EVALUATION AND MANAGEMENT CPT CODING GUIDELINES BY BHARATH KUMAR MEDESUN STUDENT

2.  It covers patient disease, history, exam, and
MDM(medical decision making).
 80% of cpt codes covers E/M services.
 Assign E/M code whenever there is a documentation
of history examination and MDM.
 E/M code covers 10k-6k series with respective
modifiers

3.  Based upon place of service(office visits,hospital
visits,consultations)
 Based upon age
 Time taken for assessment
 Office visits again subdivided as new patient(or)
established patient
 Hospital visits again sub divided as initial(or)
subsequent patient.

4.  If time dominates a visit(taking too much time in
assessing a patient) assign separate code with respect
to time.
 Classification is very important because nature of work
varies based on type of service place of service and
patient condition.

5.  7 major components
 History
 Examination
 MDM(medical decision making)
 Time
 Counseling
 Co-ordination of care
 NPP(nature of presenting problem)

6.  First 3- components are key components
 Rest of 4- components are contributory components.
 LEVELS OF E/M SERVICE:-
it designed as
i. Giving unique code number
ii. Mentioning place/type of service provided
iii. Content of the service
iv. Finding present problem
v. Time taken for MDM decision.

7.  New patient visit requires more time than established
patient
 More resources are required for new patient
 For new patient Payment may be 40% higher than
established patient
 Separate codes are available for new and established
patients
 Patient come back within 3 years of time considered as
established patient

8.  3 years is the considering factor
 Absence of specification assume it as established
patient
 HOW TO ASSIGN E/M CODE?
 Analyze the patient(new/established)
 Place of service
 Age
 Time
 Key components

9.  8- elements are listed they are
 Location
 Duration
 Severity
 Quality
 Associated signs&symptoms
 Time
 Modifying factors
 context

10.  If 3- elements are documented, (HPI is brief)
Example: abdominal pain since morning due to
spicy food
 If more than 3- elements documented,(HPI is
expanded).
Example :edema of both legs due to ckd with
diabetic foot since 4 months and k/c/of
diabetic&hypertension since 5 years.

11.  Payment difference for every element is 10 dollars.
 Pay&chase model:-insurance company pay first later
on chase.
 Self-disclosure scheme:-under this scheme physician
can declare self errors and publish there by refunds the
money to insurance companies

12.  It is a questionnaire where patient has to respond
 There are 11- ros are there:-
 EYE
 ENT
 Cardiovascular
 Respiratory
 gastrointestinal

13.  Genitourinary
 Musculoskeletal
 Integumentary neurological
 neurologic
 Psychiatric
 Hematologic/lymphatic

14.  Physical exam is objective evidence
 ROS is subjective evidence
 NATURE OF PRESENTING PROBLEMS
 They are 5-types
 Minimal
 Self-limited
 Low severity
 Moderate severity
 High severity

15. HISTORY EXAMINATION MDM(LEVEL)
PROBLEM
FOCUSED
PROBLEM
FOCUSED
STRAIGHT FORWARD
EXPANDED EXPANDED LOW LEVEL
COMPLEXCITY
DETAILED DETAILED MODERATE LEVEL
COMPLEXICITY
COMPREHENSIVE COMPREHENSIVE COMPREHENSIVE

16.  Physical exam is done by four ways
 Inspection(seeing)
 Palpation(touching)
 Auscultation(hearing)
 Percusion(tapping)

17.  There are 2- types of guidelines for E/M coding
 1995-guidelines
 1997-guidelines
 Cpt book has 1995-guidelines
 Auditors preffers 1997-guidelines
 1995-guidelines based on history and MDM
 1997-guidelines based on bullet points

18.  If there is no specific mention code as established
patient
 Considering three key factors(history/exam/MDM)
 If a level is not matching, as per CPT guidelines drop
the level

19.  For new patient 3/3 levels should be match
 For established patient2/3 levels is minimum
 Dollar value depends on
physician+practice+malpractice insurance.

20.  Time is a considering factor for E/m services
 It includes both new/established patients
 Minimum 8- hours are required for discharging a
patient on same day
 Day-1 considered as initial hospital care
 Dy-2 is subsequent day
 Discharge is based on time.

21.  It is a type of service, in this service one physician can
refer another physician for a specific condition
 Consultant physician can start diagnosing the patient
or therapeutic services subsequently.
 Such services are reported under office visit,home
service,etc….
 Written format for consult physician may made by a
physician are documented in patient medical records..

22.  This code are given only when treatment or services
done in emergency department.
 Case must be seen by emergency physician
 Emergency department must be 24/7
 New/established patients included.
 Critical care services provide in ED reported separately

23.  Time is not a discriptive factor in ED
 ED service coding given based upon intensity.
 It may involves multiple encounters
 So time is not a considering factor

24.  Critical care is given by direct physician or any other
health care professionals
 Monitoring vital signs are very important
 It requires high complexity decision
 It depends on total duration of time
 If less than 30- minutes use appropriate E/M services.

25.  Critical care provided to 29 days to 71 months
 code from pediatric critical care.
 Critical care is provided with other E/M services code
separately
 Range of code 99291-99292.

26.  Nursing facility service codes given when E/M services
are at skilled nursing facilities.
 This codes also used for psychiatric residential
treatment center.
 If any other services are along with this code
separately.

27.  Prolonged services without direct patient codes are
99358-99359.
 Preventive medicine services are include
infants,children, and adults
 Range of code for new patient 99381-99387
 Range of code for established patient 99391-99397
 Telephonic services are not face-to- face services

28.  Telephonic services are given through telephone
 Range of code 99441-99443
 On line medical evaluation is by physician to patient
through internet sources
 Range of code 99444
 https://www.medesunglobal.com

29. THANK YOU