ICD-9, CPT, E

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ICD-9, CPT, EM Coding Documentation and
Compliance

• or the in-service for the
• in-service!!

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Youve just seen a patient in your office

• and after the exam
• You want to get paid
• (After all, you need to pay mortgage, food, etc)
• Insurance will pay you if
• You tell the company what you didAND
• You tell the company why you did it

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Types of Codes

• Procedure codes
• What I did during the visit
• Two Types
• CPT
• Evaluation and Management
• ICD
• Why I did it
• The actual diagnosis code
• and these must make sense together

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ICD codes

• ICD-9

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ICD Codes

• ICD International Statistical Classification of
  Diseases and Related Health Problems
• Provides codes to classify diseases and a wide
  variety of signs, symptoms, abnormal findings,
  complaints, social circumstances and external
  causes of injury or disease.
• Every health condition can be assigned to a
  unique category and given a code, up to six
  characters long.
• Easy to understand
• Allows for global (international) understanding
  of information

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ICD-9 (9th version- currently one in use)

• 001-139 Infectious and parasitic diseases
• 140-239 Neoplasms
• 240-279 Endocrine, nutritional, metabolic and
  immunity disorders
• 280-289 Blood ad blood-forming organs
• 290-319 Mental disorders (used by primary care
  and psych for research. DSM codes are used for
  clinical billing by psych)
• 320-359 Nervous system
• 360-389 Sense organs
• 390-459 Circulatory system
• 460-519 Respiratory system
• 520-579 Digestive system
• 580-629 Genitourinary system
• 630-676 Complications of pregnancy/childbirth
• 680-709 Skin and subcutaneous tissues
• 710-739 Musculoskeletal system and connective
  tissue
• 740-759 Congenital anomalies
• 760-779 Certain conditions originating in the
  perinatal period
• 780-799 Symptoms, signs and ill-defined
  conditions
• 800-999 Injury and poisoning
• E and V codes External causes of injury and
  supplemental classification

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ICD-9

• Can list by disease or symptom
• Get better reimbursement for more detail
• Some insurances will only pay for a certain
  number of visits per diagnosis
• e.g., diabetes
• Large book with diagnostic codes or can get on
  line
• http//www.icd9coding1.com/flashcode/home.jsp

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ICD-9 codes

• More detail the better.
• Break these down further!

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Diseases of the circulatory system (390-459)

• Hypertensive disease (401-405)
• (401) Essential Hypertension
• (401.0) Hypertension, malignant
• (401.1) Hypertension, benign
• (402) Hypertensive heart disease
• (403) Hypertensive renal disease
• (403.91) Hypertensive renal disease, unspec., w/
  renal failure
• (404) Hypertensive heart and renal disease
• (405.01) Hypertension, renovascular, malignant
• (405.11) Hypertension, renovascular, benign

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Endocrine, nutritional and metabolic diseases,
and immunity disorders (240-279)

• diseases of other endocrine glands (250-259)
• Note for 250-259, the following fifth digit can
  be added
• (250.x0) Diabetes mellitus type 2
• (250.x1) Diabetes mellitus type 1
• (250.x2) Diabetes mellitus type 2, uncontrolled
• (250.x3) Diabetes mellitus type 1, uncontrolled
• (250) Diabetes mellitus
• (250.0) Diabetes mellitus without mention of
  complication
• (250.1) Diabetes with ketoacidosis
• (250.2) Diabetes with hyperosmolarity
• (250.3) Diabetes with other coma
• (250.4) Diabetes with renal manifestations
• (250.5) Diabetes with ophthalmic manifestations
• (250.6) Diabetes with neurological manifestations
  
• (250.7) Diabetes with peripheral circulatory
  disorder
• (250.8) Diabetes with other nonspecified
  manifestations
• (250.9) Diabetes with unspecified complication

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780-799 Symptoms, signs and ill-defined
conditions

• (780) General symptoms
• (780.0) Alteration of consciousness
• (780.01) Coma, nondiabetic, nonhepatic
• (780.02) Mental status changes
• (780.09) Semicoma, stupor
• (780.1) Hallucinations
• (780.2) Syncope
• (780.3) Convulsions
• (780.31) Seizures, convulsions, febrile
• (780.39) Seizures, convulsions, other

• (780.4) Dizziness/vertigo, NOS
• (780.5) Sleep disturbance, unspec.
• (780.53) Hypersomnia, sleep apnea
• (780.53) Sleep apnea w/ hypersomnia
• (780.58) Movement disorder, sleep related
• (780.6) Fever, nonperinatal
• (780.7) Malaise and fatigue
• (780.8) Sweating, excessive
• (780.9) Other general symptoms
• (780.92) Crying, infant, excessive
• (780.93) Memory loss
• (780.94) Early satiety

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CPT

• Current Procedural Terminology

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CPT

• CPT Current Procedural Terminology
• Code Set accurately describes medical, surgical,
  and diagnostic services
• Designed to communicate uniform information about
  medical services and procedures among physicians,
  coders, patients, accreditation organizations,
  and payers for administrative, financial, and
  analytical purposes.
• The current version is the CPT 2008.

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CPT

• A CPT code is a five digit numeric code that
  is used to describe medical, surgical, radiology,
  laboratory, anesthesiology, and
  evaluation/management services of physicians,
  hospitals, and other health care providers. 
• There are approximately 7,800 CPT codes ranging
  from 00100 through 99499. 
• Two digit modifiers may be added when appropriate
  to clarify or modify the description of the
  procedure.

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Current Procedural Terminology

• Chapter 1 Evaluation and Management Codes
  (99201-99499)
• Chapter 2 Anesthesia Codes (00100-01999)
• Chapter 3 Surgery Codes (10040-69990)
• Chapter 4 Radiology Codes (70010-79999)
• Chapter 5 Pathology/Laboratory Codes
  (80049-89399)
• Chapter 6 Medicine Codes (90281-99199)
• Appendices Modifiers, Deleted codes

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V codes Supplemental classification

• V01 Contact with or exposure to communicable
  diseases
• V02 Carrier or suspected carrier of infectious
  diseases
• V09 Infection with drug-resistant microorganisms
• V10 Personal history of malignant neoplasm (i.e.
  cancer)
• V16 Family history of malignant neoplasm
• V17 Family history of certain chronic disabling
  diseases
• V20 Health supervision of infant or child
• V21 Constitutional states in development
• V22 Normal pregnancy

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V codes, cont

• V23 Supervision of high-risk pregnancy
• V24 Postpartum care and examination
• V25 Encounter for contraceptive management
• V28 Encounter for antenatal screening of mother
  
• V29 Observation and evaluation of newborns for
  suspected conditions not found
• V30 Single liveborn
• V31 Twin birth mate liveborn
• V48 Problems with head neck and trunk
• V49 Other conditions influencing health status
• V50 Elective surgery for purposes other than
  remedying health states
• V51 Aftercare involving the use of plastic
  surgery

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V codes, cont

• V56 Encounter for dialysis and dialysis catheter
  care
• V57 Care involving use of rehabilitation
  procedures
• V58 Encounter for other and unspecified
  procedures and aftercare
• V60 Housing, household and economic circumstances
  
• V64 Persons encountering health services for
  specific procedures not carried out
• V65 Other persons seeking consultation
• V66 Convalescence and palliative care
• V67 Follow-up examination
• V68 Encounters for administrative purposes
• V69 Problems related to lifestyle
• V70 General medical examination
• V71 Observation and evaluation for suspected
  conditions not found
• V80 Special screening for neurological eye and
  ear diseases
• V81 Special screening for cardiovascular
  respiratory and genitourinary diseases
• V85 Body mass index

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Relationship between CPT and ICD-9

• The critical relationship between an ICD-9 code
  and a CPT code is that the diagnosis supports the
  medical necessity of the procedure.  
• Since both ICD-9 and CPT are numeric codes,
  health care consulting firms, the government, and
  insurers have all designed software that compares
  the codes for a logical relationship. 
• For example, a bill for CPT 31256, nasal/sinus
  endoscopy would not be supported by ICD-9 826.0,
  closed fracture of a phalanges of the foot.    
• Such a claim would be quickly identified and
  rejected.

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trivia for boards

• Health Care Financing Administration (HCFA)
• Common Procedural Coding System (HCPCS)
• Diagnosis Codes ICD 9
• Creates medical necessity
• Level I CPT
• Updated Annually
• Level II (national) HCPCS (A-V)
• Alphanumeric System
• Level III (State) Local Codes (W-Z)

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E M Coding

• Evaluation and Management
• Most confusing for physicians

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What are EM Codes?

• The Evaluation Management (EM) codes are a
  sub-set of the CPT codes.
• Can be used by all privileged providers
• Describes
• Complexity of care provided to a patient for
  non-procedural visits.
• The place of service (inpatient or outpatient)
• The type of service (new vs. established,
  consult, preventive, ER, critical care, etc)
• Defined by 3 components
• The patient history
• The physical examination
• Medical decision making

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Why Code?

• REIMBURSEMENT
• Third Party Payers/Insurance Agencies
• Prospective Payment Systems (PPS)
• Over coding Fraud
• Under coding Lost Revenue

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What Do Coders Look For?

• Professional Coders in your office or from
  insurance companies have been trained to match
  documentation in charts to the billing
  information
• It is the Content, not the volume, of
  documentation that determines your EM code!

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What Do Coders Look For?

• Every patient encounter should be legible and
  include
• Date of Encounter
• Reason for the visit (chief complaint)
• Appropriate history of present illness
• An exam when necessary or appropriate i.e. a new
  patient (consistency and problem pertinent)
• Review of lab, x-ray, other ancillary services
  when appropriate
• Assessment
• Plan of care/Treatment options
• Provider signature

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Why is Documentation Important?

• The documentation must support the EM code you
  select.
• Your documentation must also support the medical
  necessity of the services provided.
• The first step is to clearly document the reason
  for every visit the chief complaint.
• The use of Follow-up is insufficient
  documentation as it does not indicate medical
  necessity.
• However it is acceptable to document Follow-up
  for _____.
• If it isnt documented, it wasnt done!

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Patient Type

• New vs. Established
• Consult
• Inpatient vs. Outpatient

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New vs. Established

• New patient
• Any patient who has not received professional
  services, within the previous 36 months, from a
  provider within the same group, of the same
  specialty
• Same group practice One Federal Tax ID number
  for all providers, if more than one Federal Tax
  ID, can consider the patient new
• e.g., current practice seen in OLBH ER and
  Outreach offices
• Professional Services Phone call, prescription,
  hospital or office visit, etc.
• Specialty Issue Optional if one federal Tax ID
  is shared by practitioners of other specialties
  (e.g., surgeon and FP)
• DOs and MDs of the same specialty DO NOT
  differ even if OMT is offered by the DO

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Average and Recommended Code Distributions
The difference in the bell curves represents loss
in physician income!!
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Determining the Correct EM Code

• There are three key components to consider when
  selecting the appropriate EM
• History
• Exam
• Medical Decision Making (MDM)
• All three components must be documented for a new
  patient (new to clinic or not seen within the
  past three years). Indicate in CC if patient is
  new.
• Only two of the three components must be
  documented for established patients (seen within
  the past three years).
• EM selection should never be based on the
  allotted time on the appointment schedule!

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Determining the Correct EM Code

• To determine the correct level EM code, consider
  the complexity of your patients condition and
  your medical decision making, then support that
  level of complexity with your documentation of
  history and/or exam.
• Remember
• For a new clinic patient, initial consult,
  initial inpatient visit or ED encounter you must
  document all three key components
• history, exam and your medical decision making.

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Defining Levels of EM Services

• 7 components
• History
• Examination
• Medical Decision Making
• Counseling
• Coordination of care
• Nature of Presenting Problem
• Time

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The Medical History
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History

• Also has several components to determine
  complexity or type
• History of Present Illness (HPI)
• Review of Systems (ROS)
• Past Family and/or Social History (PFSH)
• The extent of history is dependent on clinical
  judgment and the nature of the presenting
  problem.
• The four types of History include Problem
  focused, Expanded Problem Focused, Detailed and
  Comprehensive.

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History of Present Illness
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History Chief Complaint

• Chief Complaint Required
• concise statement that describes the symptom,
  problem, condition, diagnosis, or reason for the
  patient encounter.
• The CC is usually stated in the patients own
  words.
• For example, patient complains of upset stomach,
  aching joints, and fatigue
• Cannot be the words follow up alone

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History History of Present Illness

• Two types of HPI
• Brief, which includes documentation of one to
  three HPI elements.
• In the following example, three HPI elements
  location, severity, and duration are
  documented
• CC A patient seen in the office complains of
  left ear pain.
• Brief HPI Patient complains of dull ache in left
  ear over the past 24 hours.

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History History of Present Illness

• Extended, which includes documentation of at
  least four HPI elements or the status of at least
  three chronic or inactive conditions.
• In the following example, five HPI elements
  location, severity, duration, context, and
  modifying factors are documented
• Extended HPI Patient complains of dull ache in
  left ear over the past 24 hours. Patient states
  he went swimming two days ago. Symptoms somewhat
  relieved by warm compress and ibuprofen.

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History Components

• Location
• Area of body, localized, unilateral, bilateral,
  fixed, migratory, radiation, referred
• Quality
• Specific pattern, sharp, dull, throbbing,
  stabbing, constant, intermittent, acute, chronic,
  stable, improving, worsening
• Laceration as jagged or straight
• Sore throat as scratchy
• Severity
• Pain scale, compared to, observation by
  physician (discomfort, wincing)
• Duration

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History Components

• Timing
• Onset of problem or symptom and progression,
  recurrent, comes and goes, worsens or improves
• Context
• Associated with activity, improves with activity,
  etc
• Modifying factors
• Steps the patient has taken to alleviate
  symptoms, what exacerbates symptoms, is helped
  by, is hindered by
• Associated signs/symptoms
• Clinical impressions direct physician questioning
• Specific symptoms (weakness, headache with
  injury)
• Generalized symptoms, chills, fever, pertinent
  positives and negatives

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History Guidelines

• HPI must be documented by the physician
• ROS and/or PFSH can be recorded by ancillary
  staff
• Physician must supplement or confirm the
  information
• If obtained at a prior visit, do not need to
  re-record. Can review and update
• Describe new information
• Note date and location of earlier information

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History Guidelines

• If unable to obtain a history
• Describe patients medical condition or
  circumstance which precludes obtaining a history

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Review of Systems
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Review of Systems

• Definition
• An inventory of body systems obtained through a
  series of questions seeking to identify signs
  and/or symptoms that the patient may be
  experiencing or has experienced
• The following systems are recognized
• Constitutional (fever, weight loss) -
  Psychiatric
• Eyes - Endocrine
• Ears, nose, mouth throat - Neurological
• Cardiovascular - Allergic/Immunologic
• Respiratory
• Gastrointestinal
• Musculoskeletal
• Integumentary (skin and/or breast)
• Hematologic/Lymphatic

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Review of Systems

• Three categories of review
• Problem Pertinent
• ROS inquires about the system directly related to
  the problem(s) identified in the HPI
• Both positive responses and pertinent negatives
  should be documented
• In the following example, one system the ear
  is reviewed
• CC Earache.
• ROS Positive for left ear pain. Denies
  dizziness, tinnitus, fullness, or headache.

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Review of Systems

• Extended
• ROS inquires about the system directly related to
  HPI AND a limited number of additional systems
• 2-9 systems which are documented
• In the following example, two systems
  cardiovascular and respiratory are reviewed
• CC Follow up visit in office after cardiac
  catheterization. Patient states I feel great.
• ROS Patient states he feels great and denies
  chest pain, syncope, palpitations, and shortness
  of breath. Relates occasional unilateral,
  asymptomatic edema of left leg.

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Review of Systems

• Complete
• ROS inquires about the system directly related to
  the HPI AND all other body systems
• At least 10 body systems must be documented
• Those systems w/pertinent or- responses must be
  individually documented, however for the
  remaining systems, all other systems are
  negative is permissible

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Review of Systems

• In the following example, 10 signs and symptoms
  are reviewed
• CC Patient complains of fainting spell.
• ROS
• Constitutional weight stable, fatigue.
• Eyes loss of peripheral vision.
• Ear, Nose, Mouth, Throat no complaints.
• Cardiovascular palpitations denies chest
  pain denies calf pain, pressure, or edema.
• Respiratory shortness of breath on exertion.
• Gastrointestinal appetite good, denies heartburn
  and indigestion.
• episodes of nausea. Bowel movement daily
  denies constipation or loose stools.
• Urinary denies incontinence, frequency, urgency,
  nocturia, pain, or discomfort.
• Skin clammy, moist skin.
• Neurological fainting denies numbness,
  tingling, and tremors.
• Psychiatric denies memory loss or depression.
  Mood pleasant.

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Past Medical History

• Medical
• Family
• Social

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History - PFSH

• Past History
• Past experience with illnesses, operations,
  injuries and treatments
• Family History
• Review of medical events in patients family,
  including hereditary disease
• Social History
• Age appropriate review of past and current
  activities

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History - PFSH

• Pertinent
• review of the history areas directly related to
  the problem(s) identified in the HPI.
• Must document one item from any of the three
  history areas.
• In the following example, the patients past
  surgical history is reviewed as it relates to the
  current HPI
• Patient returns to office for follow up of
  coronary artery bypass graft in 1992. Recent
  cardiac catheterization demonstrates 50 percent
  occlusion of vein graft to obtuse marginal
  artery.

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History - PFSH

• Complete
• A review of two or all three of the areas,
  depending on the category of E/M service.
• Requires a review of all three history areas for
  services that, by their nature, include a
  comprehensive assessment or reassessment of the
  patient.
• A review of two history areas is sufficient for
  other services.

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History - PFSH

• At least one specific item from each of the
  history areas must be documented for the
  following categories of E/M services
• Office or other outpatient services, new patient
  
• Hospital observation services
• Hospital inpatient services, initial care
• Consultations
• Comprehensive Nursing Facility assessments
• Domiciliary care, new patient and
• Home care, new patient.

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History - PFSH

• Does NOT need to be re-recorded
• Record new information only
• No change PFSH can be documented

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History Algorithm
History Type HPI ROS PFSH
Problem Focused (1 point) Brief None None
Expanded Problem Focused (2 points) Brief Problem pertinent None
Detailed (3 points) Extended Extended Pertinent
Comprehensive (4 points) Extended Complete Complete
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Physical Examination
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Physical Exam

• Looked at either by
• Body Areas
• Organ Systems

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Physical Exam

• Body areas recognized
• Head (including face)
• Neck
• Chest, including breast and axillae
• Abdomen
• Genitalia, groin, buttocks
• Back (including spine)
• Each extremity (separately)

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Physical Exam

• Organ systems recognized
• Constitutional
• Eyes
• ENT, Mouth
• Cardiovascular
• Respiratory
• GI
• GU
• Musculoskeletal
• Skin
• Neurologic
• Psychiatric
• Hematologic Lymphatic Immunologic
• The general multi-system exam should include
  findings of at least 8 of the above 12 organ
  systems

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Documentation of Examination

• Make sure you note specific abnormal or relevant
  findings of affected body areas or organ systems
• Brief statement indicating negative or normal is
  sufficient for unaffected or asymptomatic systems
• Describe abnormal or unexpected findings of
  asymptomatic areas or organs

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Physical Examination
Type Either this Or this
Problem Focused (1 point) lt 1 organ system/Body area 1-5 bulleted elements
Expanded Problem Focused (2 points) 2-4 Organ Systems/Body areas gt 6 Bulleted Elements
Detailed Exam (3 points) 5-7 Organ Systems/Body Areas gt 2 bulleted elements from 6 areas or gt 12 bullets from gt 2 areas
Comprehensive Exam (4 points) gt 8 organ systems/body areas Complete single system examination or gt 2 bulleted elements from 9 areas
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Physical Examination
Type of Examination Description
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 any other symptomatic or related body area(s) or organ system(s).
Detailed An extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body areas(s) or organ system(s).
Comprehensive A general multi-system examination OR complete examination of a single organ system and other symptomatic or related body area(s) or organ system(s).
63
Physical ExaminationGeneral Multi-System
Examinations
TYPE OF EXAMINATION DESCRIPTION
Problem Focused Include performance and documentation of 1 - 5 elements identified by a bullet in 1 or more organ system(s) or body area(s)
Expanded Problem Focused Include performance and documentation of at least 6 elements identified by a bullet in 1 or more organ system(s) or body area(s).

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Physical ExaminationGeneral Multi-System
Examinations
TYPE OF EXAM DESCRIPTION
Detailed Include at least 6 organ systems or body areas. For each system/area selected, performance and documentation of at least 2 elements identified by a bullet is expected. Alternatively, may include performance and documentation of at least 12 elements identified by a bullet in 2 or more organ systems or body areas.
Comp. 1997 Documentation Guidelines for Evaluation and Management Services Include at least 9 organ systems or body areas. For each system/area selected, all elements of the examination identified by a bullet should be performed, unless specific directions limit the content of the examination. For each area/system, documentation of at least 2 elements identified by bullet is expected. 1995 Documentation Guidelines for Evaluation and Management Services Eight organ systems must be examined. If body areas are examined and counted, they must be over and above the 8 organ systems.
65
Exam Bullets

• Constitutional
• 3 vital signs
• General appearance
• Eyes
• Inspection of Conjunctiva and Lids
• Examination of Pupils and Iris (PERLA)
• Ophthalmoscopic discs and posterior segments
• Ears, Nose, Mouth and Throat
• External appearance of Nose and Ears
• Otoscopic Examination
• Assessment of Hearing
• Inspection of Nasal Mucosa/Septum
• Examination of oropharynx

66
Exam Bullets

• Neck
• Examination of Neck
• Examination of Thyroid
• Respiratory
• Assessment of respiratory effort
• Percussion of Chest
• Palpation of Chest
• Auscultation of Lungs

67
Exam Bullets

• Cardiovascular
• Palpation of PMI
• Auscultation of the Heart
• Assessment of Lower Extremity Edema
• Examination of Carotid Artery
• Examination of abdominal aorta
• Examination of femoral pulse
• Examination of pedal pulse
• Chest (breasts)
• Inspection of breasts
• Palpation of breasts and axillae

68
Exam Bullets

• Gastrointestinal (abdomen)
• Examination with notation of masses or tenderness
• Examination of liver and spleen
• Examination for presence/absence of hernias
• Examination of anus, perineum, rectum, including
  sphincter tone, hemorrhoids
• Obtain stool for occult blood
• Genitourinary (male)
• Examination of scrotal contents
• Examination of Penis
• DRE prostate

69
Exam Bullets

• Genitourinary (female)
• Examination of external genetalia
• Examination of urethra
• Examination of bladder
• Examination of cervix
• Examination of uterus
• Examination of adenexa
• Lymphatic
• Palpation of lymph nodes in two or more areas
• Neck, axillae, groin, other

70
Exam Bullets

• Musculoskeletal
• Examination of gait and station
• Examination of joints, bones and muscles of one
  or more of the following 6 areas
• Head and Neck
• Spine, ribs and Pelvis
• Right Upper Extremity
• Left Upper Extremity
• Right Lower Extremity
• Left Lower Extremity
• Examination includesInspection and/or palpation
  with notation of any misalignment, asymmetry,
  crepitation, etc range of motion with notation
  of pain, crepitation assessment of stability
  assessment of muscle strength

71
Exam Bullets

• Skin
• Examination of skin and subcutaneous tissue
• Palpation of skin and subcutaneous tissue
• Neurologic
• Test cranial nerves with notation of deficit
• Examination of DTR
• Examination of sensation
• Psychiatric
• Description of judgment and insight
• Brief assessment of mental status

72
Medical Decision Making
73
Determination of Medical Decision Making

• Based upon
• Number of diagnoses or management options
• Amount and complexity of data
• Overall risk

74
Medical Decision Making

• (MDM) refers to the complexity of determining a
  diagnosis and/or the selection of a treatment
  option.
• Measured by documentation of the following
• Number of diagnoses and/or management options
  that must be considered.
• Amount and/or complexity of data to be reviewed.
• Risk of complications, morbidity and/or
  mortality, and co-morbidities.
• Four types
• Straightforward, Low Complexity, Moderate
  Complexity, and High Complexity.

75
Documentation to Support Complexity

• Consider the following for risk
• Chronic illness(es)
• Well controlled
• Mild exacerbation
• Severe exacerbation
• Acute illness
• Uncomplicated like allergic rhinitis
• With systemic symptoms like pneumonitis

76
Medical Decision MakingDiagnoses/Management
OptionsMax of 4 points
Problem Categories Number of Problems Possible Points Score
Self Limited/minor Max of 2 1
Established Problem stable or improving 1
Established problem worsening 2
New problem (no further work up) Max of 1 3
New problem (work up needed) 4
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Documentation to Support Complexity

• Consider the following
• Did you order/review labs?
• Did you order/review X-rays, US, MRI
• Did you order/review any other testing
• Did you visualize image, tracing, or specimen
• Did you review or summarize old records
• Must document this on the record
• old records reviewed which noted .

78
Medical Decision MakingAmount and Complexity of
DataMax of 4 points
Type of Data Check if Done Possible Points Score
Review/Order tests (8xxxx clinical) 1
Review/order tests (7xxxx radiology) 1
Review/order tests (9xxxx medicine) 1
Discuss test results with performing physician 2
Independent review of tracing, specimen, image 2
Decision to obtain medical records 1
Review, summarize old records and/or obtain history 2
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Table of Risk
Level of risk Presenting problem(s) Diagnostics ordered Management options
Minimal (1 point) One self-limited/minor problem (e.g., URI) Lab tests requiring venipuncture CXR EKG Urinalysis Rest Gargles Ace wrap
Low (2 points) 2self limited/minor problems 1 stable/chronic illness Acute uncomplicated illness/injury Physiologic tests not under stress (pulm. Function) Non-cardiac imaging w/barium Lab requiring arterial puncture Skin biopsy Over the counter drugs Minor surgery w/no identified risk PT/OT IV fluids w/o additives
Moderate (3 points) 1chronic illnesses with mild progression, or side effects of treatment 2 stable chronic illnesses Undiagnosed new problem w/uncertain prognosis Acute illness with systematic symptoms Acute uncomplicated injury Physiologic test under stress Diagnostic endoscopy w/no risk factors Deep needle or incisional biopsy Obtain fluid from body cavity Minor surgery w/risk factors Elective major surgery w/no risks Prescription drug management IV with additives
High (4 points) 1 chronic illness with severe exacerbation or side effects of treatment Acute/chronic illness that poses a threat to life/bodily function Abrupt change in neurologic status Cardiovascular imaging w/contrast w/risk factors Cardiac electrophysiological tests Diagnostic endoscopies w/identified risk factors Elective major surgery w/risk factors Emergency major surgery Parenteral controlled substances DNR due to poor prognosis
80
Medical Decision Making

• The HIGHEST level of ANY ONE of the three
  aspects of a medical decision making will
  determine the overall level chosen

81
Medical Decision MakingFinal Medical Decision
Making2 of 3 rule
Decision Making Straight Forward Low Moderate High
Diagnosis /or Management Options Minimal (1) Limited (2) Multiple (3) Extensive (gt 4)
Amount of Data Reviewed Minimal (1) Limited (2) Multiple (3) Extensive (gt 4)
Table of Risk Minimal (1) Low (2) Moderate (3) High (4)
82
Defining Levels of EM Services

• 7 components
• History
• Examination
• Medical Decision Making
• Counseling
• Coordination of care
• Nature of Presenting Problem
• Time

83
Counseling and Coordination of Care

• Discussion with patient or family concerning one
  or more of the following
• Diagnostic results
• Prognosis
• Risk benefits of management options
• Instruction for management
• Compliance

84
Timeas another factor

• Appropriate in cases where counseling and/or
  coordination of care dominates (gt50) of the
  patient and/or family encounter
• Documentation requirements
• Total face to face time or encounter
• Total counseling/coordination time
• Content of counseling/coordination

85
Time based billingexample

• cc Depression
• Hx cc 59 y/o female w/depression and anxiety.
  Denies suicidal ideations. Hx ativan use in past
• Exam vitals (list)
• A/P Depression. Had long discussion w/patient
  and counseled him on exacerbating factors and
  treatment options. Rx ordered (list)
• Total visit time 25 minutes, counseling time 15
  minutes

86
Summing Up Your Services

• Billing the Correct Code

87
The Constants of Coding

• 3 of 3 rule
• Go to the lowest component
• i.e., 2,3,4 2
• 3,3,4 3
• Used for new patient, initial consults, initial
  hospital care and emergency department visits
• 2 of 3 rule
• Go to the middle component
• 2,3,4 3
• 3,3,4 3
• Used for established patient, subsequent hospital
  f/u, f/u consult

88
New vs. Established Patient

• New Patient
• All key components must meet or exceed the stated
  requirements to qualify for a particular level
• Established Patient
• Two key components must meet or exceed stated
  requirements to qualify for a particular level

89
Documentation RequirementsNew Patient Office
Visit3 of 3 rule
Level of Service History Examination Medical Decision Making
99201 Problem focused Problem focused Straight forward complexity
99202 Expanded problem focused Expanded problem focused Straight forward complexity
99203 Detailed Detailed Low complexity
99204 Comprehensive Comprehensive Moderate complexity
99205 Comprehensive Comprehensive High complexity
90
Documentation RequirementsNew Patient Office
Visit3 of 3 rule
Level of Service History Examination Medical Decision Making
99201 Problem focused Problem focused Straight forward complexity
99202 Expanded problem focused Expanded problem focused Straight forward complexity
99203 Detailed Detailed Low complexity
99204 Comprehensive Comprehensive Moderate complexity
99205 Comprehensive Comprehensive High complexity
91
Documentation RequirementsNew Patient Office
Visit3 of 3 rule
Level of Service History Examination Medical Decision Making
99201 Problem focused Problem focused Straight forward complexity
99202 Expanded problem focused Expanded problem focused Straight forward complexity
99203 Detailed Detailed Low complexity
99204 Comprehensive Comprehensive Moderate complexity
99205 Comprehensive Comprehensive High complexity
92
Documentation RequirementsNew Patient Office
Visit3 of 3 rule
Level of Service History Examination Medical Decision Making
99201 Problem focused Problem focused Straight forward complexity
99202 Expanded problem focused Expanded problem focused Straight forward complexity
99203 Detailed Detailed Low complexity
99204 Comprehensive Comprehensive Moderate complexity
99205 Comprehensive Comprehensive High complexity
93
Established Patient CPT EM Guidelines2 of 3
rule
Code History Physical Exam Medical Decision making Time
99211 Nursing service only N/A Nursing order 5
99212 Problem Focused (1) Problem Focused (1) Straight forward (1) 10
99213 Expanded Problem Focused (2) Expanded Problem Focused (2) Low Complexity (2) 15
99214 Detailed (3) Detailed (3) Moderate Complexity 25
99215 Comprehensive (4) Comprehensive (4) High Complexity (4) 40
94
Established Patient CPT EM Guidelines2 of 3
rule
Code History Physical Exam Medical Decision making Time
99211 Nursing service only N/A Nursing order 5
99212 Problem Focused (1) Problem Focused (1) Straight forward (1) 10
99213 Expanded Problem Focused (2) Expanded Problem Focused (2) Low Complexity (2) 15
99214 Detailed (3) Detailed (3) Moderate Complexity (3) 25
99215 Comprehensive (4) Comprehensive (4) High Complexity (4) 40
95
Established Patient CPT EM Guidelines2 of 3
rule
Code History Physical Exam Medical Decision making Time
99211 Nursing service only N/A Nursing order 5
99212 Problem Focused (1) Problem Focused (1) Straight forward (1) 10
99213 Expanded Problem Focused (2) Expanded Problem Focused (2) Low Complexity (2) 15
99214 Detailed (3) Detailed (3) Moderate Complexity (3) 25
99215 Comprehensive (4) Comprehensive (4) High Complexity (4) 40
96
Inpatient Codes

• Follow 3 of 3 rule
• Inpatient Services and Observation
• Inpatient Consults
• Inpatient follow ups follow the 2 of 3 rule

97
Other Medical Services

• General Consultant
• Pre/Post Operative Consults

98
Definition of Consultation

• Type of service provided by a physician whose
  opinion ad advice regarding evaluation and/or
  management of a specific problem is requested by
  another physician or other appropriate source.

99
Consultation Services

• Documentation MUST include
• Request for consultation documented in the
  medical record
• Reason for consultation (medical necessity)
• Report- Consultants opinion, advice and
  evaluation of the patient (this MUST be
  communicated back to the requesting physician)
• Have separate initial coding
• Follow up visits use established patient visits

100
Preoperative Consultation

• Must request opinion or advice regarding a
  specific problem
• Request and need for consult must be documented
  in the medical record
• Any services ordered or performed must be
  documented
• Consultants opinion, advice and evaluation of
  the patient must be communicated back to the
  requesting surgeon

101
Preoperative Clearance

• ICD-9 diagnosis codes
• V72.81 Preoperative cardiovascular examination
• V72.82 Preoperative op respiratory examination
• V72.83 Other specified preoperative examination
• V72.84 Preoperative examination, unspecified
• V72.85 Other specified examination
• Must supplement with sigh/symptom/dx codes
• Must also include surgical indication (eg,
  cataracts)

102
Rules for Consultation99241-99275

• Opinion or advise regarding EM of a specific
  problem is requested
• Documented request from appropriate source is
  required (if patient generated for 99271-99275)
• Written report sent to referring provider (a
  letter for an outpatient)
• Initiation of care at time of consult is
  acceptable
• Post-op consult by provider performing pre-op
  clearance should use subsequent hospital codes or
  established office visit codes

103
New outpatient and consultative CPT EM
Guidelines3 of 3 rule
Confirm Consult Initial consult New patient History Physical Exam Medical Decision Making Time
99271 99241 99201 Problem Focused (1) Problem Focused (1) Straight forward (1) 10
99272 99242 99202 Expanded prob. focused (2) Expanded prob. focused (2) Straight forward (1) 20
99273 99243 99203 Detailed (3) Detailed (3) Low Complex (2) 30
99274 99244 99204 Comprehensive (4) Comprehensive (4) Moderate Complexity (3) 45
99275 99245 99205 Comprehensive (4) Comprehensive (4) High Complexity 60
104
Coding Examples
105
Documentation RequirementsEstablished Patient
Office Visit
Level of service History Examination Medical decision making
99211 Nursing service only Nursing order
99212 Problem focused Problem focused Straight forward complexity
99213 Expanded problem focused Expanded problem focused Low complexity
99214 Detailed Detailed Moderate complexity
99215 Comprehensive Comprehensive High complexity
106
Example 99211Non-physician visit

• Patient Calls Advice Nurse with Possible UTI
• Patient brings and drops-off UA
• Nurse processes UA
• You (Doctor/PA/NP) review and find UTI
• Nurse calls in antibiotics and documents in Chart
• Blood Pressure Check

107
Example 992124y/o female with fever and ear pain

• Established Patient 2 of 3 required
• History 1-2 HPI
• Exam 1-5 elements
• Medical Decision Making 1 self limited minor
  problem

108
Example 992124y/o female with fever and ear pain

• History
• Fever 101
• Left ear 3 days
• Exam
• Injection with redness and drainage of tympanic
  membrane
• Pharynx red, no exudates
• anterior cervical nodes
• Lungs clear
• Heart rrr
• Medical Decision Making
• OM Prescription Antibiotics
• Fever control
• Recheck in 2 weeks

109
Example 992134 y/o female with fever and ear pain

• History
• 1-3 HPI elements AND
• ROS
• Exam 6-11 elements
• Medical Decision Making
• 2 self-limited or minor problems OR
• 1 new problem plus low risk

110
Example 992134 y/o female with fever and ear pain

• History
• Fever and Ear pain for 3 days
• ROS
• Cough/sinus congestion, sore throat, vomiting and
  diarrhea
• PFSH
• NKA/Immunization/passive smoking/any chronic meds
• Exam
• 3 vitals (weight, temp, BP)
• Left TM red, pharynx red, tender nodes, neck
  supple, lungs clear, heart regular, abdomen
  non-tender
• Medical Decision Making
• LOM
• Antibiotics/Fever Control
• Recheck in 2 weeks
• Call if worse

111
Example 9921458 y/o male at 3 month check up

• Detailed history
• Extended HPI
• Extended ROS
• One element PFSH
• Detailed exam
• 12 exam elements from at least 2 systems
• Moderate Complexity
• 2 of the following Multiple dx Moderate amount
  and complexity of data Moderate risk

112
Example 9921458 y/o male at 3 month check up

• History
• HTN DM DJD vision exam UTD (-) HA (-) SOB
  (-) CP (-) NVDC (-) Hematochezia (-) Nocturia
• PFSH
• Unchanged from prior exam
• Detailed exam
• 12 exam elements from at least 2 systems
• Medical Decision Making
• EKG, Pulse Oximetry UA, Rapid Strep
• Review of CXR
• Prescriptions written
• Document Procedures
• Document OMM

113
OMT Billing
114
OMT codes

• These are nonallopathic lesions, not elsewhere
  classified.
• CPT codes 98925 98929
• ICD codes 739.0 739.9 depending on body region
• Will be discussed at separate lecture in detail

115
Other Billable Services
116
Other Billable Services

• Injections/Immunizations
• Smoking Cessation
• Visit and procedures

117
Injections/Immunizations

• 90471 is for first administration
• 90472 is for EACH additional administration
• Cannot report if patient brings their own supply
• Cannot bill 99211 (nursing service) if only
  injection given
• Must provide separately identifiable service
• e.g., get vital signs

118
Smoking Cessation

• Document that you told patient to stop smoking
• 99406 Greater than 3 minutes, up to 10 minutes
• 99407 Greater than 10 minutes

119
Other Billable Services

• Digital Rectal Exam for Prostate Cancer Screening
• G0102
• Visual Acuity Exam (Snellen Chart)
• 99173
• Needle Sticks!!
• 96150 e.g., when an occupational health nurse
  sees a patient due to a needle stick he/she can
  code this encounter as 99499 E/M and 96150 CPT
  with the applicable ICD-9 primary for the wound
  and a secondary ICD-9 code of the External cause.

120
Billing an office Visit and a Procedure

• Procedure must be a separate service from the
  evaluation and management service
• Modifier 25 should be added to the evaluation and
  management service to identify that it is a
  separate service

121
Other Coding Opportunities

• Modifiers
• 22 Unusual procedural service
• 25 significantly, separately identifiable EM
  service by the same physician on the same day of
  the procedure or other service
• e.g., patient comes in with sinus infection you
  do OMT cause it will help vs. patient coming in
  specifically for OMT
• 32 Mandated by 3rd party (HMO)
• 51 Multiple Procedures

122
Other Miscellany
123
Other

• If you see a patient and admit directly to a
  hospital, you should submit only the hospital
  code.

124
Critical Care Codes

• Use appropriate EM code if lt 30 minutes
• 99291
• First 30-74 minutes of evaluation and management
• 99292
• Each additional 30 minutes (can round up after 15
  minutes)
• e.g., 105-134 minutes 99291 x 1 and 99292 x 2

125
Prolonged Care Codes

• Threshold time is 30 minutes over the time
  component allotted for the EM code
• Outpatient
• 99354-99355
• Face to face time
• Inpatient
• 99356-99357
• Inpatient or outpatient office/floor/unit time
  without direct patient contact
• 99358-99359
• e.g., IV running for rehydration in your office
  for 1 hour

126
Other Coding Opportunities
99050 After Hours
99052 Services Provided between 11pm and 8am
99054 Sundays/Holidays
99024 Post op follow up in Global Period
99058 Office services on Emergent basis
99082 Unusual Travel (transport/escort)
99090 Analysis of Data Stored on Computer
127
For Further Information

• Evaluation and Management Services Guide - AMA