Coding and Compliance Training

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Detailed EM Coding Course
Click on these links to go directly to the topic
Common EM categories Consultations Levels of
service History Exam Medical decision
making Documentation requirements at various
levels Time-based services Modifier 25 Clinical
examples at various EM levels
?UNC SOM Compliance
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EM Services Classifications most common

• Outpatient - clinic visits
• Consult
• New
• Established
• Inpatient hospital visits
• Initial
• Subsequent
• Consult, initial and follow-up

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Medicare Outpatient E M
Approximate Allowables
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New or Established Patient

• New patient has not received any professional
  evaluation and management (EM) services from the
  physician or another physician of the same
  specialty who belongs to the same group practice
  within the past three years
• Established patient has received an EM service
  from group within three years

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Consultations

• A Consultation is an EM service provided by a
  physician whose opinion and advice is requested
  by another physician or appropriate source
• Consultations should be viewed as a three-part
  cycle (1) a request is made (2) an evaluation is
  undertaken and (3) an opinion is rendered and
  sent to the requesting physician.
• The consultant may initiate diagnostic and/or
  therapeutic services at the same visit

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Consultations

• A patient who is self-referred or referred for
  management of a condition is a new or
  established patient, not a consult

• If ongoing care of a particular condition is
  assumed in advance, service is not a consult but
  a new/est. patient visit

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Consult Documentation Requirements

• Written or verbal request must be documented. As
  an example Mr. Jones is seen in consultation at
  the request of Dr. Smith for evaluation of
  worsening cough.

• Consultants opinion must be communicated by
  written report to the requesting physician

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Levels of Service
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Defining Levels of Service

• History
• Physical Examination
• Medical Decision Making
• Other Considerations

• Time
• Counseling
• Coordination of Care
• Nature of Presenting Problem

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History Three Parts

• History of Present Illness
• Review of Systems
• Past, Family and Social History

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History of the Present Illness (HPI)

• Location
• Quality
• Severity
• Duration

• Timing
• Context
• Modifying factors
• Associated signs and symptoms

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Two Levels of HPI

• Brief 1-3 elements described
• Extended 4 elements described OR
• Status of at least 3 chronic or inactive
  conditions

Mr. Peters has for two weeks felt a sharp pain
in his left shoulder when he raises his arm.

• Duration

• Quality

• Context

• Location

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Review of Systems (ROS)

• An inventory of body systems obtained through
  questions seeking to identify signs and/or
  symptoms which the patient has or has had.

• Constitutional symptoms (e.g. fever, weight loss)
• Eyes
• Ears, Nose, Mouth, Throat
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary

• Musculoskeletal
• Integumentary (including breasts)
• Neurological
• Psychiatric
• Endocrine
• Hematologic/Lymphatic
• Allergic/Immunologic

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Review of Systems (ROS)
Three levels of ROS
Problem Pertinent (1 system) Extended
(2-9) Complete (at least 10)

• May be completed by patient, nurse or other staff
• Pertinent positives and negatives must be
  referred to in the note
• May use all other systems negative or the
  balance of ten systems reviewed is negative
  indicating a complete ROS was done
• If unable to obtain, document why

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Past, Family and Social History (PFSH)

• Past
• Current medications
• Prior illnesses/injuries
• Dietary status
• Operations/hospitalizations
• Allergies

• Family
• Health status or cause of death of
  siblings/parents
• Hereditary/high risk diseases
• Diseases related to the chief complaint, HPI, ROS

• Social
• Living arrangements
• Marital status
• Drug or tobacco use
• Occupational/educational history

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Two Levels of PFSH

• Pertinent one of the three areas
• Complete document specific item from all three
  areas
• Complete for established patients two of three
  areas is sufficient

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Four Levels of History

• Problem focused
• Brief HPI
• Expanded problem focused
• Brief HPI, Pertinent ROS, no PFSH
• Detailed
• Extended HPI and ROS, 1 PFSH element
• Comprehensive
• Extended HPI, Complete ROS and PFSH

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History Example

• 2 y/o male c/o vomiting/diarrhea 2 day
  fever. Diarrhea watery for 4 days, temp 102-103.
  Vomited 2X this a.m., ? appetite. Started
  Pedialyte 3 days ago. Drank several oz Pedialyte
  this a.m. Ø rhinorrhea, Ø cough, Ø daycare

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History Example
bchief complaint
b HPI duration

• 2 y/o male c/o vomiting/diarrhea 2 day
  fever. Diarrhea watery for 4 days, temp 102-103.
  Vomited 2X this a.m. ? appetite. Started
  Pedialyte 3 days ago. Drank several oz Pedialyte
  this a.m. Ø rhinorrhea, Ø cough, Ø daycare

b HPI quality
b HPI severity
b HPI modifying factors
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History Example

• 2 y/o male c/o vomiting/diarrhea 2 day
  fever. Diarrhea watery for 4 days, temp 102-103.
  Vomited 2X this a.m. ? appetite. Started
  Pedialyte 3 days ago. Drank several oz Pedialyte
  this a.m.
• Ø rhinorrhea, Ø cough, Ø daycare

b ROS GI
b ROS Resp
b ROS EENT
b PFSH Social
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History Documented in Example

• Chief Complaint Always required
• HPI, 4 descriptors Extended
• ROS, 4 systems Extended
• PFSH, social (1) Pertinent
• Detailed

Outpatient established EM visit _at_ 99214
new patient or consult _at_ 99203, 99243
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Documenting the Physical Exam

• A general multi-system exam or any single organ
  system exam may be performed by any provider.
• The type and content are selected by the provider
  depending upon medical necessity.
• Note specific abnormal relevant negative
  findings of the affected or symptomatic
  area(s)--abnormal is insufficient.
• Describe abnormal or unexpected findings of
  asymptomatic areas or systems.
• Noting negative or normal is sufficient to
  document normal findings in unaffected areas.

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The Physical Exam Component

• The following slides describe two methods of
  determining the level of physical exam 1995
  Guidelines and 1997 Guidelines. Either may be
  used. There is no need to satisfy the
  requirements of both methods.

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Physical Exam Guidelines (1995)

• 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
  systems
• Comprehensive
• A general multi-system examination (8 or more of
  the 12 systems) or complete examination of a
  single organ system

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General Multi-system Exam (1997)
See next page for the list of multi-system exam
elements referred to below

• Problem Focused
• Documentation of 1-5 elements
• Expanded Problem Focused
• At least 6 elements
• One or more organ/body system
• Detailed
• at least 6 organ/body system covered
• for each system/area, at least 2 elements noted
• OR
• At least 12 elements total
• 2 or more organ/body systems
• Comprehensive
• At least nine organ systems/areas covered
• For each, all elements should be performed
• Document at least 2 elements in each system/area

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General Multi-system Examination (1997
Guidelines)
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Single Organ System Examination

• Requirements for elements documented similar to
  1997 multi-system
• Single organ system exams for the following

• Eyes
• Ears, Nose, Mouth, and Throat
• Cardiovascular
• Respiratory
• Genitourinary
• Musculoskeletal
• Skin
• Neurological
• Psychiatric
• Hematologic/Lymphatic/Immunologic

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Medical Decision Making (MDM)

• Based on any two of the following
• Number of Diagnostic and/or Management Options
• Amount and Complexity of Data
• Risk

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Medical Decision Making Elements

• Diagnostic and/or management options
• (max 4 points)
• Self-limited, minor (1 ea)
• Established problem stable, improved (1 ea)
• Established problem worsening (2 ea)
• New problem, no addl workup planned (3 ea)
• New problem, addl workup planned (4 ea)

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Medical Decision Making Elements

• Amount complexity of data (max 4 points)
• Review/order of clinical lab, radiologic study,
  other non-invasive diagnostic study (1 ea type)
• Discussion of diag study w/interpreting phys. (1)
• Independent review of diagnostic study (2)
• Decision to obtain old records or get data from
  source other than patient. (1)
• Review/summary old med records or gathering data
  from source other than patient (2)

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Medical Decision Making Elements

• Risk
• Presenting problem
• Diagnostic procedures
• Management options

Choose the highest level of associated risk
expressed in any one of these three categories on
the table on the next page.
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Table of Risk
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Level of Medical Decision Making Documented

• Four levels
• Straightforward
• Low complexity
• Moderate complexity
• High complexity

Two of the three areas dx options, amount of
data, risk establish the MDM level
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Note on Medical Decision Making Level

• Co-morbidities and underlying diseases, in and
  of themselves, are not considered in selecting a
  level of E/M services unless their presence
  significantly increases the complexity of the
  medical decision making.

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New Outpatient Visits/Consults
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Established Outpatient Visits
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Initial Hospital/Observation
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Subsequent Hospital and Follow-up Consults
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Documenting Time-based Coding

• If time spent counseling and/or coordinating care
  is more than 50 of encounter, use time
• May count TP face-to-face time only for OP,
  coordination, time on floor for IP
• Document amount of time counseling and total time
  spent on encounter and describe counseling,
  coordination activities
• Document only minimal history, exam OR medical
  decision making

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Time as the Controlling Factor
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Examples of Time-based Codes

• Critical care
• Other EM visits where gt50 counseling
• Individual psychotherapy codes (non EM)
• Prolonged services

TP presence or concurrent observation for
entirety of time-based services Resident note may
support level and type service, addl TP summary
note to document involvement
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Modifier 25

• Append a modifier 25 to an EM code if a
  significant, separately identifiable EM service
  is performed by the same physician on the same
  day of a procedure or other service.
• The patients condition must require EM services
  above and beyond what would normally be performed
  in the provision of the procedure.
• The necessity for the EM service may be prompted
  by the same diagnosis as the procedure.
• A new patient EM service is considered separate
  from the same day surgery or procedureno 25
  modifier needed.

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Modifier 25

• For an established patient, if the EM service
  resulted in the initial decision to perform a
  minor procedure (0-10 days global period) on the
  same day and medical necessity indicates an EM
  service beyond what is considered normal protocol
  for the procedure, the 25 modifier is
  appropriate.
• To determine the correct level of EM service to
  submit, identify services unrelated to the
  procedure and use as EM elements.
• Clearly mark the encounter form to indicate that
  a 25 modifier should be attached to the EM.

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Clinical ExamplesPrimary Care

• New patient 99204
• Initial office visit for a 17-yr-old female with
  depression
• Initial office visit for initial evaluation of a
  63-yr-old male with chest pain on exertion
• Initial office visit for evaluation of 70-yr-old
  patient with recent onset of episodic confusion.

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Clinical ExamplesPrimary Care

• Established patient 99213
• Office visit for a 62-yr-old female, established
  patient, for follow-up for stable cirrhosis of
  the liver.
• Office visit for a 60-yr-old, established
  patient, with chronic essential hypertension on
  multiple drug regimen, for blood pressure check.
• Office visit for a 50-yr-old female, established
  patient, with insulin-dependent diabetes mellitus
  and stable coronary artery disease, for
  monitoring.

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Clinical ExamplesPrimary Care

• Established Patient 99214
• Office visit for a 28-yr-old male, established
  patient, with regional enteritis, diarrhea, and
  low-grade fever.
• Office visit for a 28-yr-old female, established
  patient, with right lower quadrant abdominal
  pain, fever, and anorexia.
• Office visit with 50-yr-old female, established
  patient, diabetic, blood sugar controlled by
  diet complains of frequency of urination and
  weight loss, blood sugar of 320 and negative
  ketones of dipstick.

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Clinical ExamplesPrimary Care

• Established Patient 99215
• Office visit with 30-yr-old, est. patient, for 3-
  month history of fatigue, weight loss,
  intermittent fever, and presenting with diffuse
  adenopathy and splenomegaly.
• Office visit for evaluation of recent onset
  syncopal attacks in a 70-yr-old woman, est.
  patient.
• Office visit for a 70-yr-old female, est.
  patient, with diabetes mellitus and hypertension,
  presenting with a two-month history of increasing
  confusion, agitation and short-term memory loss.

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Where To Get Help

• www.med.unc.edu/compliance/
• UNC PA Professional Charges 962-8391
• School of Medicine Compliance Office 843-8638
• Confidential Help Line 800-362-2921
• AMA CPT Manual