Session 2:
Evaluation and Management (E/M)
Coding for Mental Health
Alison C. Lynch MD
Robert E. Smith MD
November 30, 2012
Outline of this session
• Length of time = 90 minutes
• Break down E/M coding into components
• Go over criteria for assessment and
documentation of these components
• Practice using charts (hand outs) to determine
what elements need to be obtained and
documented
Evaluation and management codes—
Overview
• Medical providers use Evaluation and
Management (E/M) codes when billing general
office or facility-based visits.
• These codes have replaced 90862 and can be
used when an E/M service is done in addition to
psychotherapy.
• The Centers for Medicare and Medicaid Services
have established guidelines for selecting the
appropriate E/M code.
• Codes are divided by new and established
patients, site of service, and level of complexity
or amount of work required.
• The amount of work required is driven by the
nature of the presenting problem.
• If counseling and coordination of care accounts
for 50% or more of the patient encounter, you
can select the E/M code on the basis of time
EXCEPT when done in conjunction with a
psychotherapy visit. (More on this later….)
Overview
• Billing for an E/M service requires the
selection of a Current Procedural Terminology
(CPT) code that best represents:
– Patient type
– Setting of service
– Level of E/M service performed
– Medical necessity
E/M coding should
• Reflect the work that was done
• Be supported by the documentation
– Content, not volume
• Reflect care that is reasonable and necessary,
that is compliant with the standards of good
medical practice
• Medical necessity is the over-arching
determinant of what code is used
Who can use E/M codes?
•
•
•
•
•
Physicians
Nurse practitioners*
Clinical nurse specialists
Certified nurse midwives
Physician assistants
*NP’s Medicare benefit must permit billing of E/M services, and services must
be furnished within the scope of practice in the state in which the NP
practices in order to receive payment from Medicare.
What are the codes?
•
•
•
•
•
99201
99202
99203
99204
99205
•
•
•
•
•
•
99211
99212
99213
99214
99215
et. al.
• So how do you know what code to use???
Patient type
The first question to ask yourself
about a visit is whether the patient
is new ….
New vs. Established Patient
• New: A patient who has not received any professional
services from the physician or another physician/nonphysician practitioner of the same specialty who belongs
to the same group practice, within the past three years.
• Established: A patient who has been seen within the
past three years.
New: > 3 years
• Multisite practices are considered a single group practice for
coding
New vs. Established
Why does it matter?
• For new patients, must document all three key
coding components (history, exam and
medical decision-making)
– For established patients, 2 of the 3 components
will do
• Earn more RVUs for new patients, at all levels
of coding
– Get credit (and reimbursed) for the work you are
doing
What about consultations?
• Same codes apply to new and established
patients for consultations
• So no distinction is necessary
Determine Setting
•
•
•
•
Office or other outpatient setting
Hospital inpatient
Emergency department
Nursing facility
Determine level of care
• This is the most complicated component….
• In general, the more complex the visit, the
higher level of code used, (and the higher
reimbursement rate)
Level of care—3 components
• History
• Examination
• Medical decision making
• Exception• Time is the key factor in determining level of care
if the visit consists predominantly (>50%) of
counseling or coordination of care
(More about this later…)
History types (4)
•
•
•
•
Problem focused
Expanded problem focused
Detailed
Comprehensive
History Components
•
•
•
•
Chief complaint
History of Present Illness
Review of Systems
Past, Family, and/or Social History
Criteria for history type
History components—CC
• Chief Complaint
– Required for all levels of E/M services
– A concise statement that describes the symptom,
problem, conditions, diagnosis, or reason for the
patient encounter.
– Frequently stated in the patient’s own words.
History Components—HPI
• History of Present Illness elements
–
–
–
–
–
–
–
Location (e.g. low mood)
Quality (e.g. hopeless, emptiness)
Severity (e.g. 7 on a scale of 1 to 10)
Duration (e.g. for the past 2 weeks)
Timing (e.g. constant, especially at night)
Context (e.g. when alone)
Modifying factors (e.g. felt better after going to
church)
– Associated signs and symptoms (e.g. crying, insomnia)
HPI—2 types
• Brief HPI
– Includes 1-3 elements
– Example:
• CC: anxiety
• Brief HPI: Avoiding leaving home for past week
• Extended HPI
– 4+ elements, related to present HPI or associated
comorbidities, or status of at least 3 chronic or
inactive conditions
– Example:
• CC: anxiety
• Extended HPI: Patient has been avoiding leaving home
for past week. This is the 1 year anniversary of her
daughter’s accident. She is having some flashbacks
about it, the worst she’s ever had. She’s sleeping about
4 hours/night. She has missed 3 days of work.
History Components—ROS
ROS Elements
•
•
•
•
•
•
•
Constitutional
Eyes
Ears, Nose, Mouth, Throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
• Musculoskeletal
• Integumentary (skin +/breast
• Neurological
• Psychiatric
• Endocrine
• Hematologic/Lymphatic
• Allergic/Immunologic
ROS
•
•
•
•
•
•
•
Constitutional (e.g. fatigue)
Eyes (e.g. blurry vision)
Ears, Nose, Mouth, Throat (e.g. dry mouth)
Cardiovascular (e.g. palpitations)
Respiratory (e.g. cough)
Gastrointestinal (e.g. constipation)
Genitourinary (e.g. decreased libido)
ROS
•
•
•
•
•
•
•
Musculoskeletal (e.g. tremor)
Integumentary (skin +/- breast) (e.g. itching)
Neurological (e.g. weakness)
Psychiatric
Endocrine (e.g. polydipsia)
Hematologic/Lymphatic (e.g. bruising)
Allergic/Immunologic (e.g. hives, NKDA)
ROS—3 types
• Problem pertinent ROS
– Inquires about the system directly related to CC
• Extended ROS
– Inquires about the system directly related to CC, plus
2-9 additional systems
• Complete ROS
– Inquires about the system directly related to CC, plus
10+ additional systems
– All positives and pertinent negatives must be
individually documented. Notation that all remaining
systems are negative is permissible.
Past, Family, and/or Social History
• PMH, PPH, illnesses, operations, injuries,
treatments, medications, allergy
• FH: medical events, diseases, hereditary
conditions that may place patient at risk
• SH: age appropriate review of past and
current activities
PFSH—2 types
• Pertinent PFSH:
– At least one item from any of the three areas is
documented.
• Complete PFSH:
– At least one specific item from 2 of the 3 history
areas are documented (established pt).
– At least one specific item from all 3 of the 3
history areas are documented (new pt).
Other notes on the history
• ROS and/or PFSH obtained during earlier
encounter does not need to be re-recorded if
clinician reviews and updates previous info.
• ROS and/or PFSH may be recorded by ancillary
staff or on a form completed by the patient.
Clinician must note review and confirmation of
info recorded by others.
• If clinician unable to get history from pt or other
source, record should describe the patient’s
condition which precludes obtaining a history.
Examination—4 types
•
•
•
•
Problem focused
Expanded problem focused
Detailed
Comprehensive
• The type and extent of the examination is
based upon clinical judgment, patient’s
history, and nature of presenting problem(s).
Psychiatry-specific exam
• Can be used for examination of patient with a
mental health presenting problem, in place of
a general multi-system examination
Exam types
• Problem focused exam
– Perform and document exam of 1-5 elements
• Expanded problem focused exam
– Perform and document exam of 6-8 elements
• Detailed exam
– Perform and document exam of 9-13 elements
• Comprehensive exam
– Perform and document exam of 14-15 elements
Exam elements
Constitutional
Musculoskeletal
• 3 of 7 vital signs
• Muscle strength, tone,
atrophy, abnormal
movements
• Examination of gait and
station
–
–
–
–
–
–
–
Sitting/standing BP
Supine BP
Pulse rate, regularity
Respiration
Temperature
Height
Weight
• General appearance
Exam elements—Mental Status
•
•
•
•
Speech
Thought processes
Associations
Abnormal or psychotic
thoughts
• Judgment and insight
• Orientation to time,
place, person
• Recent and remote
memory
• Attention span,
concentration
• Language
• Fund of knowledge
• Mood and affect
MS Exam Details
• Thought processes: rate of thoughts, content
of thoughts, abstract reasoning, computation
• Associations: loose, tangential, circumstantial,
intact
• Abnormal or psychotic thoughts:
hallucinations, delusions, homicidal or suicidal
ideation, obsessions, preoccupation with
violence
MS Exam Details
• Speech: rate, volume, articulation, coherence,
spontaneity, perseveration, paucity of
language
• Language: naming objects, repeating phrases
Other notes on the examination
• Specific abnormal and relevant negative findings
of the examination of the affected or
symptomatic area/system should be
documented.
• Abnormal or unexpected findings of the
examination of any asymptomatic area/system
should be described.
• A brief statement indicating “negative” or
“normal” is sufficient to document normal
findings related to unaffected area/system.
Medical Decision Making
• Refers to the complexity of establishing a
diagnosis and/or selecting a management option
• Determined by
– Number of possible diagnoses
– Number of management options
– Amount/complexity of medical records, diagnostic
tests, other info that must be obtained, reviewed,
analyzed
– Risk of significant complications, morbidity, mortality,
and comorbidities, associated with CC, diagnostic
procedures, and possible management options
MDM—4 types
•
•
•
•
Straightforward
Low complexity
Moderate complexity
High complexity
Number of diagnoses or
management options
• Minimal
– 1 established diagnosis
– Problem(s) improved
– 1 or 2 management options
• Limited
– 1 established diagnosis and 1 rule-out or
differential
– Stable or resolving problem(s)
– 2 or 3 management options
Number of diagnoses or
management options
• Multiple
– 2 rule-out or differential diagnoses
– Unstable or failing to change problem(s)
– 3 changes in treatment plan
• Extensive
– More than 2 rule-out or differential diagnoses
– Worsening or marked change in problem(s)
– 4 or more changes in treatment plan
Amount and/or complexity of
data to be reviewed
• None or minimal
– 1 source of medical data
– 2 diagnostic tests
– Confirmatory review of results
• Limited
– 2 sources of medical data
– 3 diagnostic tests
– Confirmation of results with another physician
Amount and/or complexity of
data to be reviewed
• Moderate
– 3 sources of medical data
– 4 diagnostic tests
– Results discussed with physician performing tests
• Extensive
– 4+ sources of medical data
– >4 diagnostic tests
– Unexpected results, contradictory reviews,
requires additional reviews
Risks of significant complications,
morbidity, or mortality
• Minimal
– One self-limited problem (e.g. medication side
effect)
– Diagnostic testing: laboratory tests requiring
venipuncture, urinalysis
– Management: reassurance
Risks of significant complications,
morbidity, or mortality
• Low
– 2 or more self-limited or minor problems, or 1
stable, chronic illness (e.g. well-controlled
depression), or acute uncomplicated illness (e.g.
exacerbation of anxiety disorder)
– Diagnostic testing: psychological testing, skull film
– Management: psychotherapy, environmental
intervention (e.g. agency, school/vocational
placement), referral for consultation
Risks of significant complications,
morbidity, or mortality
• Moderate
– 1 or more chronic illness with mild exacerbation,
progression, or side effects of treatment; or 2 or
more stable chronic illnesses; or undiagnosed new
problem with uncertain prognosis (e.g. psychosis)
– Diagnostic testing: EEG, neuropsychological
testing
– Management: Prescription drug management,
open door seclusion, ECT (no co-morbid medical
conditions)
Risks of significant complications,
morbidity, or mortality
• High
– 1 or more chronic illnesses with severe exacerbation,
progression, or side effect of treatment (e.g.
schizophrenia) or acute illness with threat to life (e.g.
suicidal or homicidal ideation)
– Diagnostic testing: lumbar puncture, suicide risk
assessment
– Management: drug therapy requiring intensive
monitoring (e.g. benzo taper for pt in withdrawal),
closed-door seclusion, suicide observation, ECT (with
co-morbid medical condition), rapid IM neuroleptic
administration, pharmacological restraint
Other notes on MDM
• Clinically, there is a close relationship between
the nature of the presenting problem and the
complexity of medical decision making
– Patient comes in for a prescription refill:
straightforward decision making
– Patient comes in with suicidal ideation: decision
making of high complexity
Medical Decision Making
Putting It All Together
Need Two of Three to Qualify for Level
Overall MDM
Problem Points
Data Points
Level of Risk
Straightforward Complexity
(992x2)
1
1
Minimal
Low Complexity
(992x3)
2
2
Low
Moderate Complexity
(992x4)
3
3
Moderate
High Complexity
(992x5)
4
4
High
Medical Decision Making:
Diagnosis/Management Options
Problem Points
Problem
Points
Self limited or minor (maximum of 2)
1 each
Established problem, stable or improving
1 each
Established problem, worsening
2 each
New problem, no additional work up planned (maximum of 1)
3
New problem, with additional work up planned
4
Examples of Straightforward Medical
Decision-Making
• Weekly weight check on patient with anorexia
• Prescription refill with no examination
• Routine (e.g. weekly) CBC with diff for patient
taking clozapine
• Advice to patient
Examples of Low Complexity Medical
Decision-Making
• Major depression, mild (PHQ=10), with
recommendation for psychotherapy
• Dry mouth as a side effect to treatment with
nortriptyline, patient agrees to monitor symptoms
(no med adjustment) and will try to drink more
water and chew sugarless gum
• Stable anxiety without complications or
comorbidities, continue CBT
• OTC sleep aid (e.g. melatonin) for insomnia
Examples of Moderate Complexity Medical
Decision-Making
• Patient with worsening depression.
• Patient with bipolar disorder, developed mild rash
with lamotrigine, which has been stopped. The
rash is resolved. Pt. needs an alternative mood
stabilizer.
• Patient with alcohol dependence in partial
remission who would like to try naltrexone.
Examples of High Complexity Medical
Decision-Making
• Patient with suicidal ideation, new or
worsening.
• Patient with first psychotic break.
• A patient with anorexia nervosa who is now
below 85% ideal body weight.
Ways to Document Complexity
•
•
•
•
•
•
•
Barriers obtaining history, additional sources
Old records reviewed
Labs/EKG reviewed or ordered
Treatments or medications ordered
Differential diagnoses
Co-morbidities or underlying diseases
Patient instructions given
• (This is not interactive complexity code, 90785.)
Putting it all together
What are the codes?
• 9920x (1-5), new patient, outpatient visit
• 9921x (1-5), established patient, outpatient
visit
Office or other outpatient services:
new patient
• 99201 (all 3 required)
– Problem-focused history (1-3 HPI elements)
– Problem-focused exam (1-5 elements)
– Straightforward medical decision making
– CC: self-limited or minor
– Typical time: 10 minutes face-to-face with patient
and/or family
Office or other outpatient services:
new patient
• 99202 (all 3 required)
– Expanded problem-focused history (1-3 HPI, 1
ROS)
– Expanded problem-focused exam (6-8)
– Straightforward medical decision making
– CC: low to moderate severity
– Typical time: 20 minutes face-to-face with patient
and/or family
Office or other outpatient services:
new patient
• 99203 (all 3 required)
– Detailed history (4+ HPI, 1 PFSH, 2-9 ROS)
– Detailed exam (9-13)
– Medical decision making of low complexity
– CC: moderate severity
– Typical time: 30 minutes face-to-face with patient
and/or family
Office or other outpatient services:
new patient
• 99204 (all 3 required)
– Comprehensive history (4+ HPI, 3 PFSH, 10+ ROS)
– Comprehensive exam (14-15)
– Medical decision making of moderate complexity
– CC: moderate to high severity
– Typical time: 45 minutes face-to-face with patient
and/or family
Office or other outpatient services:
new patient
• 99205 (all 3 required)
– Comprehensive history (4+ HPI, 3 PFSH, 10+ ROS)
– Comprehensive exam (14-15)
– Medical decision making of high complexity
– CC: moderate to high severity
– Typical time: 60 minutes face-to-face with patient
and/or family
Office or other outpatient services:
established patient
• 99211—this code is used for a service that
may not require the presence of a
physician/prescriber. Presenting problems are
minimal, and 5 minutes is the typical time that
would be spent performing or supervising
these services.
Office or other outpatient services:
established patient
• 99212 (2 of 3 required)
– Problem-focused history (1-3 HPI)
– Problem-focused exam (1-5 elements)
– Straightforward medical decision making
– CC: self-limited or minor
– Typical time: 10 minutes face-to-face with patient
and/or family
Office or other outpatient services:
established patient
• 99213 (2 of 3 required)
– Expanded problem-focused history (1-3 HPI, 1
ROS)
– Expanded problem-focused exam (6-8)
– Medical decision making of low complexity
– CC: low to moderate severity
– Typical time: 15 minutes face-to-face with patient
and/or family
Office or other outpatient services:
established patient
• 99214 (2 of 3 required)
– Detailed history (4+ HPI, 1 PFSH, 2-9 ROS)
– Detailed exam (9-13)
– Medical decision making of moderate complexity
– CC: moderate to high severity
– Typical time: 25 minutes face-to-face with patient
and/or family
Office or other outpatient services:
established patient
• 99215 (2 of 3 required)
– Comprehensive history (4+ HPI, 2 PFSH, 10+ ROS)
– Comprehensive exam (14-15)
– Medical decision making of high complexity
– CC: moderate to high severity
– Typical time: 40 minutes face-to-face with patient
and/or family
Documentation Requirements for
Established Patient Visits
99211
99212
99213
99214
99215
CC
N/A
Required
Required
Required
Required
HPI
N/A
1-3
1-3
4+
4+
ROS
N/A
N/A
Pertinent
2-9
10+
PMSF
N/A
N/A
N/A
1
2
Exam
N/A
1-5
6-8
9-13
14-15
Medical
DecisionMaking
N/A
Straightforward
Low
Moderate
High
Time
5 min
10 min 15 min 25 min 40 min
Documentation Requirements for
New Patient Visits
99201
99202
99203
99204
99205
CC
Required
Required
Required
Required
Required
HPI
1-3
1-3
4+
4+
4+
ROS
N/A
Pertinent
2-9
10+
10+
PMSF
N/A
N/A
1
3
3
Exam
1-5
6-8
9-13
14-15
14-15
Medical
DecisionMaking
Straightforward
Straightforward
Low
Moderate
High
Time
10 min 20 min 30 min 45 min 60 min
Notes about “typical time”
• The specific times expressed in the visit code
descriptors are averages, and therefore
represent a range of times which may be
higher or lower depending on actual clinical
circumstances.
• Face-to-face for office and outpatient
• Unit/floor for hospital and inpatient
• Time is not a criteria for level of service.
Examples of different levels
99211 (5 min)
•
•
•
•
•
BP check by nurse
Weight check for metabolic syndrome
Lab draw
Picking up prescription refill
Picking up return to work or school
certificate. (If mail or call in, no CPT code
allowed)
• May not require physician presence
99212 (10 min)
• One self limited problem
• 1-3 HPI elements
– (no ROS)
• Focused exam (1-5 elements)
• Example: 1 month follow up after stopping a
medication, to confirm patient is still doing
well
99213 (15 min)
Decision Making (low)
• 2 or more self limited
problems
• one stable chronic illness
• acute uncomplicated illness
(social anxiety)
History
• 1-3 HPI elements
• Pertinent ROS
Physical
• 6+ elements
99214 (25 min)
Decision Making (moderate)
• 1+ chronic illness with mild
exacerbation
• 2+ or more stable chronic
illnesses
• Undiagnosed new problem
with uncertain diagnosis
• Acute illness with systemic
symptoms
• Acute complicated injury
History
• 4 HPI elements
• 2-9 ROS
• 1 of 3 PFSH
Physical
• Detailed (affected
area and related
organ system)
Time vs. Complexity
• The PTSD exacerbation that requires two
hours of office time
• The patient who takes 30 minutes just to
review problems, adjust medications, counsel
and coordinate care – but doesn’t require an
exam or complex medical decision-making
Billing for time
• Sometimes you can use the length of time
spent face-to-face with a patient instead of
using history, exam, and MDM criteria in E/M
coding.
Coding Based On Time
• When you’ve spent the time, but the points just
don’t add up
• If clinician spends more than 50% of face-to-face visit
counseling or coordinating patient’s care, can code
based on time spent – even if hx, exam or medical
decision-making elements lacking
• Documentation may refer to prognosis, diff dx, risks,
benefits of tx, instructions, compliance, risk
reduction, or discussion with another health
provider.
How to do it
• Documentation must state total time spent face-toface or coordinating care, what the content of that
counseling or coordination was, and that more than
50% of the total time was spent in counseling or care
coordination.
– “20 minutes of 25 minutes face-to-face time spent
counseling/coordinating care re: importance of medication
compliance with mood stabilizer for bipolar disorder”
– “45 minutes spent meeting with pt and Case Manager
discussing plan of care for complex patient with depression
and fibromyalgia”
Time vs. Code
Typical time
New patient codes
5 min
10 min
99211
99201
15 min
20 min
99212
99213
99202
25 min
30 min
Established patient codes
99214
99203
40 min
99215
45 min
99204
60 min
99205
Physician Work RVU’s (2013)
New Patients
99201 - 99205
Established Patients
99211 - 99215
Level I
0.48
0.18
Level II
0.93
0.48
Level III
1.42
0.97
Level IV
2.43
1.5
Level V
3.17
2.11
Suggestions for clinicians
• Assess appropriate level of care in first 5
minutes of encounter
– Helps to organize the gathering of information
• Organize documentation to identify the
elements that support the E/M code level
– CC, HPI, ROS, P/F/S Hx
– Exam
– Medical Decision Making/Plan
Categorical Note Outline
• Chief Complaint
• History of Present Illness
• Past Medical, Psychiatric, Family & Social
History
• Review of Systems
• Examination
• Diagnosis
• Formulation/Plan of Care
Review: 99213
•
•
•
•
2+ or more self-limited or minor problems
1 stable chronic illness
Acute uncomplicated illness
Typically 15 minutes face-to-face with
pt/family
Review: 99214
• 1+ chronic illness with exacerbation
• 2+ or more stable chronic illnesses
• Undiagnosed new problem with uncertain
diagnosis
• Acute illness with systemic symptoms
• Acute complicated injury
• Typically 25 minutes face-to-face with
pt/family
What is often missing?
• Most frequent deficiencies identified in audits
of mental health records
① Failure to provide and record the required
number of elements in the ROS for the level of
history designated
② Failure to provide and record the required
number of constitutional elements (including
vital signs)
Don’t Forget…
• Submit question cards
• We will answer some after lunch
• Others will be answered via online support
through IPS after the course.
Thank you!
References
• Evaluation and Management Services Guide,
US Department of Health and Human
Services, December 2010.
• Procedure Coding—Handbook for
Psychiatrists, 4th Ed., C. W. Schmidt et al., APA
Publishing, 2011.
• American Academy of Child and Adolescent
Psychiatry (AACAP) website resources
www.aacap.org (useful!!)