Billing training coding e&m

Editor's Notes

• #3: The first edition of Physicians’ Current Procedural Terminology appeared in 1966, and the book was subsequently revised in 1970, 1973, and 1977. Since 1984, the Physician’s Current Procedural Terminology has been updated and revised annually. CPT uses a five digit system for coding services rendered by physicians, plus two digit add-on modifiers or separate five-digit numbers representing the modifiers to indicate complications or special circumstances. The International Classification of Diseases (ICD) had its beginnings in England during the 17 th Century. The United States began using ICD toward the 19 th Century to report causes of death and prepare mortality statistics. Hospitals started using ICD in 1950 to classify and index diseases. ICD-9 code numbers have from three to five digits.
• #4: CPT is the systematic listing of procedures PERFORMED BY PROVIDERS. Unless otherwise specified, it is assumed that the Provider performed the procedure or service and reimbursement is paid with that assumption. There is one exception to this rule, Office visit 99211, a Level I patient encounter, can be done by medical staff qualified to do the task as long as it is supervised by a physician. This is a common code used for those coming in for a BP check, injection or minimal service usually performed by a physician’s assistant (RN, LPN, others). Coding must be correct if claims are to be paid promptly. Every individual diagnosis and procedure or service must be assigned correct and complete code numbers. Two coding systems are used in physicians’ offices; International Classification of Diseases, Ninth Revision (ICD-9) for diagnosis. Physicians’ Current Procedural Terminology (CPT) to identify services. A Provider can use any code he/she is qualified to do.
• #5: To facilitate understanding of the coding system it is helpful to dissect the code itself. In this case we use as an example the code related to the evaluation and management of a new patient. As you can see the first two numbers identify the section where the code is located. The third number allows you to define your search while the fourth number specifies what type of code is used. Normally for E & M codes the fourth number will identify whether the services are been provided to a new or established patient. The last code relates to the complexity of the encounter.
• #6: Most procedures are stand alone definitions of the services offered. Regardless, based on the complexity of the services offered, additional components have been added to the code system to assist Providers in the definition of the most appropriate service. Some of the most common components identify characteristics such as age, time and size. On the other hand, the person coding services must be aware that these components may not have anything to do with the key components of evaluation and management.
• #7: The levels of E/M services encompass the wide variations in skill, effort, time, responsibility and medical knowledge required for preventing, or diagnosing and treating illness or injury, and promoting optimal health. Codes for E/M services are categorized by the place of service (e.g., office or hospital) or type of service (e.g. critical care or preventive medicine services). The narrative for most of the E/M services recognize seven components. But before we discuss these seven components and how they are to be used it will be helpful to define the types of E/M Codes.
• #8: New Patient – has not received services from Provider or another Provider of the same specialty who belong to the same Group within the past three years. Established Patient – has received services from Provider or another Provider of the same specialty who belong to the same Group within the past three years.
• #9: There are three components (history, examination and medical decision making are the most often used components to define the levels of E/M services. Information regarding at least two, and occasionally all three, must be documented in the patient’s record to justify the selected code. Counseling and Coordination of care need not be provided on every visit. However, when counseling and coordination of care takes up more than 50% of the time, time then becomes the determining factor is selecting the proper code. Time must be indicated in the record whenever this factor is used to determine the level of service.
• #10: Problem focused – chief complaint, brief history or present illness/problem Expanded Problem Focused – chief complaint, brief history or present illness/problem, problem-pertinent system review Detailed – chief complaint, extended history or present illness/problem, problem-pertinent system review extended to include a review of a limited number of additional systems, and pertinent past, family and/or social history directly related to the patient’s problem Comprehensive– chief complaint, extended history or present illness/problem, review of systems that are directly related to the problem identified in the history of present illness, plus a review of all additional body systems, and complete past, family and social history.
• #11: CC – concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other reason for the encounter. Usually stated in the patient’s words. HPI – chronological description of patient’s condition. A brief HPI consist of three elements while an extended HPI is at least four elements . location quality severity associated signs/symptoms timing context duration modifying factors ROS – inventory of body systems obtained through a series of questions. Problem pertinent requires review of one system. Extended involves two to nine systems . Complete is at least 10 systems . Constitutional symptoms (e.g., fever, weight loss) Eyes Ears, nose, mouth, throat Cardiovascular Respiratory Gastrointestinal Genitourinary Neurological Intergumentary (Skin/breast) Musculoskeletal Psychiatric Hematologic/Lymphatic Allergic/Immunologic Endocrine PFSH- Pertinent is at least one item. Complete is at least two of the three items must be documented. PFSH consists of a review of three areas: - past history – past experiences with illness, injuries, treatments & surgeries - family history – review of medical events in family, including disease that may be hereditary or place patient at risk - social history – age appropriate review of past and current activities
• #13: Problem focused - examination limited to the affected body area or organ system. One to five elements. Expanded Problem Focused – limited examination of the affected body area or organ system and other symptomatic or related organ system. At least six elements. Detailed – extended examination of the affected body area (s) and other symptomatic or related organ system(s). At least twelve elements in two or more organ systems. Comprehensive – general, multisystem examination or complete single organ operating system examination. For each area/system at least two elements or minimum of nine systems and two elements of each system selected.
• #15: See attachment “General Multi System Examination” for a complete list!!
• #16: Straightforward – minimal number of possible diagnosis or management options; minimal data to be reviewed (if any), minimal risk or complication or morbidity/mortality Low Complexity – limited number of possible diagnosis or management options; limited data to be reviewed, low risk or complication or morbidity/mortality Moderate Complexity – multiple number of possible diagnosis or management options; moderate amount of data to be reviewed and moderate risk or complication or morbidity/mortality High Complexity – extensive number of possible diagnosis or management options; extensive amount of data to be reviewed and high risk or complication or morbidity/mortality
• #19: Minimal – problem that may not require the presence of the Provider, but service is provided under the Provider’s supervision Self-limited or minor – transient problem, and low probability of permanently altered state; or good prognosis with management/compliance Low Severity – problem that has a low risk of morbidity or little, if any, risk of mortality without treatment; full recovery is expected without functional impairment Moderate Severity – problem that carries a moderate risk of morbidity or mortality without treatment; uncertain outcome or increased probability of prolonged functional impairment High Severity – problem that has a high to extreme risk of morbidity or mortality without treatment; or high probability of severe, prolonged functional impairment
• #20: Counseling – Discussions wit patient or family regarding: Diagnostic results Prognosis Risks and benefits of management (treatment) options Instructions for management (treatment) or follow-up Importance of compliance with chosen management (treatment) options Risk factor reduction Patient and family education Coordination of care – contact with other Providers on behalf of the patient. If no patient encounter included then a case management code should be used Time – only a guideline except in appropriate counseling. Used only when counseling or coordination represents more than 50% of the time spent with the Provider (face to face)
• #21: Number of components required (history, exam, and medical decision making). Key Phrases to code selection appear in bold face. If more than 50% of the service involves counseling or coordination of care, then time is used to determine the code selected. A presenting problem is a disease, condition, illness, injury, symptom, sign, finding, or complaint.
• #22: Use these codes if the patient has not been seen by the physician, or any member of the group who is of the same specialty, within the past three years. Consider assigning the appropriate critical care code instead of these codes if the physician provided constant attention to a critically ill patient. Consider assigning the appropriate consultation code instead of these codes when an opinion or advice was provided about a patient for a specific problem at the request of another physician or other appropriate source. Report only the appropriate initial hospital care, hospital observation or comprehensive nursing facility assessment code if the patient is admitted to the hospital or a nursing facility on the same day to the office visit. Do not consider the time spent by other staff (e.g., nurse, nurse practitioner or physician assistant as part of face-to-face time. Use a case management code when coordination of care involved other providers or agencies but did not involve a patient encounter on that day. Report additionally prolonged services codes 99354-99355, as appropriate, for E/M services that exceed 30 minutes of the typical time specified in the code narrative. Only the direct physician-patient (face-to-face) contact should be used to determine the prolonged service code. The time must be clearly documented in the medical record. (Some third party payers may allow reporting of prolonged services with only modifier-21 and the highest level of E/M service code. Be sure to verify the reporting requirements of the individual payer). Add modifier – 25 or 09925 to report that a separately identifiable E/M service was performed by the same physician on the same day as a procedure or service. Only the content associated with the separate E/M service should be considered when determining the correct level of service. Add modifier – 57 or 09957 to indicate that the decision to perform surgery was made at this visit. For Medicare, the decisions must be to perform major surgery (surgery with a 90-day post-operative period). Report separately the codes for the diagnostic tests or studies performed.
• #23: Use these codes if the patient has been seen by the physician, or any member of the group who is the same specialty, within the pat three years. These codes also apply to preoperative medical evaluation services rendered by the primary care physician at the request of the surgeon. Consider assigning the appropriate critical care code instead of these codes if the physician provided constant attention to a critically ill patient. Consider assigning the appropriate consultation code instead of these codes when an opinion or advice was provided about a patient for a specific problem at the request of another physician or other appropriate source. Report only the appropriate initial hospital care, hospital observation or comprehensive nursing facility assessment code if the patient is admitted to the hospital or a nursing facility on the same day as the office visit. Do not consider the time spent by other staff (e.g., nurse, nurse practitioner or physician assistant) as part of face – to – face time. Use a case management code when coordination of care involved other providers or agencies but did not involve a patient encounter on that day. Report additionally prolonged services codes 99354 – 99355, as appropriate, for E/M services that exceed 30 minutes of the typical time specified in the code narrative. Only the direct physician-patient (face-to-face) contact should be used to determine the prolonged service code. The time must be clearly documented in the medical record. (Some third party payers may allow reporting of prolonged services with only modifies-21 and the highest level of E/M service code. Be sure to verify the reporting requirements of the individual payer). Add modifier-24 or 09924 to indicate that an E/M service performed during the postoperative period was not related to the prior procedure. The claim should show a different diagnosis from that for the surgery. Add modifier-25 or 09925 to report that a separately identifiable E/M service was performed by the same physician on the same day as a procedure or service. Only the content associated with the separate E/M service should be considered when determining the correct level of service. Add modifier-57 or 09957 to indicate that the decision to perform surgery was made at this visit. For Medicare, de decision must be to perform major surgery. Report separately the codes for the diagnostic tests or studies performed.
• #26: Modifiers permit the Provider to indicate circumstances in which a procedure as performed differs from that described by its usual five digit code. Providers and coders must keep present that not all modifiers may be used with every CPT. Applicable modifiers are usually found at the beginning of each section.
• #28: -21 can only be used on the highest code in a category E/M 99205 99215 99245 99255 No specific payment amount attached. -22 Services are greater than those usually performed. Report should be included. -24 Used only on E/M code. Must be for condition or problem not related to the operation performed by surgeon 0-90 days preceding the visit -25 Used only on E/M code. Patient’s condition must warrant significant separate service. Most frequently used to bill office visit in conjunction with preventive medicine in the same day. -26 Used to indicate the professional component when technical component is billed by another Provider. If whole service is provided -26 is not needed.
• #29: If a patient comes into the office requiring emergency care and the Provider bills for the office visit, suturing of the laceration, and the surgical tray most insurance carriers will only pay for the suturing. However, if the office visit is coded as an emergency, most carriers may reimburse for the office visit. 99203 = $ 94.68 12001 = $141.69 99070 = $ N/A 99058 = $N/A $236.37
• #30: If multiple lacerations are repaired with the same technique and are in the same anatomic category, the Provider should add up the total length of all the lacerations and report one code to obtain maximum reimbursement. Coding these lacerations individually will result on the first laceration been paid at full price with the second and third laceration been down coded or pay at a fraction of the cost. 12011 = $150.06 12013 = $164.86/82.43 12013 = $164.86/N/A 12015 = $245.51 $232.49 $245.51
• #31: Legible by a common person Completeness include: Reason for encounter and relevant history Physical examination findings Prior diagnostic test results Assessment, clinical impression, or diagnosis Plan for care Date and legible identity of the observer Rationale for ordering tests documented unless easily inferred Past and present diagnoses should be accessible Health risks factors should be identified Patient’s progress, response to and changes in treatment should be documented
• #32: S = subjective statements of symptoms and complaints in the patient’s own words, chief complaint O = data from physical examination, x-rays, laboratory and other diagnostic tests A = assessment of subjective and objective parts of the chart note P = Diagnostic and therapeutic plan and instructions to the patient