Coding Clinical Encounters
Definition of Terms: CPT E/M and
Procedure Codes

The CPT E/M section is divided into broad
categories such as office visits, hospital visits,
and consultations

CPT Procedure Codes are based upon the
specific procedure being performed.
National Correct Coding Policy
Applies to services billed by a single provider for a patient on the same day
Some CPT Procedure codes have been developed that are considered
“comprehensive”

These CPT Procedure codes incorporate the E/M service; therefore the
E/M Code should not be coded

The RVU assigned to these CPT Codes are based on the
comprehensiveness of the procedure (i.e., incorporate the “value” of the
E/M service)

However, ADM 3.0 software requires an E/M to be coded
CCI EDITS
Audit checks to ensure (and deleted if found) additional codes are not billed
with comprehensive or exclusive codes
RVUs
Relative Value Units (RVUs)

Since 1992, reimbursement (payment) to providers has been
based on a fee schedule using RVUs

RVUs are a nationally recognized measurement of the
resources (the amount of time, effort and intensity) required
to provide a particular service or procedure
Every CPT E/M and Procedure Code has an RVU assigned, but
some are ZERO
RVU is multiplied by the standard conversion factor to get the
“payment amount”
RVUs are tracked as an indication of provider workload
ICD 9 CM Diagnosis


What’s the Same?

Same method for deciding the diagnostic code

Refer to flow sheet and superbills

Can code up to four diagnoses

V71.09 and 799.9 are not recommended for use; Code
presenting symptom or chief complaint
What’s Different?

New Codes for Consultative BH Care in medical clinic

New method for deciding the CPT E/M and procedure
Codes
ICD 9 CM Diagnosis
The type of diagnosis (psychiatric or physical) now guides the type of
CPT E/M and Procedures Codes to use

PSYCHIATRIC Diagnosis (YELLOW on Superbill in Appendix 11)


PHYSICAL Diagnosis (PEACH on Superbill in Appendix 11)


Use 99499 (E/M) along with 90801 (new patient) or 90804
(follow-up patient) for CPT Procedure
Use 99499 (E/M) along with 96150 (new patient) or 96152
(follow-up patient) for CPT Procedure
OR Use 99242 (consultative E/M code) for any “new patient”,
regardless of diagnosis, with NO CPT Procedure Code
E & M Codes
If using a CPT Procedure code, then use 99499
(unlisted E/M Code) because the CPT
Procedure Codes used for BH in primary care
are Comprehensive Codes
Telephone contacts are types of CPT E/M
codes – 3 types

DO CODE these

DO NOT code a CPT Procedure code with telecons
Consultation E/M Codes
Consultation E/M Codes (99241, 99242)

Consultations are provided at the request of another provider, to render an
opinion or advice regarding the evaluation and management of a specific
problem.

You must document the need in the patient’s record You may initiate
diagnostic and/or therapeutic services, such as writing prescriptions or
initiating treatment plans.

You must document the opinion you render and services you order or
perform in the patient’s medical record.


Report this information to the requesting provider.

Report separately any identifiable procedure or service performed on,
or subsequent to, the date of the initial consultation.
When you assume responsibility for the management of any or all of the
patient’s care subsequent to the consultation encounter, consult codes are
no longer appropriate.
BH CPT Procedure Codes
Two Categories of BH CPT Procedure Codes

Health Behavior Assessment and Intervention (96150-96155) – Use
“quantities” for these

Psychiatric (90801; 90804, etc)
Both sets of CPT procedure codes are ‘comprehensive’ and have CCI edits
Use 99499 E/M code (unlisted E/M code) with these
Use diagnosis to determine which category to use
Can code multiple CPT Procedure codes for one visit (but not same CPT; if
same CPT use quantities)

For example, using a CPT procedure code for health risk assessment
(99420), but there are no RVUs for this service
If you choose to use a consultation E/M code, do not also use a CPT Procedure
code. Use only for initial BHC consultation visits. (there is no ‘right’ answer)
Coding Logic
CPT CODES
Non-Consultative Codes
Consultation E/M Codes
(99499 E/M Code plus CPT
Procedure Code determined from
logic below)
(99241, 99242, 99243)
Psychiatric ICD-9 CM
Diagnosis
Physical ICD-9 CM
Condition/Diagnosis
(Use CPT Procedure Codes
90801, 90804)
(Use CPT Procedure Codes
96150-96155)
Examples
P A T IE N T
TYPE
N ew
P atien t
REFERRAL
Q U E S T IO N /
P R E S E N T IN G
PRO BLEM
H ead ach e
IC D -9
CM
CODE
E /M
CODE
CPT
CODE
7 8 4 .0
99499
96150
RVUs
.7 2 x 2 =
1 .4 4
x co n sta n t
($ 3 6 .2 0 ) =
D o lla r
V a lu e
E q u iv a len t
$ 5 2 .1 3
Examples
P A T IE N T
TYPE
REFERRAL
Q U E S T IO N /
P R E S E N T IN G
PRO BLEM
IC D -9
CM
CODE
E /M
CODE
CPT
CODE
RVUs
x co n sta n t
($ 3 6 .2 0 ) =
D o lla r V a lu e
E q u iv a len t
N ew
P atien t
R /O A n x iety
D iso rd er
3 0 0 .0 1
99242
-------
1 .8 8
$ 6 8 .0 6
N ew
P atien t
H ead ach e
7 8 4 .0
99242
-------
1 .8 8
$ 6 8 .0 6
F o llo w -U p
P atien t
H ead ach e
7 8 4 .0
99242
-------
1 .8 8
$ 6 8 .0 6
Examples
P A T IE N T
TYPE
REFERRAL
Q U E S T IO N /
P R E S E N T IN G
PRO BLEM
IC D -9
CM
CODE
E /M
CODE
CPT
CODE
RVUs
x co nsta n t
($ 36 .2 0 ) =
D o lla r V a lue
E q u iv alen t
N ew
P atien t
D ep ressio n
2 9 6 .3 0
9 9 4 99
9 0 8 01
3 .7 9
$ 1 3 7 .20
N ew
P atien t
S leep
D istu rb an ce,
U n sp ecified
7 8 0 .5 0
9 9 4 99
9 6 1 50
.7 2 x 2 =
1 .4 4
$ 5 2 .1 3
Examples
PA T I E N T
TY PE
REFERRAL
Q U ESTIO N /
PR E SE N T IN G
PR O B L E M
IC D -9
E /M
CM
CODE
CODE
CPT
CODE
RVU s
x c o nsta nt
($ 3 6 .2 0 ) =
D o lla r
V a lue
E q uiv a le nt
F ollo w - U p
Pa tie nt
Ins o m n ia
3 0 7 .4 2
99499
90804
1 .6 4
$ 5 9 .3 7
F ollo w - U p
Pa tie nt
D ia b etes
M a na g e m e n t
2 5 0 .0 2
99499
96152
.6 6 x 2
= 1 .3 2
$ 4 7 .7 8
F ollo w - U p
Pa tie nt
D e pr essio n
2 9 6 .3 0
99499
90804
1 .6 4
$ 5 9 .3 7
Review and Questions
Review Mini-Guides in revised
Appendix
Questions from participants
? Questions ?