Basic CPT
Evaluation & Management (E/M)
Coding
ED Coding
February 20, 2008 1– 3 pm MST
Irene Mueller, EdD, RHIA
Montana Hospital
Association
MT-NC Tele-Video
Spring 2008
Objectives
Assign correct CPT codes by applying
knowledge of
• Basic CPT E&M coding conventions, and
• Basic CPT coding process for ED
2/06/08 Schedule
• 1pm – 1:05
– Overview of session
• 1:05 – 1:50 pm
– CPT E/M Coding
• 1:50 – 2 pm Break
• 2:00 - 2:45
– CPT Coding for ED
• 2:45- 3:00 pm
– Questions
Identifiable procedures and E/M
• Any procedure id with specific CPT code
performed on/subsequent to the date of
initial/subsequent E/M services SHOULD
BE reported separately
– Performing/interpreting dx test/studies
– -26 for professional component only
– E/M related to procedures is part of their codes
– -25 indicates that E/M services were above and
beyond those associated w/procedure (do not
need different dx code)
Most E/M Codes reflect
Cognitive Services
• Provider must
– Acquire information from patient, exam, tests, etc.
– Use reasoning skills to process information
– Interact with pt to provide feedback
– Respond by creating a plan
• Do NOT include significant procedures
• Do include cleaning traumatic lesions, adhesive strip
closures, applying dressings, counseling/education
E/M “work”
• Work not easy to measure, so other measures
used to establish work
• Intraservice times
– F2F = office, other outpt visits
• With patient/family
• Valid indication of total work done before, during,
after visit
– Unit/Floor = hospital, other inpt visits
• On floor and at bedside
• Valid indication of total work done before, during,
after visit
Medicine and E/M Sections
• Medicine section has some codes that describe
procedures and specialty services that include
E/M
– Allergy testing, immunotherapy, osteopathic
manipulation, PT services, neuro/vascular
testing
– General/special ophthalmologic
– General/special dx and tx psychiatric
• When Medicine procedural specialty codes are
assigned, do NOT also assign an E/M code
• IF significant, sep. id E/M service provided, assign
E/M code with -25 modifier
E/M Section
• Appears at beginning of code book
• 99201-99499
• Items are used by most physicians in
reporting a significant portion of their
services.
• E/M codes are specific to a SETTING
(Place of Service (POS)
E/M Section
• Categories (by setting, etc.)
– Subcategories
– Ex: Office visits subcategories of new pt, est. pt
– Ex: Hospital visits – initial and subsequent
–Levels of E/M services
–3-5 levels (last digit)
• Physician’s work varies by
– Type of service (TOS)
– Place of service (POS)
– Patient’s status
– Misc. services (eg prolonged, care plan
oversight)
New vs. Established Patient
• Distinguished by Professional Services
– F2F services rendered by a physician and
reported via CPT codes
• New – one who has NOT received any
professional services from the Dr (or
another Dr of the SAME specialty who is in
the SAME group practice), within the past
3 years
New vs. Established Patient
• Established – one who has received
professional services from the Dr or
another Dr of the SAME specialty who
belongs to the SAME group practice,
within the past 3 years.
• On call/Covering physician – encounter is
classified as if it would have been
performed by the physician who is NOT
available.
• *Decision Tree in E/M Guidelines
Concurrent Care
• USUALLY, one E/M code reported for one
day for one patient by one provider
• Provision of similar services to the same pt
on the same day by more than one provider
is CONCURRENT CARE
• Be sure to assign different dx codes to avoid
claim denial
Concurrent Care
• EX: Pt adm for AMI on 2/15. On 2/17,
cardiologist requested consult for anxiety and
depression.
• Cardiologist’s coder assigns AMI dx code(s)
• Psychiatrist’s coder assigns Anxiety/depression
dx
• IF both bill for AMI, 1st claim is paid, 2nd claim
denied
Unlisted E/M services
• Only 2
• 99429
• 99499
• Requires special report to demonstrate the
medical appropriateness of service
Special Report
• Complexity of symptoms
• Description of nature, extent, need for
service
• Dx and Tx procedures
• Follow-up care
• Pt’s final dx and concurrent problems
• Pertinent physical findings
• Time, effort, equipment required
Clinical Examples
• Appendix C
– Examples, not descriptors
Levels of E/M Services
• 3-5 levels within each category/subcategory
• Levels NOT interchangeable between categories
• Include
– Exams, Evaluations, Tx, conferences
with/about pts, health supervision, other
medical services
– Medical screening
• Hx, exam, medical decision-making
• Required to determine need/location for
appropriate care/tx
• Each level may be used by all physicians
E/M components
• Seven
– Hx, Exam, Medical Decision-making (KEY)
– Counseling, Coordination, Nature of
presenting problem (Contributory)
– Time
• Contributory components may not be provided
at every encounter
• Coordination w/out pt encounter = Case Mgt
Codes
Key Components
• New Pt – All 3 components must be at a level to
justify assignment
• Established Pt – 2 of 3 components to justify level
assignment
• Some E/M categories don’t distinguish between
New/Est pts
• Documentation MUST support the key
components used to select E/M code
– (Handout)
CMS Documentation Guidelines for
E/M Services
• Guidelines and notes perceived as insufficient for
consistent coding and reliable review by payers
• CMS Doc Guidelines for elements of comprehensive
multisystem/single-system exams.
• 1995 – providers felt single-system exams unclear
• 1997 – providers felt confusing and burdensome
(extensive counting)
• CMS policy
– Providers to use whichever set of guidelines is
most advantageous for reimbursement
• AMA and CMS still working on developing an
acceptable approach
Documentation and Coding
• Provider does NOT have to re-document
Hx, ROS during a previous encounter IF
review and location of the information is
documented in current note.
• Provider then should update information
that is no older than one to two years.
E/M Coding Process
•
•
•
•
•
ID Category/Subcategory of service (POS)
ID TOS provided
ID if pt new/established if necessary
Review Reporting Instructions
Review Level of E/M Services provided
– Key components
– Counseling/coordination of care different
• Apply CMS Documentations Guidelines
Office or Other Outpt Services
• When a Dr provides two E/M services for the same
pt on the same day for the same problem, report just
ONE E/M code (highest level)
– Critical Care Services is an exception to this
• When a Dr provides multiple E/M services in this
setting to same pt on the same day for DIFFERENT
problems, report multiple E/M codes
– Be sure to link different dx to relevant E/M codes
– Add -25 to 2nd and subsequent E/M codes
• When pt receives Office E/M services and is
admitted as inpt the SAME day by the SAME Dr,
report the initial hospital care E/M code ONLY
Office or Other Outpt Services
• When pt receives Office E/M services and is
admitted as inpt the SAME day by the SAME Dr,
report the initial hospital care E/M code ONLY
• When Dr performs comprehensive exam in office
and on a later day the pt is admitted to hospital as
a PLANNED admission, report a lower-level-ofservice initial hospital care E/M code
• When pt’s admission is UNPLANNED on a later
day, report the appropriate E/M codes for each
episode of care
99211
• “Nurse visit”
• Code can be reported by any other provider
– NP, PA, Physician
• CMS guidelines – “incident to”
– Physician must be PHYSICALLY PRESENT in
offices when service provided
• Documentation
– CC and service description
– Hx and Exam documentation NOT required
Nursing Facility Services
• Provided AT an NF, SNF, intermediate care
facility/mentally retarded (ICF), LTCF, or psychiatric
residential tx facility
• NFs provide convalescent, rehab, or LT care for pts
• Comprehensive assessment must be completed on
each pt
– Medical, nursing, mental, psychological needs
– Pt’s functional capacity, ID of potential problems,
nursing plan
– Required on admission/readmission/substantial
change
NF Services
• When a pt is discharged from hospital or
observation and admitted to a NF, SNF,
ICF, or LTCF on the SAME day, code for
both types of E/M services
• Do NOT code ED or office E/M with initial
NF care when provided on SAME day for
SAME pt by SAME physician.
NF services
• Do NOT code NF care and initial hospital
care on the same date for the same pt by the
same physician, code ONLY the initial
hospital care.
• Code subsequent NF care when
– evaluation of pt’s assessment plan is NOT
required
– pt has not had a major/permanent change of
health status
NF Services
• NF discharge – 99315 or 99316
• Pronouncement of death, completion of
death summary, and discussion with family
– 99315 or 99316
– Provider MUST personally visit pt and
document pronouncement of death BEFORE
midnight on date of death
Misc.
1. Application of casts and strapping
If sole procedure and not to treat a fracture; use
appropriate E/M code and 99070 for supplies.
If to treat fracture without reduction; assign code
that states "closed treatment without
manipulation".
2. Closure of wounds with adhesive strips is included
in E/M code. p.
3. Maternity care/delivery
If physician does NOT perform delivery, but
proved some antepartum/postpartum care, use
E/M codes ONLY.
4. Vaginal foreign body
If removal is done WITHOUT anesthesia, use E/M
codes ONLY.
Examples
• Dr. Smith provided a level 3 E/M service to new pt
in office for anxiety. The pt returns 4 hours later
with anxiety problem, and Dr. Smith provides a
level 2 E/M service.
– Code(s)?
• Dr. Jones provides level 3 services to an est. pt.
for HTN. The pt returns 5 hours later for level 4
E/M services related to hip pain caused by a fall
at home.
– Code(s)?
• Dr. Green provides level 4 E/M services in office.
Pt is later admitted to hospital, where Dr. Green
performs level 3 initial hospital care E/M services.
– Code(s)?
Examples
• Based on standing orders, Office nurse
administers monthly B12 injection after
taking and recording vital signs.
• Based on standing orders, Office nurse
administers testosterone injection.
Physician provided level 3 E/M services
last week.
Examples
• 10/14 – 97 y/o female pt transferred from
hospital to NF in stable condition. Attending
provided hospital discharge day mgt services
and provided a level 2 initial NF service.
• 11/14 – Physician provided level l subsequent
NF care.
• 11/30 – Pt expired. Physician was not in
attendance.
Break Time
Fluid Exchanges
ED Coding
• E/M exam documentation guidelines can be the
1995 or the 1997 guidelines, whichever is
preferable to the provider.
• Evaluation and Management Services Guide
(2007)
• “prepared as a tool to assist providers” “is a
general summary…, but is not a legal document”
• “does not replace content found in ’95/’97
guidelines”
ED Services
• Provided in a hospital
• Open 24 hrs/day
• Unscheduled episodic service to pts needing
immediate medical attention
• Emergency
– the sudden and unexpected onset of medical
condition or
– the acute exacerbation of a chronic condition
that is threatening to life, limb, or sight and
that requires immediate medical treatment
– or that manifests painful symptomology
requiring immediate palliative effort to relieve
suffering.
ED Services
• Any physician who provides services to a pt
REGISTERED in the ED may report the ED
services codes.
• The physician does NOT have to be assigned to
the ED
• If services provided in the ED are determined
NOT to be actual emergency, ED services codes
are STILL reportable IF ED services were
provided.
• Typically, the hospital will report lower level ED
services code for non-emergency conditions.
ED Services
• When emergency services are provided in
the office, DO NOT assign ED E/M codes.
• If PCP meets pt in ED and the pt is NOT
registered in ED, then report an Office or
Other Outpt E/M code
• When ED services are provided the same
day by the same physician as a
comprehensive nursing facility
assessment, do NOT report ED E/M code.
E/M Components in ED
• Time is NOT a component for the ED levels
Hospital E/M Coding for ED
• Since the MC hospital outpt PPS (HOPPS)
began in 2000, hospitals have been
coding clinic/ED visits using CPT
• E/M codes often do NOT fit the type of
services provided by hospitals
• CMS requires hospitals to develop a
methodology with internal guidelines for
code assignment that maps to E/M levels
of effort that refer to facility resources
consumed by staff
Hospital E/M coding for ED
• CMS requirements
– Services must be documented
– Medically necessary
– Reasonably reflect intensity of resources
– Based on resource consumption that is NOT
separately payable (x-rays, labs, etc)
• Lack of standardization
– Poor data for APC reimbursement
– Possible violation of HIPAA code set requirements
– Coder confusion
– Less effective compliance programs
ED and Clinic E/M coding Model
• See Handouts
Hospital Established Pt
• If a patient has a medical record that was
created within the past 3 years, the patient
is considered an established patient to the
hospital.
CMS Requirements for Hospital OPPS
• 2008 Hospital Clinic Visits
– Continue using E/M outpatient visit codes
– Continue differentiating between new, est. pts
– Type of service is not differentiated
– Consultation E/M codes will not be recognized
– Use new/est visit code
CMS Requirements for Hospital OPPS
• 2008 Hospital ED Visits
– Type A ED visits – ED meets CPT definition, must be open 24/7.
– Continue to use CPT ED codes
– Type B ED visits – ED does not meet CPT definition, open less
than 24 hours/day
– Use following codes
– G0380, G0381, G0382, G0383, G0384
• Critical Care
– Must provide a minimum of 30 minutes to report 99291
– < 30 minutes, used clinic/ED visit code
G0380
• G0380
Level 1 hospital emergency department visit provided in a
type b emergency department; (the ED must meet at least one of
the following requirements: (1) It is licensed by the state in which it is
located under applicable state law as an emergency room or
emergency department; (2) it is held out to the public (by name,
posted signs, advertising, or other means) as a place that provides
care for emergency medical conditions on an urgent basis without
requiring a previously scheduled appointment; or (3) during the
calendar year immediately preceding the calendar year in which a
determination under 42 CFR 489.24 is being made, based on a
representative sample of patient visits that occurred during that
calendar year, it provides at least one-third of all of its outpatient
visits for the treatment of emergency medical conditions on an
urgent basis without requiring a previously scheduled appointment)
CMS Guidelines Principles
• Hospitals should continue to report visits
according to own internal guidelines
• CMS has 11 principles that internal guidelines
should follow
• First 6 reaffirmed,
• Five new ones this year
• Principles/Clarification available in
• AHA Coding Clinic for HSCPS, v 7, #4, Fourth
Quarter, 2007, pp. 1-3
Hospital E/M Coding for ED
• Example - Handout
http://adam.about.com/encyclopedia/Sewing-a-wound-closed-series.htm
Resources
• AMA CPT Web Site
– www.ama-assn/org/go/cpt (early releases)
• CPT 2008 Professional Edition. AMA
• Green, Michelle. (2007). 3-2-1 Code It! Thomson
Delmar Learning. ISBN 1-4180-1255-6
• Hospital E/M Coding Panel. Recommendation for
Standardized Hospital Evaluation and Management
Coding of ED and Clinic Services. AHIMA. June 2003.
• Peters, R. and Wiedemann, L. Applying Facility E/M
Codes in the Hospital Emergency Department. Journal
of AHIMA, 78, no. 5 (May 2007): 68-69.
• Pitotti, Margaret. Coding the Emergency Room visit.
ADVANCE for Health Information Professionals,
10/22/07
Resources
• OPPS Visit Codes Frequently Asked
Questions
http://www.cms.hhs.gov/HospitalOutpatient
PPS/downloads/OPPS_Q&A.pdf
• CMS- 1506-P Proposed rule Section IX
Proposed Hospital Coding and Payments
for Visits (Clinic, Ed, Critical Care)
http://www.cum.hhs.gov/HospitalOutpatient
PPS/downloads/CMS1506.P.pdf
Resources
 Evaluation and Management Services
Guide (2007)
http://www.cms.hhs.gov/MLNProducts/dow
nloads/eval_mgmt_serv_guide.pdf
? From previous workshops
• Not coding DM if that wasn’t what brought
the patient in
– This is a case of dueling guidelines
– As pointed out by Helen Ovitt (relaying a
question from a coder in her facility)
– 2008 Coders’ Desk Reference – Diagnoses –
it states “diabetes is a systemic disease and,
as such, should be coded even in the
absence of documented, active intervention
during a patient encounter”.
Questions from
Previous Workshops
• A Glycosolated Hemoglobin test is not for
anemia and has nothing to do with it. It is
to check the blood sugar control over a
three month period in diabetics. A
Glycosolated Hemoglobin of 7.9 would
indicate the blood sugars were not in very
good control. A regular hemoglobin of 7.9
would require intervention of some
kind, possibly a transfusion.
HGB vs HbA1c
• The confusion is occurring because the
wrong test name and normal values were
used on the lab report.
• You noticed the Dr. referred to the test as
glycosylated hemoglobin and I noticed the
name on the lab test was HGB with normal
values from 13.8-17.2.
• The lab report is for blood hemoglobin
because of the name and the normal
ranges. For HGB the result for the blood
hemoglobin is very low and needs
intervention.
• The correct name for the glycosylated
hemoglobin test on a lab report would be
HbA1c and the normal range for this test that
indicates the average blood glucose level for
the last 3 months is 4.5 – 6, with anything
over 8 being considered significant.
imueller@email.wcu.edu