Sandra M. Nettina, MSN, CRNP
President, NPAM
Nurse Practitioner, Columbia Medical Practice
CODING
 ICD-9 International Classification of Diseases
 Published by United States Government
 Diagnoses based
 Assign codes to your assessment at the highest level of
differentiation
 CPT Current Procedural Terminology
 Copyrighted by American Medical Association
 Procedural rather than disease or disorder
Coding (cont.)
 ICD-9 codes are used to justify medical
necessity of a service
 CPT codes are used for billing
 Evaluation and management codes (E&M)
are CPT codes that describe consultations,
ER, and office visits
Evaluation and Management Codes
new and established office visit
99201/99211: 10 min. (new) or 5 min. (est.)
Presenting problem is self limiting or minor
99202/99212: 20 min. (new) or 10 min. (est.)
low to moderate severity
99203/99213: 30 min. (new) or 15 min. (est.)
moderate severity
99204/99214: 45 min. (new) or 25 min. (est).
moderate to high severity
99205/00215: 60 min. (new) or 40 min. (est.)
moderate to high severity
Other Encounters
 Outpatient consultation: 99241 to 99245
 Inpatient consultation: 99251 to 99255
 Emergency Room: 99281 to 99285
 Initial hospital observation: 99221 to 99223
 Subsequent hospital: 99231 to 99233
 Initial nursing facility: 99304 to 99306
 Subsequent nursing facility: 99307 to 99310
 Domiciliary, Rest home, custodial care
Billing
Use E&M codes for Outpatient Visits,
Consultations (outpatient and inpatient),
ER visits
Calculated by 7 components
Similar process for hospital observation,
nursing facility, and home care, but will
not be discussed
Components
determine E&M coding level—must be documented
 Key
 History
 Exam
 Medical Decision
Making
(MDM)
 Contributing
 Counseling
 Coordination
 Nature of Presenting
Problem
 Time
HISTORY
 Chief Complaint—required for all level of visits
 History of Present Illness (HPI)—brief or extended
 Review of Systems (ROS)—problem focused,
extended, complete
 Past, Family, Social History (PFSH)—pertinent or
complete
How much information is obtained and documented?
CC and HPI
 Chief complaint is required for all level of histories:
simple statement
 HPI elements: OLFQQAAT, OLDCART, PQRST
Onset, location, frequency, duration, quality (character),
quantity (severity), aggravating factors, relieving
factors (treatments tried), associated factors
REVIEW of Systems
 Constitutional
 Neurologic
 Eyes
 Psychiatric
 Ears, nose, throat
 Endocrine
 Cardiac/vascular
 Heme/lymph
 Respiratory
 Allergy/immunology
 GI
 GU
 Musculoskeletal
 Intgumentary/breast
Past Medical, Family, and Social
History
 Past illnesses, chronic conditions, surgeries,
injuries, hospitalizations, health screening and
diagnostic tests
 Medications
 Related family history
 Social history—tobacco, alcohol, drugs, exercise,
diet, work, sexual activity
Level of History
Type of
History
CC
HPI
ROS
PFSH
Problem
Focused
Required
Brief (1-3
elements)
Not required
Not required
Expanded
problem
focused
Required
Brief (1-3
elements)
Problem
pertinent
Not required
Detailed
Required
Extended (4+
elements, or
status of 3+
chronic
conditions)
Extended (2-9
systems)
Pertinent (1
item from 1
area)
Extended
Complete (10+
systems)
Complete (1
item from 2
areas (est.) or
3 areas (new))
Comprehensiv Required
e
Level of History (cont.)
 Complete ROS—10 or more systems or some systems
with statement “all other systems negative”
 Complete PFSH—need 3 for new patients,
consultations, hospital observation, initial nursing
facility care
 Determine the level of history by the column farthest
to the left (one poorly documented element can bring
the level down).
EXAM
 Body Area
 Head/face, Back/spine, Chest/breast/axilla,
Genitalia/groin/buttocks, Abdomen, Neck, Each
Extremity
Organ Systems
Constitutional, Eyes, Ears/nose/throat, Cardiovascular,
Respiratory, GI, GU, Musculoskeletal, Skin, Neuro,
Psych, Heme/lymph/immune
EXAM
Problem
focused
Expanded Detailed
problem
Comprehensive
Single Organ System
1-5
elements
At least 6
elements
At least 12
(eye and
psych: 9)
All
elements
Multi-system Exam
1-5
elements
in 1 or
more
systems
At least 6
elements
in 1 or
more
systems
At least 6
systems
with 2
elements
each
At least 9
systems
with 2
elements
each
Medical Decision Making
 Number of diagnoses and treatment options
 Amount and complexity of data reviewed
 Risk of complications
 Morbidity and mortality
Number of Diagnoses and
Treatment Options
Problem Status
Points
Self limited or minor
1
Established problem (to examiner): stable or improved
1
Established problem (to examiner): worsening
2
New problem (to examiner): no additional work up
3
New problem (to examiner): additional work up planned
4
Add up the scores for all problems to obtain a total. Self limited or minor
maximum of 2. New problem with no additional work up maximum of 1.
Amount and Complexity of Data
Reviewed
Reviewed Data
Points
Review and/or order of clinical lab tests
1
Review and/or order of radiology
1
Review and/or order of other medical tests
1
Discussion of test results with performing physician
1
Decision to obtain old records or history from someone other
than patient
1
Review and summarize old records and/or obtain history from
someone else and/or discuss case with another health care
provider
2
Independent review of imaging, tracing, or specimen itself
2
Total
Risk of Complications,
Morbidity/Mortality
 Minimal—one self-limited or minor problem
 Low—2 or more self-limited or minor problems; 1
stable chronic illness; 1 acute, uncomplicated illness
 Moderate—1 or more chronic illness with minor
exacerbation; 2 or more stable chronic illnesses;
undiagnosed new problem with uncertain prognosis;
acute illness with systemic symptoms; acute
complicated injury
Risk (continued)
 High
 1 or more chronic illnesses with severe
exacerbation
 Acute or chronic illnesses or injuries that
may pose a threat to life or bodily function
 An abrupt change in neurologic status
Minimal Risk examples
 Cold, insect bite, tinea corporis
 Order blood work, chest xray, ECG
 Recommend rest, gargles, superficial
dressing
Low Risk Examples
 2 or more self limited or minor problems
 1 chronic illness that is well controlled
 Acute illness such as UTI, simple sprain,
allergic rhinitis
 PFT, skin biopsy, non-cardiac imaging
 OTC meds, physical therapy, minor surgery
without risk factors, IV fluid without
additives
Moderate Risk examples
 One or more chronic condition, worsening
 Two or more stable chronic conditions
 Acute illness with systemic symptoms such as
pylonephritis, pneumonia
 Acute complicated injury such as concussion
 New problem needing additional work up
 Stress test, endoscopy, cardiovascular imaging
 Minor surgery with risk factors, prescription drugs,
closed treatment of fracture
High Risk examples
 One or more chronic illness with severe exacerbation,
abrupt change in neuro status
 Acute threatening illnesses such as severe respiratory
distress, acute MI, pulmonary embolus, peritonitis,
acute renal failure
 Invasive tests with identified risk factors
 Elective surgery with risk factors
 Drug therapy requiring intensive monitoring
 Decision not to resuscitate or de-escalate care
Summary of Decision Making
Summary of Results of Complexity
(Level of Medical Decision Making)
Straigh
tforwar
d
Low
Compl
ex
Number of diagnoses or treatment
options (points)
<1
2
minimal limited
3
multiple
>4
Extensive
Amount and complexity of data (points)
<1
Minima
l or low
3
multiple
>4
extensive
Highest Risk
minimal low
moderat
e
High
2
limited
Moderat High
e
Compl
Comple ex
x
If all 3 are not at the same level, then level of medical decision making is
determined by the second highest indicated.
Established Office Visit
Level 2
(99212)
Level 3
(99213)
Level 4
(99214)
Level 5
(99215)
History
Prob-focused
Expanded PF
Detailed
Comprehensiv
e
Exam
Prob-focused
Expanded PF
Detailed
Comprehensiv
e
MDM
(complexity)
Straight
forward
Low
Moderate
High
Approximate
time
10 min.
15 min.
25 min.
40 min.
Level is determined by at least 2 components in the same level.
Level 1 (99211) is a minimal visit that may be done by ancillary staff
New Patient/Consultation
I
II
III
IV
V
History
PF
EPF
Detailed
Comp
Comp
Exam
PF
EPF
Detailed
Comp
Comp
MDM
SF
SF
Low
Medium
High
New patient—Has not had any professional face-to-face services from
the provider or any provider in the same specialty in the group in
previous 3 years.
Requires 3 components on the same level.
Preventative Services
 By age, coverage and reimbursement are preset and
vary by insurance
 Medicare does not cover a routine yearly physical
 Welcome physical in first year
 Other preventative services and screenings at
determined intervals
 Must use appropriate codes
Counseling/Coordination of Care
 For an encounter dominated by counseling about a
medical condition or coordination of care, time is a
determining factor.
 For outpatient visit, must be face-to-face time
 For inpatient, can be time on unit
 Time can be estimated
 Must document 3 components: total time, at least 50%
of the visit was spent counseling, nature of the
counseling
Incident To
 Paid at full physician fee schedule amount
 NPs and other non-physician providers are usually
allowed at 85%
 Usually used for follow up of a physician’s patient
following the same plan of care.
Incident To Providers
 Auxiliary personnel: RNs, LPNs, Technicians
 Non Physician Providers (NPPs): NP, PA, CNS, CNM
(can supervise auxiliary personnel for payment, except
in hospital outpatient departments)
 Physical therapists, occupational therapists, clinical
social worker
 On claim report both name and NPI of initiating
physician and supervising physician
Requirements
 Services must be furnished in the office (not hospital)
 Furnished under direct supervision of a doctor
 Must have employment relationship
 Are integral, although incidental to the doctor’s
services.
 Commonly rendered without a physician charge but
incur some expense (for dressing change, drug
administration)
Direct Supervision
 Supervising physician can be any member of
the group
 Must be present in the office suites and
immediately available.
 Does not need to speak to or lay hands on
the patient.
Employment Relationship
 Employee
 Leased employee
 Independent contractor of physician or
legal entity that employs or contracts
physician
Documentation must
 Identify who rendered the service
 Indicate supervision requirement is met
 Show physician’s initiation and continued
involvement in treatment plan
 Show that care was reasonable and
necessary
 Show that care was within the scope of
practice of NPP
Modifiers
 25—significant, separate E&M performed by
same provider on same day
 24—unrelated E&M done by provider at
post operative visit
 50—bilateral (pays 150%)
 51—multiple procedures
Documentation should show medical
necessity and what was done in addition
Comprehensive Error Rate Testing
 CMS program monitors accuracy of claims and
payments
 National error rate is 4.5%
 Maryland and surrounding states: 4.3%
 Services associated with errors:
 Consults 27%
--Established office visits 21%
 other outpatient 21%
 Initial hospital 15% ---Subsequent 13%
Billing and Coding Tip
 Document every visit using a SOAP note
with subheads and bulleted points for HPI
(OLDCART, PQRST), ROS, related
past/family/social history, exam by systems,
diagnoses, and treatment plan.
 You will more easily be able to determine
the E&M level, or if you document
electronically, a computer program may
determine the E&M.
Resources
 Center for Medicare and Medicaid Services
www.CMS.hhs.gov
 www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.aps
(Documentation Guidelines)
 www.cms.hhs.gov/MLNProducts/downloads/1995dg.pdf
(1995 Guidelines)
 www.cms.hhs.gov/MLNProducts/downloads/master1.pd
f (1997 Guidelines)
 www.cms.hhs.gov/manuals (Claims processing)
Resources (cont.)
 Highmark Medicare Services
www.highmarkmedicareservices.com
 www.highmarkmedicareservices.com/faq/p
artb/index.html (Frequently Asked
Questions)
 www.highmarkmedicareservices.com/partb
/reference/scoresheets.html (E&M score
sheets)