Evaluation and Management
Coding
Disclaimer
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All CPT codes trademarked by the American Medical
Association. All rights reserved.
CARRIERS may differ on E&M auditing criteria. This
workshop my not be exactly what your Medicare
Administrative requires.
This should not be the only source used for coding and
billing. All coding and billing decisions should be made on
a case-by-case basis based upon documentation and
insurance guidelines.
All information contained herein is valid for the date of this
seminar only. This presentation is based on national
guidelines.
This presentation is a summary only. For Medicare
regulations, see www.cms.hhs.gov or your local Medicare
web site.
Agenda
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
Introduction
CMS Documentation Guidelines
Major Components
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History
Physical
Medical Decision-making
Common Oncology Services
Best Practices and Practical Tips
Introduction



Evaluation and Management coding was
introduced by the American Medical
Association and CMS in 1993.
Ever since, providers have been confused
about how to best document and bill for
these services.
Oncologists are no exception to this rule.
They tend to be overly-aggressive when
billing initial services (consults and
hospital admits) and not aggressive
enough when billing office visits (9921299215)---but every office is different.
Other Common Problems in
Oncology
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Poor chart legibility in terms of written notes,
nursing documentation, and form completion.
Lack of understanding of E/M documentation
criteria--particularly for counseling.
Consultations---these are a problem for every
specialty--particularly the Medicare criteria.
Use of forms that are not inclusive all required data
elements.
Electronic templates that are the same for everyone,
regardless of condition.
Mismatch of billed DOS and actual DOS in hospital
charts.
Thinking that just because Oncology patients are
“sicker” that higher level services are billable for
every patient.
Documentation Guidelines
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
“If it wasn’t written, it wasn’t done:
This also includes:

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“If you can’t read it, it wasn’t done”
“If you can’t find it, it wasn’t done”
“If it is not filed in the record, it wasn’t
done.”
“If it was not ordered, it wasn’t
necessary.”
Documentation Guidelines

General Principles (CMS) for your charts-

The medical record must be complete and
legible.
The documentation of the each patient
encounter must include




Reason for the encounter and relevant history,
physical, and prior health examination results;
Assessment, clinical impression, or diagnosis;
Plan for care; and,
Date and legible identity of the observer.
CMS Documentation Guidelines
(cont’d)
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If it is not documented, the rationale for
ordering diagnostic and other ancillary services
should easily be inferred.
Past and present diagnoses should be
accessible to the treating and/or consulting
physician.
Appropriate health risk factors should be
identified.
The patient’s progress, response to and
changes in treatment, and revision of diagnosis
should be documented.
AND, the CPT and ICD-9-CM codes reported on
the bill should be supported by the
documentation in the medical record.
Do your records meet these standards?
Review Question

The documentation for each encounter
must include:
a)
b)
c)
d)
e)
f)
Reason for the encounter and relevant
history, physical, and prior health
examination results
Assessment, clinical impression, or diagnosis
Plan for care
Date and legible identity of the observer.
None of the above
All of the above
Review Question

If a physician discovers a side
effect during the physical
examination and decides to treat it
with a billable item or service, they
need to make sure that they
document the new diagnosis in the
record and notify their billing staff.
a)
b)
True
False
Evaluation and Management
Services
Documentation Guidelines
 History
 Physical
 Medical Decision-making
Categories of E/M Services
Each
•
•
•
•
•
•
E/M service category has special instructions for use
Office/Other
Outpatient
Hospital Inpatient
Consultations
Hospital Observation
Emergency
Department
Prolonged Services
AMA 2004 CPT Manual
•
•
•
•
•
•
Nursing Facility
Domiciliary, Rest
Home or Custodial
Care
Home
Case Management
Preventive Medicine
Special Services
E/M Definition of a New Patient

A new patient is one that has not been
seen by the documenting physician or a
member of their specialty in the same
group practice in the past three years
(thirty-six months).
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This does not mean that a second consult
would not be allowed, if it was medically
necessary and met consultation criteria.
It does mean that, if you hire a physician from
across town, their patients would NOT be new
patients.
Type of Common E/M Services
Initial Encounter
Subsequent
Encounter
CPT Codes
99212-99215
99231-99233
Discharge
Encounter
CPT Codes
99238-99239
An initial inpatient
encounter may be
billed by admitting
physician only
A new patient visit
will be billed if the
patient is referred
for a known care
plan and it meets
the definition of new
patient.
Only one visit per
day per member of
the same specialty
in the same group.
Utilized by physician
to report all services
provided on date of
discharge, service
need not be
continuous
Requires 3 of 3 key
components:
history, exam and
decision making
Requires 2 of 3 key
components:
history, exam and
decision making
CPT Codes
99201-99205
99221-99223
For concurrent care,
make sure your
specialty diagnosis
is on the claim.
Requires time
documented if 30
minutes or more as well
as services provided for
over 30 minutes.
Consultation
CPT Codes
99241-99255
Requires a request
 Requires a reason
 Rendering an
opinion/advice
 Respond to
requesting physician
in writing
 Transfer of care???

Requires 3 of 3 key
components:
history, exam and
decision making
1995 Versus 1997 Criteria for E&M

Only difference is the physical exam
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In 1997, single organ exams are outlined that
do not really apply to Oncologists, e.g.
musculoskeletal, urologic.
1997 multi-system exam is much more
detailed and is harder to get to a higher code,
unless documentation is detailed.
1997 does give credit for partial exams of body
areas or organ systems, which 1995 does not.
1995 is used most frequently by Oncologists.
But, Medicare will use either that is most
favorable in an audit. Just be consistent for
every visit.
See these at
http://www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.as
p
Driving Force of E/M Medical
Necessity
“ NPP (the nature of the presenting problem)…is the
indicator for selecting the appropriate level of
medical care warranted by the severity of the
patient’s illness.”
THE NATURE OF THE PRESENTING PROBLEM
INDICATES THE LEVEL OF MEDICAL CARE AND
CODING WARRANTED BY THE PATIENT’S ILLNESS.
IT IS THE CPT CODING SYSTEM’S E/M VEHICLE FOR
EVALUATING MEDICAL NECESSITY.
Practical E/M
Stephen R. Levinson, MD
Nature of the Presenting Problem

Example: subsequent hospital visits
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99231--Usually the patient is stable,
recovering, or improving
99232--Usually the patient is responding
inadequately to therapy or has developed a
minor complication.
99233--Usually the patient is unstable or has
developed a significant complication or new
problem.
If you find out in the history the patient is
stable, recovering, and/or improving-how much do you really need to do in
terms of physical and decision-making?
Medical Necessity (Trailblazer)
1.
The guiding principle of Medicare is
whether an item or service was
“medically necessary”. For E&M, this
means
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Frequency of service/ intensity of service.
Separate from whether criteria was met.
Does the H&P meet the patient’s actual needs
at the time of service? If so, you can prove
to an auditor that the encounter met medical
necessity criteria. Someday, this may be
more important than you think right now.
Medical Necessity (Trailblazer)
2.
Information used by Medicare is contained within
the medical record documentation of the history,
physical, and medical decision-making. Medical
necessity is based on these attributes:
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Number, acuity, and severity of problems addressed
in the E&M criteria.
Context of the service in terms of other services
previously rendered for the same problem.
Complexity of documented co-morbidities that
influence physician work.
Physical scope encompassed by the problems, i.e.
number of physical systems affected by the problem.
Medical Necessity Tips
(Trailblazer)
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Identify presenting complaints and/or reasons for
the visit.
 Demonstrate the history, physical and MDM
associated with each.
 Demonstrate how physician work was affected by
co-morbidities or chronic problems noted.
Ensure that the nature of the presenting problem is
consistent with the level billed (99213 = low to
moderate severity).
Become familiar with the clinical examples in CPT
Appendix C of the book.
Review question

Why is nature of the presenting
problem important?
a)
b)
c)
d)
e)
You get paid more for it.
It reflects the patient’s complaint
It shows you know your
documentation guidelines
It drives the level of history, physical,
and medical decision-making of the
encounter
None of the above
Components of E&M Services
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Major Components
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History
Physical
Medical Decision-making
Number of these that must be included by
type of visit:
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All three for consults, initial admissions, and
new patients
2 of 3 for established or follow up encounters.
Components of E&M Services

Other Components that are
important but are not key
components
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Counseling
Coordination of Care
Nature of Presenting Problem
Time
The History: Its Components
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Chief Complaint
History of Present Illness (HPI)
Review of Systems (ROS)
Past, Family, and Social History
History

Chief Complaint--A brief
statement,generally in the patient’s
own words or by the physician,
conveying the reason for the visit to
the physician/provider. This can be
documented by the patient, the
nurse, or the provider.
Chief Complaint
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The medical record should clearly reflect
the chief complaint for every encounter.
The chief complaint should be the reason
that instigated today’s encounter.
This can include symptom, problem,
condition, diagnosis, ‘return to’ ordered
by physician, or other factor that is the
reason for the encounter.
Don’t say that patient came in for “follow
up” with no problem for which they need
follow up.
History of Present Illness (HPI)

HPI is a chronological narrative of
the course of the patient’s
presenting illness, from its initial
date of diagnosis to the present
visit. This should also include any
complicating factors or comorbidities. The HPI includes
assessment and documentation of
one to eight elements…
History of Present Illness (HPI)

Elements include:
Location
 Quality
 Severity
 Duration
 Timing
 Context
 Modifying Factors
 Associated Signs and Symptoms
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Dimensions of the HPI
Location
Site of problem
Duration
Length of time existed
Timing
Regularity of occurrences
Severity
Intensity or degree
Quality
Description or characteristic
Context
Events surrounding occurrence
Modify Factor
Effect on symptom
Associated Signs
& Symptoms
Significantly related to presenting problem
AMA 2008 CPT Manual
History of Present illness

Documentation of HPI
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BRIEF:1-3 elements of the HPI.
EXTENDED: 4 or more elements of the
HPI.
The specificity of the HPI can also
describe the medical necessity of
why the patient is being seen and
the level of service that may be
billed.
Documentation Example of HPI

45 year old female lung cancer
patient complains of intermittent
sharp pain in her left hip after
falling out of bed today.
Additionally, she complains of left
leg numbness; describing the pain
as a 9 on a scale of 1-10. She
states aspirin has not relieved this
pain.
Evaluation of Example HPI
45 year old female lung
cancer patient complains of
intermittent sharp pain in
her left hip after from bed .
Additionally, she complains
of left leg numbness;
describing the pain as a 9
on a scale of 1-10. She
states aspirin has not
relieved this pain.
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Location = Hip
Duration = today
Timing = intermittent
Severity = 9 (scale 1-10)
Quality = sharp pain
Context = falling from
bed, lung cancer
Modifying Factor = aspirin
Associated S&S = pain,
numbness in leg
Review of Systems: Next
Component of the History

Documents the patient’s responses
to a series of questions of their
experiences, symptoms, or
irregularities in fourteen medical
systems. This can be current (since
the last visit) or chronic but still a
factor in today’s treatment or
problem.
Review of Systems
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Systems to be documented
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Constitutional
Eyes
Ear, Nose, Throat, Mouth
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary (includes breasts)
Neurological
Psychiatric
Endocrine
Hematological/lymphatic
Allergic/immunologic
Review of Systems (ROS)
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
A problem pertinent ROS identified, through a series of
questions, inquires about the system directly related to the
problem
Extended ROS must identify the positive responses and
pertinent negatives for at least (2) and not more than (9)
systems
Complete ROS must evidence documentation of ten organ
systems. The attending physician may use “All other
systems negative” when (2) pertinent positives and/or
negatives are documented. In absence of such a notation, all
systems must be documented. Some Medicare contractors do
not allow this notation at all anymore--always check your
contractor’s web site.
If unable to obtain, document why, If the patient is unable to
communicate due to mental state or language barrier “ROS
unavailable due to …..” unconscious, intubated, poor
historian, non-English speaking without a translator.
Review of Systems

Tips for ROS

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
Can be documented by someone else-- NP, RN,
the patient on a form or from another MD’s
history—but, the documenting provider should
initial and date or refer to it in dictation.
Obviously, the patient needs to respond to these,
if you use their responses.
If available in the chart, can use former ones if
referred to by date of review of systems--but it
must be relevant to today’s service.
Noted presenting problems may be included in
the ROS, even if they are also in the History of
Present Illness.
Past, Family, Social History

What are they?



PAST: Patient’s past experience with illnesses,
operations, injuries,medications (prescriptions,
herbal, OTC), allergies, and treatments.
FAMILY: Medical events in the patient’s family
that pose a risk to the patient and/or are
related to the current illness or chief
complaint.
SOCIAL: An age appropriate review of past and
current activity which can include marital
status, employment history, sexual history,
living arrangements, smoking (primary and
secondary), drinking, or exposure to
environmental toxins.
Past, Family, Social History

Levels:


Pertinent = At least one from any of these areas
Complete:





For established patients in the office at least two of these.
For new patients and hospital patients, plus initial visits
anywhere all three are necessary
Can refer to a prior assessment and state that it is
unchanged. Again, this is questionable if it appears in
every single visit.
Do not state that PFSH is ‘non-contributory’. State the
actual status of question asked. “Negative” is an
acceptable response, if it is specific to the area reviewed.
This may documented by the patient, a staff member, or
the physician. The physician (or other billing provider)
must refer to it or sign and date documentation by others.
E/M Levels in Review: The History
History
Focused
Expanded
Detailed
Comprehensive
CC
Required
Required
Required
Required
HPI
1-3
Elements
1-3
Elements
4+
Elements
4+
Elements
ROS
N/A
1
System
2-9
Systems
10+
Systems
PFSH
N/A
N/A
1
Element
3 of 3 Elements
(new/consult)
2 of 3 (est)
Review Question

To bill for a high level consult , how
many HPI elements do you need?
a)
b)
c)
d)
e)
2 are listed and the rest are non-contributory.
10
4
8-12
None of the above
Review Question

You need to document a past,
family and social history every
time the patient comes in?
a)
b)
True
False
Examination (1995)

Body Areas:
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Head including face
Neck
Chest including breasts and axillae
Abdomen
Back
Genitalia, groin, and buttocks
Each extremity
Examination

Organ Systems
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Constitutional
Eyes
Ear, Nose, Throat, Mouth
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary (includes breasts)
Neurological
Psychiatric
Endocrine
Hematological/lymphatic
Allergic/immunologic
Examination (1995)

Levels:




Problem Focused = a limited exam of affected
body area or organ system.
Expanded Problem Focused = a limited exam
of affected areas and other symptomatic or
related organ systems (2-7 organ systems).
Detailed = an extended examination of
affected areas and other symptomatic or
related organs (2-7 organ systems).
Comprehensive = a general multi-system
examination or a complete examination of a
single organ system. Generally, this is 8-12
organ systems for a multi-system exam.
The Examination (1995)

Tips the Exam:





It is preferable that a provider (MDs or NPPs) performs the
exam as necessary to ascertain abnormalities. But, Nurses
and MAs can do constitutional part.
The type of exam must be relevant to the diagnosis and the
severity of the problem. Doing a comprehensive exam or
having a template that does it can be a problem unless the
patient actually needs the exam. Always examine systems
most relevant to the presenting problem.
The depth of the exam description can drive whether it is
DETAILED OR EPF, both are 2-7 organ systems. ENTM must
include the ears, nose, throat, and mouth. Lymph nodes must
be include all nodes for the system to be ‘detailed’..
Brief statement or notation indicating “negative” or “normal”
is sufficient for findings within normal limits
Documentation of “abnormal” is not sufficient without
elaboration.
Review Question

To document a detailed exam (say, for a
99214) under 1995 criteria, you need
what..?
a)
b)
c)
d)
e)
2-7 body areas
2 complete organ systems
2-7 organ systems in detail
One complete exam of the area most relevant
to the chief complaint.
None of the above
Review Question

You can use body area exams as a
basis for lower level visits.
a)
b)
True
False
Medical Decision-Making

What is this? Two out of three of these-


The number of possible diagnoses and
treatment options that must be considered in
light of the presenting problem and HPI.
The amount or complexity of data considered,
i.e. diagnostic tests, medical records, and/or
other information obtained including from
additional providers.
The risk of significant complications, morbidity,
or mortality associated with the patient’s
presenting problems, diagnostic procedures
ordered, and/or possible or definite treatment
options.
Medical Decision-Making

Number of Diagnoses and Treatment Options





Diagnosis (es) treated today are those counted.
Patients with co-morbidities that impact current
treatment are more complex. These should be
discussed.
For established diagnoses, it should be shown if
they are worsening, improved, controlled or
complicating.
The necessity to change the course of treatment
must be documented. If the treatment is
unchanged, this is a lower level of decision-making.
Referrals and consultations are a treatment option.
Number of Diagnoses/Treatment
Options



This is again what diagnoses you
considered in making a decision for
today’s encounter. Just because a patient
has lots of diagnoses does not always put
you at a higher level, if they are not
addressed in the specific encounter.
Improved, feeling well, or stable lower the
intensity of the diagnosis criteria.
Consultations, review of information with
other physicians to arrive at a treatment
or diagnosis is considered higher level.
Amount or Complexity of Data
Reviewed




Types of testing done and reviewed
dictates severity, i.e. a cardiac cath as
opposed to a CBC.
Independent review of specimens and
smears is more complex.
Review of old records or obtaining a
history from someone other than the
patient is a higher level, if new
information is obtained.
Discussions of tests with the performing
physician is considered more complex.
Medical Decision Making Data Complexity Elements:
Example of Scoring
Amount and/or Complexity of data reviewed
Points are assigned to each section below based on the
number of data items reviewed max = 4 pts
Points
Review and/or order of clinical labs
1
Review and/or order of tests Radiologic study, other
non invasive diagnostic study
1
Discussion of diagnostic study w/interpreting MD
1
Decision to obtain old records and/or obtaining
history from someone other than the patient
1
Review and summarization of old records or
gathering data from source other than patient
2
Independent visualization of image, tracing or specimen
itself
2
Total Points
Total
1
2
3
E/M – Medical Decision Making
Component

Risk of Complication and/or
Morbidity/Mortality

Four Levels
Minimal
 Low
 Moderate
 High

Risk of Complications, Morbidity and/or
Mortality


Refers to patient’s level of risk at
the visit
Sources of risk




Presenting problem
Diagnostic procedures ordered
Management options selected
Illustrated by clinical examples in
“Table of Risk”
1995 Documentation Guidelines
Table of Risk (USE THE HIGHEST LEVEL DOCUMENTED)
Level of
Risk
Presenting Problem(s)
Minimal
* One
self–limited or minor
problem,
e.g. cold, insect bite
*Lab tests requiring venipuncture
*CXRs
*ECG/EEG, U/A, echo
*
*
*
*
Low
• 2 or more self–limited or minor
problems
• 1 stable chronic illness
Acute uncomplicated illness or
injury,
e.g. cystitis, sprain
* Physiologic tests not under stress,
* OTC drugs
* Minor surgery w/ no identified risk
factors
* PT, OT
• IV fluids w/out additives
Moder
ate
* 1 or more chronic illnesses with mild
* Physiologic test under stress, e.g.
cardiac stress test, fetal contraction
stress test
* Diagnostic endoscopies with no
identified risk factors
* Deep needle or incisional biopsy
* CV imaging studies with contrast and
no identified risk factors, e.g.
arteriogram and cardiac cath
* Obtain fluid from body cavity
* Minor surgery with identified risk
factors
* Elective major surgery (open,
percutaneous, or endoscopic) with no
identified risk factors
* Prescription drugs
* Therapeutic nuclear medicine
* IV fluids w/ additives
* Closed tx of fracture or dislocation
without manipulation
High
* 1 or more chronic illnesses with
severe exacerbation, progression, or
side effects of treatment
* Acute or chronic illnesses or injuries
that may pose a threat to life or bodily
functions, e.g. peritonitis, acute failure,
multiple injuries, acute MI
* An abrupt change in neurological
status, e.g. seizure
* CV imaging studies with contrast
with identified risk factors
* Cardiac EP test
* Diagnostic endoscopies with
identified risk factors
* Discography
*Elective major surgery w/ identified
risk factors
* Emergency major surgery
* Parenteral controlled substances
* Drug therapy requiring intensive
monitoring for toxicity
* Decision not to resuscitate or to de–
escalate care because of poor prognosis
exacerbation, progression, or side effects of
treatment
* 2 or more stable chronic illnesses
* Undiagnosed new problem with uncertain
prognosis, e.g., lump in breast
* Acute illness with systemic symptoms,
e.g. pyelonephritis, pneumonia, colitis
* Acute complicated injury, e.g. head injury
with brief LOC
Diagnostic
Procedure(s) Ordered
e.g. PFTs
* Non–CV imaging with contrast, e.g.
barium enema
* Superficial needle biopsy
* Clinical lab test requiring arterial
puncture
* Skin biopsies
Management Option
Selected
Rest
Gargles
Elastic bandages
Superficial dressings
Documentation Tips for MDM




Established diagnoses should indicate:
Stable, well-controlled, worsening, failing
to improve
Independent review of diagnostic test
should document: visualization of image,
tracing or specimen
Review of old records, document findings
or lack of findings
Document co-morbidities, underlying
diseases that increase risk of treating that
patient.
Medical Decision Making (MDM)
Four levels:
 Straightforward
 Low complexity
 Moderate
complexity
complexity
 High
Two of the three areas:
Dx. Options, Amount of Data, and
Risk Establish the MDM Level
Dx./mgt. options
0-1
2
3
4
Amount of data
0-1
2
3
4
Minimal
Low
Moderate
High
Straightforward
Low
99221
99231
99243
Moderate
99222
99232
99244
High
99223
99233
99245
Overall risk
Level of MDM
99241
99242
Review Question

All cancer patients have severe
diagnoses and significant risk of
death or morbidity; therefore, we
always have high-level decisionmaking.
a)
b)
True
False
Counseling/Coordination of Care

When counseling
dominates >50%
of the visit, time
may be used as
the dominating
factor---BUT READ
THE FINE PRINT!
Counseling/Coordination of Care

Must document the following three items:




Total Visit Time
 99214 = 25 minutes
 99215 = 40 minutes
Time Spent Counseling (must be over 50%)
Subject Matter of Counseling—diagnosis,
prognosis, code status, side effects, chemo
options, etc.
This is incorrectly documented or underbilled in Medical Oncology.
Counseling/ Coordination of Care

Counseling is a discussion with the patient and/or
family (Medicare patients must ALWAYS be
present) concerning one or more of the following
areas:
 Diagnostic results, impressions, and /or
recommended diagnostic studies;
 Prognosis, risks and benefits of management
(treatment) options; instructions for
management and/or follow-up; importance of
compliance with chosen management options;
 Risk factor reduction; and patient family
education
Review Question

Ms. Genesis, a Medicare patient, is in
the hospital with terminal cancer. Her
family comes to the office for a 40minutes discussion about her prognosis.
What can you bill?
a)
b)
c)
d)
e)
99213
99214
99215
Not enough information
None of the above
Putting it All Together: Office Visits
Key Factors 2 of Level 5
3
History
• HPI
• ROS
• PFSH
Level 4
Level 3
•
4
• 10
• 2 of 3
•
4
•2
• 1 of 3
•
1
•1
• NA
EXAM
8 organ systems
a) An extended
exam of affected
area 2-7 organ
systems or b) 12
bullets (1997)
a) Limited exam of
affected and
related system (27) or b) 6 bullets
(1997)
MDM (2 of 3)
• Dx/Tx Options
• Data
• Risk
High Complexity
• Extensive
• Extensive
• High
Moderate
• Multiple
• Moderate
• Moderate
Low Complexity
• Limited
• Limited
• Low
Bell Curve 2005: Hem-Onc
% of Medicare SVCS Est OV 2005
45.00%
40.00%
35.00%
30.00%
25.00%
% of SVCS
20.00%
15.00%
10.00%
5.00%
0.00%
1
2
3
Level of Office Visit (83)
4
5
Putting it All Together-- Consults
Key Factors 3 Level 5
of 3
History
• HPI
• ROS
• PFSH
Level 4
Level 3
•
4
• 10
• All Three
•
4
• 10
• All Three
•
4
•2
• 1 of 3
EXAM
8 organ systems
8 organ systems
a) An extended
exam of affected
area or b) 12
bullets (1997)
MDM (2 of 3)
• Dx/Tx Options
• Data
• Risk
High Complexity
• Extensive
• Extensive
• High
Moderate
• Multiple
• Moderate
• Moderate
Low Complexity
• Limited
• Limited
• Low
Bell Curve 2005: Hem-Onc
Medicare Office Consults 2005 (83)
60.00%
50.00%
40.00%
30.00%
Series1
20.00%
10.00%
0.00%
1
2
3
Levels of Service
4
5
Review Question

You are auditing your partner, Dr. James,
who has billed all of her visits this year
to 99214. Her EMR documentation
seems to be perfect. Is there a problem
here?
a)
b)
c)
d)
No, all you need is good documentation.
Yes, you set up red flags when you
repeatedly bill to one level.
No, our EMR takes care of good
documentation.
Yes, all of the 99214s could not be medically
necessary and, by the way, shouldn’t there
be some 99215s?
Common Oncology Services
Medicare Consultations (Medicare)

Transmittal 788, CR #4215, December 2005
 No shared visits for consultations in either office or
hospital. Either the NPP or MD should charge for the
consult. This is black and white in the transmittal.
 3 R’s have been more formalized and one has been
added…






REQUEST from another physician for consultant’s
opinion must be clearly documented in BOTH the
receiving and referring physician charts.
Referring MDs must have it in their plan of care,
but there is no need for you to check every record.
The REASON for the consult must be clearly
documented in the medical record.
Opinion RENDERED by the consultant with
RECOMMENDATIONS for treatment.
REPORT goes back to the referring physician.
99211 may not be used for a consult.
Consultations

Consultations (Cont’d)
 Consultations may be billed based on
time for counseling/coordination of care,
but an opinion must be rendered.
 Also, if care is continuous before the
consult for the same/original problem,
an additional consult may not be billed.
 Only ONE consultation may be billed per
inpatient stay.
Consultations
Transfer of Care

A transfer of care occurs when a physician or NPP requests that
another physician or NPP take over the responsibility for managing
the patient’s complete care for the condition, and does not expect to
continue treating or caring for the patient for that condition.

When this transfer is arranged, the requesting provider is not asking
for an opinion or advice to personally treat this patient and is not
expecting to continue treating the patient for the condition. The
receiving physician or NPP shall document this transfer of the patient’s
care in the patient’s medical record or plan of care.

If a transfer of care occurs, report the appropriate new or established
patient visit code should be billed based on place of service.

51 Specialty Societies have objected to this language (including the
AMA, ASCO, and ASH), but this Transmittal is still in effect and has
been the Medicare rule since 1/1/2006.
Other Common E/M Services in
Med Oncology

Hospital Admissions (99221-99223)



Patient must be admitted by you for
this to be billed by you
This may be the only service billed in a
day, so add all documentation for that
day into your level of service.
Billed for admission that lasts over one
calendar day.
Other Common Services in
Medical Oncology

Hospital Follow Up Visits (9923199233)



Dominating factor is nature of the
presenting problem.
May use as a hospital discharge service
if you are not discharging the patient.
May only be billed once per day by a
member of your specialty in your
practice.
Prolonged Services (99354-99357)


These should be billed with other codes for extra
time spent cumulatively face-to-face with the
patient.
 99354-99355 go with office/outpatient
services
 99356-99357 go with hospital inpatient
services
Document your time and it must be based on 30
minutes past the CPT time. Services of less than
thirty minutes past the visit time are not chargeable.
 99214 (25 minutes in CPT book) can only be
charged with 99354, if the visit is longer than
55 minutes.
 Counseling must be over 70 minutes as you
must bill 99215 with prolonged services of
counseling.
Modifier -25


Modifier -25 must be used on E/M
services on the same day as drug
administration services.
Per Claims Processing Manual Chapter 12,
Section 30.6.7 (D)

Medicare will pay for medically necessary
office/outpatient visits billed the same day as a
drug administration service with Modifier -25
when the modifier indicates that a significant,
medically necessary, separately identifiable
Evaluation & Management service was
performed and documented that meets a
higher complexity level of care than a service
than 99211. No separate diagnosis is
necessary.
Review Question

Dr. Hayes, a surgeon, sends Ms. Jones, a
Stage II breast cancer to your practice.
She has had her surgery and Radiation
and now she is ready for chemotherapy.
Dr. Hayes says in his note: “Please see
patient for chemotherapy administration”.
Is this a consultation?
a)
b)
Yes
No
Review Question

Your patient, Mr. Ramsey, has COPD and
lung cancer. The pulmonologist admitted
the patient to the hospital and you are
following the patient there. Can you get
paid if you both submit a bill for a
hospital visit?
a)
b)
c)
d)
No, it is concurrent care
Yes, if you use the lung cancer diagnosis and
it was the reason you are following Mr.
Ramsey
Not enough information
I never bill for these visits.
Practical Tips and Best Practices
o
o
o
Know the criteria for every E/M service
you perform. To best accomplish this,
read the E/M Documentation Guidelines
once per year.
Do not use templates for EMRs or
dictation, unless you are 100% positive
that they meet E/M criteria. Use only one
format per practice.
Do not stand for illegibility on the part of
any provider in your group.
Practical Tips and Best Practices


Think about medical necessity when
billing for E/M services. Just
because you can fill in the boxes on
a form or EMR does not mean that
the patient needs that level of care.
“Clustering” at any one level of
service may target you for an
insurance audit.
Practical Tips and Best Practices



Getting a patient history every time the
patient comes into the practice is only
relevant insofar as to changes in condition
or chronic conditions that are important in
current treatment.
Be sure you know the difference between
a consultation and a new patient referral.
Not EVERY INITIAL visit is a consult.
Have a peer review process in your
practice for E/M services. You are liable
for every provider billing under practice’s
Tax identification number.
What can you do?

Enlist support from these areas:







Nurse Practitioners and PAs (for more
efficiency in your practice).
Patient Surveys (Read, Initial, Date)
Lab Data (Read, Initial, Date)
Past Reports (Refer back)
Blanks in dictation can be gaps in
payment or liability issues.
Do not forget to document changes in
diagnoses in the medical record.
Treat your medical records like your
checkbook!