Coding 101:
Getting Paid for What You Do
Jeannine Z. P. Engel, MD
Assistant Professor of Medicine
Vanderbilt University Medical Center
Background

HCFA, now CMS (Center for Medicare and
Medicaid Services) issued guidelines for
documentation of different service codes in 1995.
They were revised in 1997. Either can be used.
 In general, the 1995 guidelines are more favorable
for General Internists.

This presentation will focus on 1995 guidelines.
Why should we care?

Individual Benefits
• Thought vs. Action: General IM reimbursement
traditionally lower than procedure-based
specialties
• Getting paid for what we do - reimbursement for
practice groups and individuals can increase
• “Playing the game” vs. “Changing the game”
Disclaimer

This presentation will provide basic information
regarding documentation and coding. Before
applying this information at your institution or
practice site, YOU MUST CHECK WITH YOUR
COMPLIANCE OFFICE or LOCAL MEDICARE
CARRIER to be sure these general principles are
appropriate for your practice situation.
Learning Objectives

Review documentation requirements for basic
outpatient office visits, including Annual Exams

Learn efficient documentation of Medical Decision
Making

Discuss appropriate use of Office Consultation by
General Internist

Gain comfort in coding levels 3, 4, 5 return office
visits
Basic Coding
Rules and Regulations
New vs. Return

A new patient has not received professional
services from you or a member of your group in
any service location (e.g. hospital) in the past 3
years

Multi-specialty groups: variable

If established patient has not been seen in 3
years, bill them as New
Elements for E&M visits

History

Exam

• Chief Complaint (CC)
• History of Present Illness (HPI)
• Review of Systems (ROS)
• Past, family, and social history (PFSH)
•
Number of organ systems (1995 guidelines)
Medical Decision Making (MDM)
• # diagnoses or management options
• Amount of data/complexity
• Risk level to patient
New Patient- outpatient visit
3/3 needed
CPT
99201
99202
99203
99204
99205
HPI
1
1
4
4
4
1
2
10
10
1
3
3
ROS
PFSH
Exam
1
2
5
8
8
MDM
Straightforward
Straightforward
Low
Moderate
High
Time
10
20
30
45
60
(min)
New Outpatient Visit
Need 3 of
3
History (need
all)
HPI
ROS
PFSH
Exam
MDM (2/3)
#Dx
Data
Risk
Time if
counseling is
>50%
99201
99202
99203
99204
99205
1
1
1
4
2
1
4
10
3
4
10
3
1
2
5
8
8
1new w W/U
or 2 worse
4
Life threaten
60
1
0
No meds
1
0
No meds
2
2
1 stable
prob
1new no w/u
or 3 stable
3
Prescription
med
Or 2 stable pr.
10 min
20
30
45
Elements for E&M visits

History
•
•
Chief Complaint
History of Present Illness (7)
 Location
 Quality
 Severity
 Duration
 Timing

Modifying Factors

Associated signs and
symptoms
Elements for E&M visits

History
• Chief Complaint
•
•
History of Present Illness
Review of Systems (14)
 Constitutional-fever/wt
 Eyes
 Ears/nose/mouth/throat
 CV
 Respiratory
 GI
 GU







Musculoskeletal
Skin
Neurologic
Psychiatric
Endocrine
Heme/lymphatic
Allergic/immunologic
Elements for E&M visits

History
•
Chief Complaint
•
History of Present Illness
• Review of Systems
•
Past, Family, and Social History
−Past Medical History
−Family history
−Social history
Pearls for documenting History

Can refer to previously documented elements:
“Problem list updated as part of today’s visit”

“All other systems reviewed and negative” may be
used in most cases to document negatives.

Taking history from someone other than the
patient increases level of medical decision making.

Single bullets satisfy PFSH requirements - does
not need to be exhaustive
Elements for E&M visits

History

Exam
•
# of organ systems (12)
 Constitutional-VS, general
appearance
 Eyes
 Ears, nose, mouth, throat
 Cardiovascular (inc edema)
 Respiratory
 GI






GU
Musculoskeletal
Skin
Neurologic
Psychiatric
Heme/lymph/immunologic
Physical Exam
 How many organ systems can you
document before you lay a stethoscope on
your patient??
Physical Exam

SEVEN!!
•
General appearance
•
Eyes - sclera anicteric/injected
• HENT - hearing intact (hard of hearing)
•
MSK - normal gait/limping
•
Psych - normal (depressed/flat) affect
•
Skin - no rash on face, arms
•
Immunologic - NKDA (use for PMH or PE)
Coding New Patient Visits

Need 3 of 3 elements documented (history, exam,
decision making)

MDM and MEDICAL NECESSITY SHOULD
DRIVE CODING
MDM and MEDICAL
NECESSITY SHOULD
DRIVE CODING
Coding Return Patient Visits

Only need 2 of 3 elements documented to meet
level of service coded (History, PE, MDM)

MDM and MEDICAL NECESSITY STILL
DRIVE CODING
Return Patient- outpatient visit
2/3 needed
CPT
99212
99213
99214
99215
HPI
1-3
1-3
4+
4+
ROS
None
1
2-9
10+
None
none
1
2
1 system
2-4
systems
5-7 systems 8+
systems
MDM
Straightforward
Low
Moderate
High
Time
10 min
15 min
25 min
40 min
PFSH
Exam
99211
Nonphysician
visit
Return Outpatient Visit
Element
99212
99213
99214
99215
1
1
1
4 (or 3 chronic)
2
1
4 (or 3 chronic)
10 (“o/w neg”)
2
Exam (# systems) 0
2
5
8
Complexity
3 stable est
prob or
1 new, no w/u
2 prob-worse or
1 new, w/u
4
Severe side
effects, DNR
45
(Need 2 of 3)
History
HPI
ROS
PFSH
Dx
1 prob
Data
0
2 est probstable or
1 est probworse
2
Risk
No meds
1 stable prob
3
Prescriptn med
or 2 stable prob
10 min
20
30
(need 2 of 3)
Time if counseling
is >50%
Documenting
Medical Decision Making
The Real Meat of Internal Medicine
Medical Decision Making

Diagnoses

Data

Risk
Medical Decision Making

Number of diagnoses
•

Amount/complexity of data reviewed
•
•

Number and type of presenting problems
Ordering tests and reviewing of tests
Obtaining records or history from others
Overall risk of complications to patient before
seeing another medical professional
• See “Table of Risk”
Number of Diagnoses

Self-limited or minor: 1 point each (2 max)

Established problem, stable: 1 point

Established problem, worsening: 2 points

New problem, no addt’l workup: 3 points

New problem, with further workup: 4 points

Complexity (and thus level of service)
•
Straight-forward=1; Low=2, Moderate=3, High=4
Amount and Complexity of Data






Review and/or order of clinical test: 1 point
• Basically all labs
Review and/or order of radiology: 1 point
Review and/or order of medical test: 1 point
• Includes vaccines, ECG, echo, PFTs
Discussion of test with performing MD: 1 point
Independent review of test: 2 points
Old records or hx from another person
• Decision to do this: 1 point
• Doing it and summarizing: 2 points
Overall Risk Table

Learn and Love the overall risk table

3 categories: presenting problem, dx procedures,
management options

Highest level of risk in ANY of the 3 categories is
the overall risk level for that patient
Overall Risk Table
 Pearls:
• Prescription drug management: moderate
• 2+ stable chronic illnesses: moderate
• Abrupt mental status change: high
• 1 chronic illness w/ severe exacerbation: high
Overall Decision Making Table
Need 2 of 3 elements to qualify for given level
Type of
MDM
# dx
Amt data
Overall
Risk
Straightforward
99201/02
99212
Low
99203
99213
Moderate
99204
99214
High
99205
99215
1
2
3
4+
0 or 1
2
3
4+
minimal
low
moderate
high
Counseling, Annual Exams
and Office Consultation
Counseling

When time spent counseling >50% of total visit,
then TIME becomes the deciding factor for coding

Total billing physician face to face time
• 99213: 15 min
• 99214: 25 min
• 99215: 40 min

Must document time spent and reason for
counseling
Counseling is:
• “A discussion with the patient and/or family
concerning one or more of the following areas” CPT book
• Recommended tests, diagnostic results, impressions
• Prognosis
• Risks/benefits of treatment (management) options
• Instructions for treatment (management) options and
•
•
•
follow up
Importance of compliance with treatment (management)
options
Risk factor reduction
Patient and family education
Preventative Service Visits

NO Chief complaint or HPI

MUST HAVE
•
•
•
•
•
Comprehensive ROS (10 organ systems)
Comprehensive or interval PFSH
Comprehensive assessment of risk factors
appropriate to age
Multi-system physical exam appropriate to age and
risk factors (RF)
Assessment/Plan which includes counseling,
anticipatory guidance and RF reduction
Preventative Service Visits



New vs. Return rules are the same

Documentation of anticipatory guidance/risk
factor reduction is the common missing element

Can refer to previous ROS, PMH, FH, etc.
Coding based on age of patient
NO specific guidelines for what to include with
each age group
Outpatient Consultation

Consultations require:
• A request from another provider
• The provision of a consultation evaluation service
• A report of the service to the requesting provider

Simply put, one provider asks a question, and the
consultant answers it.
Consultation Requirements


New CMS requirements as of Jan 2006:

A consultation request may be written on an order form in a
shared medical record.

The consultant must also document the reason for the
consultation.

The “Question” must be documented in 2 medical records
The written request for a consultation must be included in
the requesting provider’s plan of care.
Consultation Requirements

The written report may be part of a common
medical record or in a separate letter to the
requesting provider and must be readily available.

The written report must include the findings and
recommendations (the “answer” to the original
provider’s question.)

The consultant is expected to have expertise
beyond that of the requesting provider.
Coding Outpatient Consultations

CPT codes 99241-99245

Documentation requirements are identical to
New Patient visit codes

Outpatient Consult F/U codes were deleted in
Jan 2006
Pre-Operative Consultations

This is the most common scenario for a General
Internist

You CAN bill Consultation on an established
patient, as long as all the criteria are met

CMS rules state: “a pre-operative consultation at
the request of a surgeon is payable if the service is
medically necessary and not routine screening.”
Pre-Operative Consultations

Following a pre-operative consultation, if the
same MD/NPP assumes responsibility for
management of all or part of the patient’s care
postoperatively, the subsequent visit codes must
be used.
•
Example – IM performs preop consult for patient
prior to surgery; surgery occurs and surgeon requests
IM inpatient MD to provide post operative care, in
this scenario the inpatient IM MD cannot bill a
second consult.
Second Opinions - Outpatient

For 2nd opinion evaluations in the outpatient or
office setting, report the appropriate Office or
other outpatient codes (new or established patient)
for the level of service performed.

Confirmatory Consultation codes were deleted in
Jan 2006
Consults Within a Group

Payment will continue to be made for a
consultation if a provider in a group practice
requests a consultation from another MD in the
same group practice when the consulting MD
has expertise in a specific medical area beyond
the requesting professional’s knowledge.
You have the Basics
Let’s apply them to some
real cases!
Case #1

CC: 55 yo woman (known to you) presents with
back pain

Level 3, 4, or 5?

Depends on:
• medical necessity
• what is done
• what is documented
Case #1

CC: 55 yo woman (known to you) presents with
back pain

HPI
• Patient awoke 1 week ago with constant, sharp,
moderately-severe LBP assoc w/ intermittent spasms.
Improves w/ ibuprophen. Remote history of similar sx.
No trauma, fevers, weakness, bowel or bladder sx.
Case #1 (cont’d)

Exam
•
•
Gen: BP 110/60
Back: lumbar paraspinous tenderness

Assessment

Plan
• LBP, probably muscular
• Continue ibuprofen
• Begin cyclobenzaprine 10mg TID prn
• Return in 2 weeks if not better, sooner prn
Outpatient Established Patient
Element
(need 2 of 3)
99211
99212
99213
99214
99215
Min.
prob.
may
1
1
1
4 (or 3 chronic)
2
1
4 (or 3 chronic)
10
2
Exam* # systems
not
0
2
5
8
Complexity (2/3)
Dx
Data
Risk
need
MD
1
0
No meds
2
2
1 stable prob
3 (1 new no w/u) 4 (1 new w/ W/U)
3
4
Prescription med
Life threaten
Time (≥50%counsel’g)
5
10
15
25
History
HPI
ROS
PFSH
Or 2 stable pr.
40
Hx: location, quality, severity, duration, timing, modifying factors (or status of 3)
*Exam: ’95 audit tool definitions (’97: 6 bullet points 99214 and 12 bullet points 99215)
Dx: est prob-stable 1; est. prob-worse 2; new-no W/U 3(max3); new prob W/U 4
Data: lab 1; xray 1; other 1; disc w/testing MD 1; decision to review records/hx 1; review old records/hx
from non-pt 2; discuss w/ another provider 2; independent review test 2
Outpatient Established Patient
Element
(need 2 of 3)
99211
99212
99213
99214
99215
History
HPI
ROS
PFSH
Min.
prob.
may
1
1
1
4 (or 3 chronic)
2
1
4 (or 3 chronic)
10
2
Exam* # systems
not
0
2
5
8
Complexity (2/3)
Dx
Data
Risk
need
MD
1
0
No meds
2
2
1 stable prob
3
3
4 (1 new w/ W/U)
Prescription med
Or 2 stable pr.
Life threaten
Time
5
10
15
25
40
(≥50%counsel’g)
4
Hx: location, quality, severity, duration, timing, modifying factors (or status of 3)
*Exam: ’95 audit tool definitions (’97: 6 bullet points 99214 and 12 bullet points 99215)
Dx: est prob-stable 1; est. prob-worse 2; new-no W/U 3(max3); new prob W/U 4
Data: lab 1; xray 1; other 1; disc w/testing MD 1; decision to review records/hx 1; review old
records/hx from non-pt 2; discuss w/ another provider 2; independent review test 2
Case #1 - Modification A
More Documentation

Add reference to PFSH (PMH, FH, or SH)
•
“Problem list and medications reviewed, see
summary page” OR
• 50 yo woman with HTN OR
• 50 yo non-smoker OR
• Patient with NKDA OR
• Meds-Premarin
Outpatient Established Patient
Element
99211
(need 2 of 3)
History
HPI
ROS
PFSH
Exam #
99212
99213
99214
99215
Min.
prob.
may
1
1
1
4 (or 3 chronic)
2
1
4 (or 3 chronic)
10
2
not
0
2
5 (or Detailed)
8
1
0
No meds
2
2
1 stable prob
3
3
4 (1 new w/ W/U)
4
Prescription med
Or 2 stable pr.
Life threaten
10
15
25
40
systems
Complexity
(2/3)
Dx
Data
Risk
Time
need
MD
5
(≥50%counsel’g)
Hx: location, quality, severity, duration, timing, modifying factors (or status of 3 chronic)
Exam: Check with compliance or local Medicare intermediary for their rules re: detailed
Dx: est prob-stable 1; est. prob-worse 2; new-no W/U 3(max3); new prob W/U 4
Data: lab 1; xray 1; other 1; disc w/testing MD 1; decision to review records/hx 1; review old records/hx
from non-pt 2; discuss w/ another provider 2; independent review test 2
Case #1 - Modification B
More Complexity


Now consider if the patient has a T:102.1
Additional history:
•
•


PFSH: “non-smoker”
ROS: “complete 10 organ ROS o/w negative”
No change in exam
Additional workup:
•
Will order CBC, urgent MRI lumbar spine, discuss with
spine surgeon
•
“Concern for epidural abscess”
Outpatient Established Patient
Element
(need 2 of 3)
99211
99212
99213
99214
99215
Min.
prob.
may
1
1
1
4 (or 3 chronic)
2
1
4 (or 3 chronic)
10
2
Exam # systems
not
0
2
5
8
Complexity (2/3)
need
MD
1
0
No meds
2
2
1 stable prob
3
3
4
4
Life threaten
10
15
25
History
HPI
ROS
PFSH
Dx
Data
Risk
Time (≥50%counsel’g)
5
Prescription med
Or 2 stable pr.
40
Hx: location, quality, severity, duration, timing, modifying factors (or status of 3 chronic)
Exam: Check with compliance or local Medicare intermediary for their rules re: detailed
Dx: est prob-stable 1; est. prob-worse 2; new-no W/U 3(max3); new prob W/U 4
Data: lab 1; xray 1; other 1; disc w/testing MD 1; decision to review records/hx 1; review old records/hx from
non-pt 2; discuss w/ another provider 2; independent review test 2
Case #2







60 yo male presents for 3 month f/u visit for HTN,
AODM. Also reports mild fatigue and some leg
cramps, occurring 2-3 times per week. BP better
since addition of HCTZ at last visit. Sugars
running <160. Pt denies CP, SOB, LE edema.
Meds updated in problem list
PE: BP:138/80 HR:75 RR:16
Gen: looks well
CV: RRR, no m,r,g
Lungs: Clear
Ext: no edema, no calf tenderness to palpation
Case #2 (cont’d)

A/P: 1. HTN, well controlled, continue same
meds

2. AODM, well controlled, continue meds/diet,
exercise, check HgA1c

3. Leg cramps- possible low K, check BMP,
Mg.

F/U in 3 months
Case #2 (cont’d)







60 yo male presents for 3 month f/u visit for HTN, AODM.
Also reports mild fatigue and some leg cramps, occurring
2-3 times per week. BP better since addition of HCTZ at
last visit. Sugars running < 160. Pt denies CP, SOB, LE
edema. 2 chronic problems, stable and 1 new; 5 HPI 3ROS
Meds updated in problem list 1 PFSH level 4 Hx
PE: BP:138/80 HR:75 RR:16
Gen: looks well
CV: RRR, no m, r, g
Lungs: Clear
4PE level 3 Exam
Ext: no edema, no calf tenderness to palpation
Case #2 (cont’d)

A/P: 1. HTN, well controlled, continue same
meds

2. AODM, well controlled, continue meds/diet,
exercise, check HgA1c

3. Leg cramps, fatigue - possible low K, check
BMP, Mg. F/U in 3 months

Moderate MDM: diagnoses-high; data-low; riskmoderate

99214 (count History and MDM)
Final thoughts

The coding rules initially appear complex but
can be mastered.

It takes some practice.

Use these tools to “self-audit.”

It is your responsibility to select the right code
for the work that you do.