PROFESSIONAL BILLING
COMPLIANCE TRAINING PROGRAM
MODULE 2
EVALUATION AND MANAGEMENT (E/M)
SERVICES
Evaluation and Management (E/M)
Documentation
E/M Documentation Background:
• Physician payment for inpatient and outpatient clinical visits and
consults are E/M codes that are derived from medical documentation.
• A pathway that translates physician patient care work into claims and
reimbursement mechanisms.
• Ensures correct payments.
• Supports correct E/M code level that provides validation for medical
review.
2
Key Components of E/M
7 Components of E/M Services:
1.
2.
3.
4.
5.
6.
7.
History
Physical Examination
Medical Decision Making
Time
Counseling
Coordination of Care
Nature of Presenting Problem
Key components
The first three components, History, Physical Examination and Medical
Decision Making are the key components in selecting the level of E/M
services.
3
Three Key Components
The chart below provides an example of how the three key components
(History, Examination and Medical Decision Making) are used in selecting
the levels of E/M new patient services.
Inpatient
New Patient Visit
History
Examination
Medical Decision
Making
99201
Problem Focused History
Problem Focused
Examination
Straightforward
99202
Expanded Focused
History
Expanded Problem
Focused Examination
Straightforward
99203
Detailed History
Detailed Examination
Low Complexity
99204
Comprehensive History
Comprehensive
Examination
Moderate Complexity
99205
Comprehensive History
Comprehensive
Examination
High Complexity
4
Key Components of E/M
Breakdown: Three key components - History, Examination and Medical
Decision Making including the elements in each component.
5
E/M Key Component - History
History levels are determined by the following:
1.
2.
3.
4.
Chief Compliant (CC)
History of Present Illness (HPI)
Review of Systems (ROS)
Past, Family, and/or Social History (PFSH)
The extent of the history is dependent upon clinical judgment and on
the nature of the presenting problem (s).
6
E/M Key Component – History (continuation)
First Part – Chief Complaint:
• A concise statement describing the symptoms, problem, condition,
diagnosis, or other factors as the reason for the encounter.
• Normally first notation in record.
Examples:
• Pain, shortness of breath, fever.
• Management of diabetes & HTN, follow-up visit for dizziness.
• Annual physical exam.*
* Preventative services may not be covered by certain payors.
7
E/M Key Component – History (continuation)
Second Part – History of Present Illness (HPI):
• Chronological description of the development of the patient’s
illness from the 1st sign and/or symptom to the present.
• Current E/M guidelines identify 8 elements used to provide further
elaboration about the patient’s condition.
8
HPI: 8 Elements
Location:
• Where is the pain/problem? (abdomen, chest)
Quality:
• Describe the pain/problem? (sharp, dull)
Severity:
• How severe is the pain /problem? (slight)
Duration:
• How long have you had this pain/problem? When did it start?
(Two weeks, started after I returned from my trip abroad)
Timing:
• Does this pain/problem occur at a specific time? (one hour after
eating)
9
HPI: 8 Elements (continuation)
Context:
• Where were you at the onset of this pain/problem? (when walking,
after smoking)
Modifying Factors:
• What makes the pain/problem worse or better? (improves when
lying down, worse after eating)
Associated Signs/Symptoms:
• What other associated problems are present? (nausea and vomiting,
rash, leg swelling)
10
Two Levels of HPI
• Brief = 1-3 elements described
• Extended = 4 or more elements described, or status of at least 3 chronic
or inactive conditions
– Example of HPI with 5 elements:
9Duration
9Quality
9Location
“Mr. Doe has for two weeks felt a sharp pain in his left shoulder
when he raises his arm. He states that aspirin does not relieve the
9Context
pain. 9Modifying
11
E/M Assessment – Question 1
• True or False:
The following scenario contains 6 HPI elements.
Irritating abdominal pain in the right upper quadrant since last night
with some nausea prior to the onset of pain.
12
E/M Assessment - Answer
The answer is False.
There are only 4 HPI elements in this scenario.
1.
2.
3.
4.
Location – Right upper quadrant of abdomen
Quality – Irritating
Duration – Since last night
Associated signs or symptoms – Nausea prior
13
E/M Key Component - History
Third Part of History - Review of Systems (ROS):
An inventory of body systems obtained through a series of
questions seeking to identify signs and/or symptoms which the
patient has or has had. ROS includes 14 systems.
• 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
14
E/M Key Component – History
(continuation)
Third Part of History – ROS:
Examples of documentation for complete ROS:
• Patient’s ROS is positive for fever and chills, nausea and vomiting.
Other 12 systems are negative.
• Full ROS performed, all 14 systems are negative.
• Fourteen system review performed; all systems are negative, except
as documented above. (This implies that the positive systems were
documented in the “subjective” or in the “HPI” sections).
• Complete ROS performed; non-contributory.
15
E/M Key Component – History
(continuation)
Third Part of History – ROS:
Unacceptable examples for documentation of a Complete ROS:
• All systems reviewed are negative. (Not clear what systems
reviewed)
• ROS is unremarkable
• ROS is non-contributory
16
Three Levels of ROS
• Problem Pertinent (1 system)
– Directly related to the problem(s) identified in the HPI (rash –
Integumentary)
• Extended (2-9 systems)
– Directly related to the problem(s) identified in the HPI (rash –
Integumentary) and a limited number of additional systems (joint
pain – Musculoskeletal)
• Complete (at least 10 systems) – See example next slide
– Medi-Cal requires all 14 systems
• May be completed by patient, nurse or other staff (see slide 30)
• Pertinent positives and negatives must be referred to in the note
17
Three Levels of ROS (continuation)
Example of a complete ROS (defined as review of at least 10
systems)*:
Patient seen in physician’s office with flu-like symptoms. For the past
two days she has had chills, fever, and muscle aches. She feels worse
in the evening. Her illness is so severe she has not been able to work.
She has lost 7 pounds in the last month. She denies abdominal pain,
diarrhea, and vomiting. Other 12 systems negative.
¾ Constitutional – chills, fever, muscle aches
¾ Gastrointestinal – abdominal pain, etc…
¾ Other 12 systems are negative gives provider credit for a Complete
ROS
* MediCal requires 14 ROS for Complete History.
18
E/M Assessment – Question 2
The ROS is an integral element in which E/M component?
a.
b.
c.
d.
History
Exam
Medical Decision Making
Counseling
19
E/M Assessment - Answer
• The answer is a.
The History component consists of:
• Chief Complaint
• HPI (History of Present Illness)
• ROS (Review of Systems)
• PFSH (Past Medical, Family, Social History)
20
E/M Key Component - History
Fourth Part - Past Medical, Family & Social History (PFSH):
• Consists of a review of one or more of the following three areas:
- Past Medical History (P)
- Family History (F)
- Social History (S)
• Considered to be interval history for subsequent inpatient visits.
• May be documented by ancillary staff or by patient – but physician
must review, date and sign.
• Non-contributory alone is not sufficient for billing purposes.
21
E/M Key Component – History (continuation)
Fourth Part of History - PFSH
•
Past Medical
– Current medications
– Prior Illnesses/injuries
– Dietary status
– Operations/hospitalizations
– Allergies
• Past Medical
– 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
22
Two Levels of PFSH
• Pertinent: one specific item from any of the three areas (Past Medical,
Family, Social)
• Complete: document specific item from all the three areas
– For established patients: two of three areas is sufficient for a
Complete level of PFSH
– For consultations: All three areas are necessary.
23
Two Levels of PFSH (continuation)
Fourth Part of History – PFSH:
• To be non-contributory a statement is required in the documentation to
qualify it for a Complete PFSH.
Example: Reviewed PFSH, non-contributory to current condition.
• For those categories of E/M services that require only a followup/interval history, it is not necessary to record information about
PFSH (subsequent hospital care and nursing facility care)
24
Four Levels of History Component
Levels of E/M Services are based on 4 levels of History:
• Problem Focused (PF)
– CC, Brief HPI, No ROS, No PFSH
• Expanded Problem Focused
– CC, Brief HPI, Pertinent ROS, no PFSH
• Detailed
– CC, Extended HPI and ROS, Pertinent PFSH (1) element
• Comprehensive
– CC, Extended HPI, Complete ROS and PFSH (3) elements (2 for
established patient)
25
Four Levels of History Components
(continuation)
Example of a detailed level of history (CC, Extended HPI and
ROS, Pertinent PFSH (1) element):
• Chief Complaint (CC) - cough
• HPI
– Extended (4 elements – severe productive cough, increase on
exertion, fever, not relieved by OTC medication)
• ROS
– Extended (2-9 systems – respiratory, constitutional, other 12
systems negative)
• PFSH
– Pertinent (1 area – smoker)
(See table next slide)
26
Four Levels of History Requirements
27
E/M Assessment – Question 3
A comprehensive history consists of:
a.
b.
c.
d.
e.
4 HPI elements or status of 3 chronic conditions
10 ROS for non-Medi-Cal cases
14 ROS for Medi-Cal cases
Complete PFSH (three areas for new or initial patients and two
areas for established patients)
All of the above
28
E/M Assessment - Answer
• The answer is (e) all of the above:
A comprehensive level of history consists of:
– Extended level of HPI (4 or more elements or status of 3 chronic or
inactive conditions)
– Complete ROS (10 for non-Medi-Cal cases and 14 for Medi-Cal
cases)
– Complete PFSH (three areas for new or initial patients and two
areas for established patients)
29
Patient Questionnaires
• Patient questionnaires may be used for ROS and the PFSH.
• ROS may be documented by ancillary staff or by patient. However,
questionnaire must be referenced in the attending physician’s or NPP’s
note and signed by the provider.
• If patient unable to give history, document reason patient is unable to
respond
- Example: Patient unconscious, intubated, poor historian
- Example: Unable to obtain the history, patient is unconscious
• Where patients unable to provide the history for billing purposes it is
deemed a Comprehensive History.
30
E/M Assessment – Question 4
• True or False:
Patient questionnaires may be used for ROS and PFSH.
However, the patient questionnaire must be referenced in the note
and signed by the attending physician and patient.
31
E/M Assessment - Answer
• The correct answer is true:
Patient questionnaire forms may be used for ROS and PFSH, and
can be obtained by ancillary personnel or provided by the patient,
and signed by the attending physician. If questionnaire is
separate from encounter note, the provider must reference in
his/her report.
32
E/M Key Component - Examination
Physical Examination:
• The extent of the examination performed is based upon clinical
judgment, the patient’s history, and nature of the presenting problem.
• A general multi-system or any single organ system exam may be
performed by any provider. (See Appendix I and II)
• Single organ system examination involves a more extensive
examination of a specific organ system.
• Note specific abnormal & relevant findings of the affected or
symptomatic area(s) – “abnormal” is insufficient.
• Include abnormal or unexpected findings of asymptomatic areas or
systems. Noting “negative” or “normal” is sufficient to document
normal findings in unaffected areas.
33
E/M Key Component – Examination
(continuation)
Examination Documentation Guidelines:
Two CMS Guidelines available (1995 or 1997) to help quantify the
physical examination.
• Providers/Coders may use either guideline
• Whichever is most advantageous to the provider
• Must follow one guideline per patient encounter
• Cannot mix and match
See Appendix I –Elements of General Multi-System Exam
See Appendix II – Single Organ System Examination
34
E/M Key Component – Examination
(continuation)
1995 Guidelines
• Based on the number and/or extent of body areas or organ
systems examined.
• Often used by internist and family practice.
1997 Guidelines
• Based on the examination of specific bulleted items identified
within a body area or organ system.
• Works well for certain specialists using the single organ system
examination (dermatology, orthopedic).
35
Levels of Examination * Appendix I and II
Examination
Problem
Focused
Expanded
Problem
Focused
Detailed
Comprehensive
1995
1 Body Area or
Organ System
Limited Exam
2-7 Body Areas or
Organ Systems
Extended Exam 2-7
Body Areas or Organ
Systems
8 Organ Systems or a
Comprehensive Single
Organ System Exam
1997
Any 1-5 Bullets
Any 6+ Bullets
General: 2 bullets
from 6 or more organ
systems/body areas or
12 bullets from 2 or
more organ
systems/body areas
General: Perform all,
document 2 bullets from 9
Organ Systems/body areas
Eye/Psych: 9+ bullets
All Others: 12+
bullets
All Others: Perform all,
document all elements in each
bolded box and 1 element in
each un-bolded box
36
E/M Assessment – Question 5
A Comprehensive Multi-System Examination consists of:
a.
8 systems examined utilizing the 1995 Guidelines.
b.
9 systems and/or areas examined utilizing the 1997 Guidelines.
c.
Both a and b.
37
E/M Assessment - Answer
• The answer is (c) both a and b.
Selection of “Comprehensive” level of examination requires
documentation of:
– 8 systems examined – under the 1995 Guidelines
– 9 systems/areas examined – under the 1997 Guidelines
38
E/M Key Component
Medical Decision Making (MDM)
• MDM refers to the complexity of establishing a diagnosis and/or
selecting a management option.
• MDM is the function of 3 variables:
1. Number of Diagnostic and/or Management Options that must be
considered
2. Amount and Complexity of Data ordered and/or reviewed
3. Risk of significant complications, morbidity and/or mortality
39
E/M Key Component MDM
First Variable of MDM- Diagnostic and/or Management Options:
• Billing credit is based on a point system
– Self-limited, minor (1 pt.)
– Established problem stable, improved (1 pt.)
– Established problem worsening (2 pts.)
– New problem, without workup planned (3pts.)
– New problem, with workup planned (4pt.)
40
E/M Key Component – MDM (continuation)
Second Variable of MDM – Amount and/or Complexity of Data:
• Billing credit is based on a point system
– Review/order of clinical lab, radiologic study, other non-invasive
diagnostic study (1 pt. per category of test)
– Discussion of diagnostic study w/ interpreting phys. (1 pt.)
– Independent review of diagnostic study (2 pts.)
– Decision to obtain old records or get data from source other than
patient (1 pt.)
– Review/summary old med records or gathering data from source
other than patient (2 pt.)
41
E/M Key Component – MDM (continuation)
Third Variable of MDM- Risk of Complications, Morbidity
and/or Mortality:
•
•
•
Refers to patient’s level of risk at the visit
Determining risk is complex and not readily quantifiable – Table of
Risk on Slide 43 shows clinical examples
Source of risk
– Presenting problem
– Diagnostic procedures ordered
– Management options selected
42
Medical Decision Making Elements
Table of Risk (Billing credit is based on the highest level
Level of
Risk
Minimal
Low
Moderate
High
Presenting Problem(s)
Diagnostic Procedures Ordered
Management Options Selected
One self-limited or minor problem, e.g., cold, insect bite,
tinea corporis
Lab tests (blood, X-rays, EKG)
X-rays
Urinalysis
Ultrasound
Rest
Superficial dressings
Gargles
Two of more self-limited problems
One stable chronic illness (e.g., well-controlled
hypertension, non-insulin dependent diabetes, cataract, BPH)
Acute uncomplicated illness or injury, e.g., cystitis, allergic
rhynitis, simple sprain
Non-CV imaging studies with contrast e.g.,
barium enema
Superficial needle biopsy
Lab test requiring arterial puncture
Skin biopsies
Physiologic tests non under stress, eg., PFTs
OTC drugs
Minor surgery with no identified risk factors
PT/OT
IV fluids without additives.
1 or more chronic illness with mild exacerbation,
progression or side effects of treatment
2 or more stable chronic illness
Undiagnosed new problem with uncertain prognosis, e.g.,
lump in breast
Acute complicated injury
Physiologic tests under stress
Diagnostic endoscopies with no identified risk
factors
Deep needle or incisional biopsy
Cardiovascular imaging studies with contrast
and no identified risk fxs
Obtain fluid from body cavity
Prescription drug management
Minor surgery with risk factors
Decision to perform elective major surgery
with no identified risk fxs
Therapeutic nuclear medicine
IV fluids with additives
Closed treatment of fracture or dislocation
without manipulation
1 or more chronic illnesses with severe exacerbation
Acute or chronic illness or injures that pose a threat
to life or bodily functions e.g., multiple trauma,
acute MI, pulmonary embolus, severe respiratory
distress, ARF, progressive severe rheumatoid arthritis
An abrupt change in neurological status
Cardiovascular imaging studies with contrast
with identified risk factors
Cardiac electrophysiological tests
Diagnostic endoscopies with identified risk
factors
Discography
Elective major surgery with identified risks
factors
Decision to perform major emergency surgery
Drug therapy requiring intensive monitoring
for toxicity
Decision not to resuscitate or to de-escalate
care because of poor prognosis
43
E/M Helpful Guidance in MDM
Documentation
• Diagnostic and Management Options
– Established diagnoses should indicate: Stable, well-controlled, worsening,
failing to improve
• Amount and/or Complexity of Data
– Independent review of diagnostic test should document: visualization of
image, tracing or specimen
– Review of old records, document findings or lack of findings.
• Risk of Complication
– Document co-morbidities, underlying diseases that increase risk of
presenting illness (those that do not significantly increase complexity of
MDM should not be considered)
44
Level of Medical Decision-Making
Four levels:
–
Straightforward
Selection of MDM Level:
–
Low complexity
1. Two of the three variables or
–
Moderate complexity
2. Column with center circle
–
High complexity
Dx/mgt options
0-1pt
2pts
3pts
4pts
Amount of data
0-1pt
2pts
3pts
4pts
Minimal
Low
Moderate
High
Strghtfwd
Low
Moderate
High
Overall risk
Level of MDM
45
Selecting Level of MDM
• Example: Evaluation of
MDM
• A/P: By history, suspect
possible herniated disk.
Patient will be referred for
MRI scan. Prescribe Motrin
800 mg. TID with food and
begin Predosine dose pack to
decrease inflammation.
• Number of dx/tx options –
new problem with add’l
workup – 4 points
• Amt/complexity of data –
ordered MRI – 1 point
• Risk – prescriptions
management - Moderate
Level of MDM: Moderate (see next slide)
46
Levels of Medical Decision Making
Diagnoses/
Management
Options
Amount and/or
Complexity of Data
to be Reviewed
Risk of Complications,
Morbidity, and/or
Mortality
Level of Medical
Decision Making
Minimal (0-1 pt)
Minimal (0-1 pt)
Minimal
Straightforward
Limited (2 pts)
Limited (2 pts)
Low
Low Complexity
Multiple (3 pts)
Moderate (3 pts)
Moderate
Moderate
Complexity
Extensive (4 pts)
Extensive (4 pts)
High
High Complexity
47
Selection of E/M Level – Example of
New Office/Outpatient Visit
•
History section
- Detailed (>4 HPI elements)
•
Physical Examination
- Detailed (2-7 extended exam)
•
Medical Decision Making
- Moderate
Documentation supports a 99203 level of E & M service code.
48
Selection of E/M Level – Example of
Established Office Outpatient Visit
•
History section
- Detailed (>4 HPI elements)
•
Physical Examination
- Expanded Problem Focused
(2-7 limited exam)
•
Medical Decision Making
- Moderate
Documentation supports a 99214 level of E & M service code.
49
E/M Documentation Requirements
Critical E/M Documentation Requirements:
• Does documentation justify the medical necessity of the service and/or
procedure performed?
• Does the documentation support the level of service reported?
50
Other Significant E/M Components
Counseling and Coordination of Care:
• An exception to the 3 key component rule exists when the visit consist
predominantly of counseling or coordination of care (such as when
50% or more of visit is spent face to face with patient for counseling
and coordination of care.)
• Time is a key or controlling factor.
51
Counseling and Coordination of Care
Counseling as it relates to E/M coding is defined as a discussion with a
patient and/or family concerning one or more of the following areas:
• Diagnostic results, impressions, and/or recommended diagnostic
studies
• Prognosis
• Risk and benefits of management (treatment) options
• Instructions for management (treatment) and/or follow-up
• Importance of compliance with chosen management (treatment)
options
• Risk factor reductions
• Patient and family education.
52
Documenting Time-based Coding
When to Use Time:
• If time spent counseling and/or coordinating care face-to-face is more
than 50% of encounter
Face-to-face is defined:
• Outpatient—patient must be in the same office/room with the
billing provider. Time spent by the resident cannot support time
based billing.
• Inpatient—patient must be on the same unit or floor with the billing
provider.
53
Documenting Time-based Coding
Documentation Requirements: (All 3 Necessary)
• Amount of time counseling
• Total time spent on encounter/visit
• What was discussed or coordination activities
54
E/M Assessment – Question 6
Time is considered the key or controlling factor in determining a
level of service if counseling and/or coordination of care dominates
the total face-to-face encounter with the patient. The physician must
document:
a) Total encounter time with the patient and the time spent
counseling.
b) What was discussed.
c) The time spent counseling only.
d) A & B
e) B & C
55
E/M Assessment - Answer
• The answer is (d) A & B.
The total length of time for the visit and total length of time counseling
and coordinating care as well as the nature of the counseling and
coordination of care must be documented in the medical record.
56
Critical Care Services (CCS)
Critical Care Services – Time Based
• Direct delivery by a physician of medical care for a critically ill/injured
patient.
Critical Illness/Injury
• Impairs one or more vital organ system
• High probability of imminent or life threatening deterioration of
condition
57
Critical Care Services (CCS) (continuation)
Duration of CCS to be reported:
• Time physician spend evaluating, providing care and managing
patient
• Time must be immediately at bedside or on floor/unit so long as
physician immediately available
• Must be medically necessary and reasonable
• Usually provided in critical care units or emergency departments
• Example: Time spent reviewing lab results or discussing ill patient’s
care with other physicians may be reported as CCS even if not at
bedside – if physician’s full attention to management of the critical
patient.
58
Critical Care Services (CCS) (continuation)
For CCS Physician Must Document:
•
•
•
•
Total time spend providing CCS
CCS provided
For each date and encounter entry
Time spent performing procedures not bundled into CCS may not be
counted toward CC time
• Non-continuous time for CCS may be aggregated
• More than one physician can provide CCS – but physicians of same
specialty in same group practice are paid though a single physician.
59
Critical Care Services (CCS) (continuation)
Coding CCS:
• CPT Codes 99291 - 99292 to report total duration of time
• CPT Code 99291- for first 30-74 minutes of CCS on a given calendar
date – may use only once per calendar day.
• CPT Code 99292- additional blocks of time - up to 30 minutes each
beyond the first 74 minutes of CCS.
• Reporting CPT Code 99291 prerequisite to CPT Code 99292
• If less than 30 minutes do not report separately using CCS Codes –
report as appropriate E/M code.
• Only one physician can bill for a particular period of time.
60
E/M Code Assignment Considerations
• Code assignment in the CPT E/M Section vary according to three
factors:
– Place of Service (e.g., office, hospital, ER, nursing home)
– Type of Service (e.g., consultation, admission, office visit)
– Patient status (e.g., new patient, established patient, inpatient,
outpatient)*
* See Slide 65 for new ad established patient.
61
E/M Code Assignment Considerations
(continuation)
• Each E/M category codes includes three to five levels of service.*
• The levels indicate the wide variations in skill, time, effort,
responsibility and knowledge required to diagnose, treat or prevent an
illness or injury.
* See Appendix III for codes.
62
General Coding Considerations
• Not medically necessary or appropriate to bill a higher level of E/M
service when a lower level of service is warranted.
• The volume of documentation should not be the primary influence
upon which a specific level of service is billed.
• Selection of code for the service should be based upon the content of
the service.
• CMS states: Medical necessity is the overarching criterion for
payment in addition to the individual requirements of a CPT code.
63
Coding Considerations
• The CPT code or service is the driving force behind reimbursement.
• The ultimate responsibility for correct coding lies with the provider of
services.
64
Code Assignment Considerations
• New patient
– Has not received any professional E/M services from the physician
or another physician of the same specialty who belongs to the same
group practice within three years.
• Established patient
- Has received E/M services from the group within three years.
65
Key Components of E/M
• The First Time Encounter
– For New Patients, Hospital Admits, & Consultations
• All three components required
– History
– Exam
– Medical Decision-Making
• Follow-up Encounter
– Established Visit and Subsequent Hospital Visit
• Two out of three components required
– History and/or
– Exam and/or
– Medical Decision-Making
66
Code Assignment Assessment- Question 7
• True or False:
A patient was seen by Dr. Smith of UCLA Rheumatology two years
ago and returns to see a different UCLA Rheumatologist (same practice
group), the patient is considered new.
67
Code Assignment Assessment-Answer
• The answer is false.
The patient was seen two year ago and now a follow-up visit with a
new physician from the same group practice is considered an
established patient. Follow-up encounter codes should be used.
68
ICD-9CM Coding Diagnosis
• The system of diagnosis codes used is the International Classification
of Diseases, 9th revision, Clinical Modification (ICD-9CM) and
composed of codes with three, four or five digits.
• The primary diagnosis must support or justify the physician’s services.
The ICD-9 diagnosis code must support the CPT code in order to be
reimbursed.
• Inpatient-consultant’s primary diagnosis would be the reason for the
consult and not necessary the admitting diagnosis.
69
ICD-9CM Coding Diagnosis (continuation)
The highest level of specificity should be given when establishing a
diagnosis. Hypertension has sub-classifications, malignant and
benign. Sites of injuries, infections, and burns should also be provided.
Therefore, try to avoid unspecified diagnoses and codes.
Example:
malignant hypertension – ICD-9 diagnosis code – 401.0
benign hypertension – ICD-9 diagnosis code – 401.1
hypertension, unspecified – ICD-9 diagnosis code – 401.9
70
ICD-9CM Coding Diagnosis (continuation)
• The highest level of certainty should be given when establishing a
diagnosis. “Suspected” or “Rule Out” diagnoses cannot be coded. If
the physician is working only with phenomena and has not yet formed a
diagnosis, then the sign, symptom, or laboratory abnormality should be
selected.
• Document all conditions that co-exist at the time of the visit that
require or affect patient care, treatment or management. Conditions
that were previously treated and no longer exist should not be coded.
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Coding Assessment – Question 8
• True or False:
The CPT and ICD-9CM codes reported on the health insurance claim
form or billing statement should be supported by the documentation in
the medical record.
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Coding Assessment - Answer
• The answer is false.
The ultimate responsibility for correct coding lies with the provider of
services. All diagnosis and procedure codes MUST be supported by
clear documentation report and/or note.
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Modifier 25
• Append a Modifier 25 to an E/M code if a significant, separately
identifiable E/M service is performed by the same physician on the
same day of a procedure or other service.
• The patient’s condition must require E/M services above and beyond
what would normally be performed in the provision of the procedure.
• The necessity for the E/M service may be prompted by the same
diagnosis as the procedure.
• Example: A preventative service (routine annual exam) with an E/M
code (treatment for hypertension)
• Example: Patient visit for follow-up hypertension where provider also
performs abscess drainage.
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Modifier 25
• A new patient E/M service is considered separate from the same day
surgery or procedure – no Modifier 25 needed.
• For an established patient, if the E/M 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 E/M service beyond what
is considered normal protocol for the procedure, Modifier 25 is
appropriate.
• To determine the correct level of E/M service to submit, identify
services unrelated to the procedure and use as E/M elements.
• Clearly mark the encounter form to indicate that a Modifier 25 should
be attached to the E/M.
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Modifier 25 (continuation)
• Example of a valid submission of Modifier 25
The patient came in to the office for her scheduled 2nd therapeutic
knee injection. On the same day, she presented with neck pain that
has been bothering her sleep for the past 3 days. The physician then
added a separate E/M service.
Codes:
99213 – 25 (established patient office visit)
20610 (therapeutic knee injection)
In this example, Modifier 25 should be billed with the E/M service.
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Coding Assessment – Question 9
Which of the following correctly classifies a case in which a patient has
both a level 2 E/M service (99212) and an indirect laryngoscopy
(31505) performed in an outpatient clinic?
a. 31505-25 and 99212-25
b. 31505 and 99212-25
c. 31505-25 and 99212
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Coding Assessment - Answer
The answer is b (31505 and 99212-25).
Modifier 25 is appended to an E/M code (99212) if a significant
separately identifiable E/M service is performed by the same physician
on the same day of a procedure or other service (31505).
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References
• Centers for Medicare & Medicaid Services (CMS) – Documentation
Guidelines for E & M Services
www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp
• Centers for Medicare & Medicaid Services - Medicare Claims
Processing Manual, Publication 100-4, Chapter 12, Sections 30.6.1
Selection of Level of Evaluation and Management Service and 30.6.12
Critical Care Services
www.cms.hhs.gov/manuals/downloads/clm104c12.pdf
• Current Procedural Terminology (CPT) 2009 – Professional
Edition.
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Appendixes
• Appendix I –Elements of General Multi-System Exam
• Appendix II – Single Organ System Examination
• Appendix III - Codes
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