagement data to be and/or Morbidity DecisionOptions reviewed or Mortality MakingMinimal Minimal or None Minimal StraightforwardLimited Limited Low Low ComplexityMultiple Moderate Moderate Moderate ComplexityExtensive Extensive High High Complexity
Table of riskLevel Diagnostic of Procedure Management Risk Problem Ordered Options_______Minimal One self limited Lab tests Restor minor (cold, Chest X-rays Gargles insect bite) EKG/EEG Elastic bands Urinalysis Superficial DressingsLow Two or more Physiological tests Over the counter drugs self-limited problems not under stress Minor surgery One stable chronic illness (pulmonary function test) Pt, Ot (well controlled test) IV fluids without hypertension, non- hypertension, non-insulin Skin biopsies additives dependent diabetes, cataract) Superficial needle biopsiesModerate One or more chronic illness Physiological tests under stress Minor surgery with identified with mild exacerbation or side effects Dx endoscopies identified risks factors Two or more stable chronic illnesses Deep needle biopsy Prescription drug mgmt Undiagnosed new problem with Obtain fluid from body cavity Therapeutic nuclear medicine with uncertain prognosis Cardiovascular imaging studies with Closed treatment of fracture or Acute complicated injury (head contrast and no identified risk factors or dislocation without manipulation injury with brief loss of consciousness) IV fluids with additivesHigh One or more chronic illness with Cardiovascular imaging studies with Elective major surgery with severe exacerbation, progression contrast and identified risk factors with identified risks factors or side effects of treatment Cardiac electrophysiological tests Emergency major surgery Acute or chronic illness or injuries Dx endoscopies with identified risk Parenteral controlled substances that pose a threat to life of body Discography Drug therapy requiring monitoring system for toxicity Abrupt change in neurological status Decision not to resuscitate
4. Nature of Present Illness Minimal Self-limited or minor Low Severity Moderate Severity High Severity
Nature of Present Illness Continuation5. Counseling6. Coordination of Care7. Time
Anatomy of a code99203 Office or other outpatient visit for the evaluation and management or a new patient, which requires these three key components: 1 A detailed history; A detailed examination; and 2 Medical decision making of low complexityCounseling and/or coordination of care with other Providers or agencies provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs 3Usually, the presenting problem(s) are of moderate severity. Providers typically spend 30 minutes face to face with patient/family 4
Office or other Outpatient Services (New) E/M Medical Decision Problem Counseling and/or Time Spent Code History* Exam* Making* Severity Coordination of Care Face to Face 99201 Problem-Focused Problem-Focused Straight Minor or Consistent with problems and patient’s or 10 min. Forward Self-limited family’s needs 99202 Expanded Expanded Straight Low to Consistent with problems and patient’s or 20 min. Problem-Focused Problem-Focused Forward Moderate family’s needs 99203 Detailed Detailed Low Moderate Consistent with problems and patient’s or 30 min. Complexity family’s needs 99204 Comprehensive Comprehensive Moderate Moderate to Consistent with problems and patient’s or 45 min. Complexity High family’s needs 99205 Comprehensive Comprehensive High Moderate to Consistent with problems and patient’s or 60 min. Complexity High family’s needs* Key Component. For new patients, all three components (history, exam and medical decision making) are crucial for selecting the correctcode
Office or other Outpatient Services (Established)E/M Medical Decision Problem Counseling and/or Time SpentCode History** Exam** Making** Severity Coordination of Care Face to Face99211 Physician Minimal Consistent with problems and patient’s or 10 min. Supervisions but family’s needs presence not required99212 Problem-Focused Problem-Focused Straight Forward Minor or Consistent with problems and patient’s or 20 min. Self-limited family’s needs99213 Expanded Expanded Low Complexity Low to Consistent with problems and patient’s or 30 min. Problem-Focused Problem-Focused Moderate family’s needs99214 Detailed Detailed Moderate Moderate to Consistent with problems and patient’s or 45 min. Complexity High family’s needs99215 Comprehensive Comprehensive High Moderate to Consistent with problems and patient’s or 60 min. Complexity High family’s needsEstablished services include follow-up, periodic reevaluation, and evaluation and management of new problems.* Key Component. For established patients, at least two of the three components (history, exam and medical decision making) are needed forselecting the correct code
Modifiers (Key reasons to use) Service/procedure has professional and technical component Service performed by more than one Provider and/or in more than one location Service has been increased or reduced Only part of the service was performed Adjunctive service was performed Service/Procedure was provided more than once Unusual events occurred Service provided during global period but not included as part of the global reimbursement
Examples of Documentation The lab test indicated abnormal lover function. The baby was delivered, the cord clamped and cut, and handed to the pediatrician, who breathed and cried immediately. Exam of genitalia reveals that he is circus sized. She stated that she had been constipated for most of her life until 1989 when she got a divorce. The patient was in his usual state of good health until his airplane ran out of gas and crashed. Rectal exam revealed a normal size thyroid. (Long fingers?) Between you and me, we ought to be able to get this lady pregnant. A midsystolic ejaculation murmur heard over the mitral area. The patient lives at home with his mother, father, and pet turtle, who is presently enrolled in day care three times a week. Both breasts are equal and reactive to light and accommodation. She is numb from her toes down. Exam of genitalia was completely negative except for the right foot. The patient was to have a bowel resection. However, he took a job as stockbroker instead. When she fainted, her eyes rolled around the room. Examination reveals a well-developed male lying in bed with his family in no distress. She has no rigors or chills but her husband says she was very hot in bed last night. She cant get pregnant with her husband, so I will work her up.
Sample modifiers -21 Prolonged E & M (09921) -22 Unusual Services (09922) -24 Unrelated E & M by same Provider during post-op (09924) -25 Significant, Separately Identifiable E & M (09925) -26 Professional Component (09926)
Sample coding 1Patient shows to your office with a 2.5 cm laceration on scalp 99203 Office visit, intermediate, new 12001 Suture of scalp 2.5 cm 99070 Surgical tray (itemized) 99058 Office services provided on an emergency basis Repair of 2.5 cm scalp laceration
Sample coding 2Patient shows to the office with multiple lacerations on the face (1st 2.5 cm; 2nd 2.7 cm; 3rd 3 cm) 12011 Repair 2.5 cm laceration of face 12013 Repair 2.7 cm laceration of face 12013 Repair 3 cm laceration of face 12015 Repair 8.2 cm laceration of face
Principles of Medical Records Complete and legible Must support CPT and ICD-9 Diagnostic testing
SOAP S (subjective) = history O (objective) = data A (assessment) = putting facts together P (plans) = Plan of Action
Summary Current Procedural Terminology (CPT) Coding Required Elements Modifiers Medical Records Coding Examples