AAPC Ch.19 Evaluation & Management

What modifier is used to report an evaluation and management service mandated by a court order?

32 Rationale: Modifier 32 is used for services related to mandated consultation and/or related services by a third party payer, governmental, legislative or regulatory requirements.

A 60 year-old woman is seeking help to quit smoking. She makes an appointment to see Dr. Lung for an initial visit. The patient has a constant cough due to smoking and some shortness of breath. No night sweats, weight loss, night fever, CP, headache or dizziness. She has tried patches and nicotine gum which has not helped. Patient has been smoking for 40 years and smokes 2 packs per day. She has a family history of emphysema. A limited three system exam was performed. Dr Lung discussed in detail the pros and cons of medications used to quit smoking. Counseling and education was done for 20 minutes of the 30 minute visit. Prescriptions for Chantix and Tetracycline were given. The patient to follow up in 1 month. A chest X-ray and cardiac work up was ordered. Select the appropriate CPT code(s) for this visit.

99203 Rationale: Patient is coming to the provider's office for help to quit smoking. The patient is new. The provider documents that 20 minutes of the 30 minute visit was spent counseling the patient. E/M Guidelines identify when time is considered the key or controlling factor to qualify for an E/M service. When counseling and/or coordination of care is more than 50% face to face time in the office or other outpatient setting, time may be used to determine the level of E/M. The correct code is 99203 based on the total time of the visit which is 30 minutes.

A 37 year-old female is seen in the clinic for follow-up of lower extremity swelling. HPI: Patient is here today for follow-up of bilateral lower extremity swelling. The swelling responded to hydrochlorothiazide. DATA REVIEW: I reviewed her lab and echocardiogram. The patient does have moderate pulmonary hypertension. Exam: Patient is in no acute distress. ASSESSMENT: 1. Bilateral lower extremity swelling. This has resolved with diuretics; it may be secondary to problem #2. 2. Pulmonary hypertension: Etiology is not clear at this time, will work up and possibly refer to a pulmonologist. PLAN: Will evaluate the pulmonary hypertension. Patient will be scheduled for a sleep study

99212 Rationale: This is a follow-up visit indicating an established patient seen in the clinic. In the CPT® Index look for Established Patient/Office Visit. The code range to select from is 99211-99215. For this code range, two of three key components must be met. History Problem Focused (HPI Brief, ROS None, PFSH Pert), Exam Problem Focused, MDM Moderate (Management options: 1 stable problem, one new problem with workup; Data reviewed: lab and EKG; Level of Risk Moderate with unknown cause of pulmonary HTN). 99212 is the level of visit supported.

An established 47 year-old patient presents to the provider's office after falling last night in her apartment when she slipped on water on the kitchen floor. She is complaining of low back pain and no tingling or numbness. Provider documents that she has full range motion of the spine, with discomfort. Her gait is within normal limits. Straight leg raising is negative. She requested no medication. It is recommended to use heat, such as a hot water bottle. Provider's Assessment: Lower Back Muscle Strain. What E/M and ICD-10-CM codes are reported for this service?

99213, S39.012A, W01.0XXA, Y92.030 Rationale: The patient is an established patient. In the CPT® Index look for Established Patient/Office and/or Other Outpatient/Office Visit. You are referred to 99211-99215. An established patient visit requires 2 of 3 key components. The provider documents an Expanded Problem Focused History (brief HPI, pertinent ROS, and no PFSH), a Problem Focused Exam (1 affected organ system, musculoskeletal) and Low MDM (New Problem to examiner, no additional work-up, 0 data points, and acute complicated injury, e.g., simple sprain). Review codes to choose the appropriate level of service. Code 99213 is the correct code. Lower Back Muscle Strain was the provider's diagnosis. In the ICD-10-CM Alphabetic Index look for Strain/low back. You are referred to S39.012-. Tabular List shows that a 7th character is reported. A is reported for the initial encounter. Next go to the External Cause of Injuries Index. Look for Slipping (accidental) (on same level) (with fall)/on/surface (slippery) (wet) NEC. You are referred to W01.0-. In the Tabular List placeholders of X are needed for the 5th and 6th characters. The 7th character is reported with A to indicate initial encounter. Next look for Place of occurrence/residence/apartment/kitchen. You are referred to Y92.030. Review the code in Tabular List to verify accuracy.

A 28 year-old female patient is returning to her provider's office with complaints of RLQ pain and heartburn with a temperature of 100.2. The provider performs a detailed history, detailed exam and determines the patient has mild appendicitis. The provider prescribes antibiotics to treat the appendicitis in hopes of avoiding an appendectomy. What are the correct CPT® and ICD-10-CM codes for this encounter?

99214, K37, R12 Rationale: This is an established patient E/M level of service due to the indication she returning to her provider for the visit. Code 99214 is appropriate when two of the three key components are met for an established patient. According to the ICD-10-CM guidelines I.B.4. or I.B.18, a definitive diagnosis is reported when it has been established. Look in the ICD-10-CM Alphabetic Index for Appendicitis which directs you to K37. Guideline I.B.5 indicates any signs or symptoms that would be an integral part of that definitive diagnosis/disease process would not be separately reported. Heartburn is not a symptom commonly seen with appendicitis so we can report this as an additional code, refer to guideline I.B.6. Look in the Alphabetic Index for Heartburn which directs you to R12. Verification in the Tabular List confirms code selections.

A soccer player hits his head during an indoor game and is admitted to observation to watch for head trauma. Admit date/time: 01/21/20XX 8:12 PM Detailed History, Detailed Exam, Low MDM Discharge date/time: 01/22/20XX 8:15 AM Discharge time: 20 minutes What CPT® code(s) is/are reported for the admission and discharge to Observation Care?

99218, 99217 Rationale: Although the patient was in observation for less than 24 hours, the service covered two dates of service. The Observation care discharge day management code 99217 states this code is to be utilized to report all services provided to a patient on discharge from observation status if the discharge is on other than the initial date of observation status Initial Observation care is reported with code range 99218-99220. The level of history, exam and medical decision making support level 99218. Code 99217 is reported for Observation care discharge.

The physician was called to the hospital floor for the medical management of a 56 year-old patient who he admitted one day ago with chest pain due to aspiration pneumonia and COPD. Patient indicates no chest pain at present, but still SOB and some swelling in his lower extremities. Patient was tachypneic yesterday; examination of the lungs reveal course crackles in both bases, right worse than left. The physician writes instructions to continue with intravenous antibiotic treatment and respiratory support with ventilator management. He reviewed chest X-ray and labs. Patient is improving and a pulmonary consultation has been requested. What CPT® code is reported?

99231 Rationale: Physician is providing subsequent hospital care to an inpatient. The physician performed an expanded problem focused interval history (brief HPI, extended ROS since last assessment), problem focused exam (1 system), and low MDM (prescription drug management, two data points [reviewing X-ray and labs], and established diagnosis is improving). Subsequent hospital codes require two out of three key components. The code documented is 99231.

A 90 year-old female was admitted this morning from observation status for chest pain to r/o angina. A cardiologist performs a comprehensive history and comprehensive exam. Her chest pain has been relieved with the nitroglycerin drip given before admission and she would like to go home. Doctor has written prescriptions to add to her regimen. He had given her Isosorbide, and she is tolerating it well. He will go ahead and send her home. We will follow up with her in a week. Patient was admitted and discharged on the same date of service. What CPT® code is reported?

99235 Rationale: This patient was admitted and discharged on the same date of service from observation status. According to CPT® guidelines for Observation or Inpatient Care Services (Including Admission and Discharge Services), services for a patient admitted and discharged on the same date of service is reported by one code. For a patient admitted and discharged from observation or inpatient status on the same date, codes 99234-99236 is reported as appropriate." The provider performed a comprehensive history, comprehensive exam, and moderate MDM (New problem to the examiner, 0 data points and moderate risk). The correct code is 99235.

The EMS brought a 31 year-old motor vehicle accident patient to the Emergency Department. After a comprehensive history, a comprehensive exam and medical decision making of high complexity, the provider determines the patient has multiple internal injuries and needs immediate surgery. What level ED code is reported?

99285 Rationale: In the CPT® Index look for Evaluation and Management/Emergency Department. The code range is 99281-99288. All three key components must be met in order to reach the level of visit. A comprehensive history, comprehensive exam and medical decision making of high complexity supports a level 5 ED visit, 99285.

Dr. Inez discharges Mr. Blancos from the pulmonary service after a bout of pneumococcal pneumonia. She spends 45 minutes at the bedside explaining to Mr. Blancos and his wife the medications and IPPB therapy she ordered. Mr. Blancos is a resident of the Shady Valley Nursing Home due to his advanced Alzheimer's disease and will return to the nursing home after discharge. On the same day Dr. Inez re-admits Mr. Blancos to the nursing facility. She obtains a detailed interval history, does comprehensive examination and the medical decision making is moderate complexity. What is/are the appropriate evaluation and management code(s) for this visit?

99239, 99304 Rationale: Hospital discharge is a time-based code. The documentation states that the provider spent 45 minutes discharging the patient. In the CPT® Index look for Hospital Services/Discharge Services. Code 99239 is for 30 minutes or more. Upon discharge the patient was readmitted to a skilled nursing facility (SNF) where he is a resident. CPT® guidelines preceding the Initial Nursing Facility Care codes state when a patient is discharged from the hospital on the same day and readmitted to a nursing facility both the discharge and readmission is reported. Initial nursing facility care codes require the three key components to meet or exceed the requirements. Documentation tells us the physician provided a detailed history, comprehensive exam, and medical decision making was of moderate complexity. Code 99304 states the history and exam can be detailed or comprehensive. Our documentation shows it to be of moderate complexity, which meets the requirements. Because our history is only detailed, the requirements are not met for 99305.

A 25 year-old male is brought by EMS to the Emergency Department for nausea and vomiting. Patient has elevated blood sugars and the ED provider is unable to get a history due to patient's altered mental status. An eight organ system exam is performed and the MDM is high. The patient was stabilized and transferred to ICU. The ED provider documents total critical care time 25 minutes. What CPT® code is reported?

99285 Rationale: According to CPT® Critical Care Services guidelines: "99291 is used to report the first 30-74 minutes of critical care on a given date. Critical care of less than 30 minutes of total duration on a given date is reported with the appropriate E/M code." For this encounter the provider is short 5 minutes of 30 minutes needed to bill the critical care code. The encounter takes place in the emergency department. In the CPT® Index look for Evaluation and Management/Emergency Department. You are referred to 99281-99285. For emergency room services, three out of three key components are required. In this case, the provider is unable to obtain a history due to the patient's condition. According to the CMS Documentation Guidelines, the provider must indicate the reason they could not obtain a history. The level is determined by the exam and MDM. The exam is comprehensive (eight organ systems) and MDM is high. The proper code is 99285. There is also a statement in the description of 99285 that states, "within the constraints imposed by the urgency of the patient's clinical condition and/or mental status."

ICU - CC: Multi-system organ failure INTERVAL HISTORY: Patient remains intubated and sedated. Overnight events reviewed. Tolerating tube feeds. Systolic pressures have been running in the low 90s on LEVOPHED. Cultures remain negative. Kidney function has worsened, but patient remains non-oliguric. PHYSICAL EXAM: BP 96/60, Pulse 112, Temp 100.8. Lungs have anterior rhonchi. Heart RRR with no MRGs. Abdomen is soft with positive bowel sounds. Extremities show moderate edema. LABS: BUN 89, creatinine 2.6, HGB 10.2, WBC 22,000. ABG: 7.34/100/42 on 50% FiO2. CXR shows RLL infiltrate. IMPRESSION Hypoxic respiratory failure Community acquired pneumonia Septic shock Non-oliguric acute renal failure PLAN: Continue NS at 75 cc/hr. Decrease ZOSYN to 2.25 grams IV Q 6H Follow cultures. Continue tube feeds. Titrate LEVOPHED to maintain SBP > 90 Usual labs ordered for tomorrow. Critical care time: 35 minutes What CPT® code(s) is/are reported?

99291 Rationale: This patient meets the definition of a critically ill patient as defined by the E/M Guidelines for Critical Care services. A critical illness is one acutely impairing one or more vital organ system with a high probability of imminent or life threatening deterioration in the patient's condition. The physician documents 35 minutes of critical care time. Critical care for 35 minutes is reported with 99291.

A provider visits Mr. Smith's home monthly. Today, the provider performs a problem focused history, an expanded problem focused examination and a medical decision making of low complexity. What CPT® code is reported?

99348 Rationale: In the CPT® Index look for Home Services/Established Patient and you are directed to code range 99347-99350. Two of three key components must be met to support a level of visit for established patient home services. 99348 is the correct code choice.

Patient comes in today at 4 months of age for a checkup. She is growing and developing well. Her mother is concerned because she seems to cry a lot when lying down but when she is picked up she is fine. She is on breast milk but her mother has returned to work and is using a breast pump but has not seemed to produce enough milk. PHYSICAL EXAM: Weight 12 lbs. 11 oz., Height 25in., OFC 41.5 cm. HEENT: Eye: Red reflex normal. Right eardrum is minimally pink, left eardrum is normal. Nose: slight mucous Throat with slight thrush on the inside of the cheeks and on the tongue. LUNGS: clear. HEART: w/o murmur. ABDOMEN: soft. Hip exam normal. GENITALIA normal although her mother says there was a diaper rash earlier in the week. ASSESSMENT Four month-old well check Cold Mild thrush Diaper rash PLAN: Okay to advance to baby foods Okay to supplement with Similac Nystatin suspension for the thrush and creams for the diaper rash if it recurs Mother will bring child back after the cold symptoms resolve for her DPT, HIB and polio What E/M code(s) is/are reported?

99391 Rationale: Documentation states the encounter is for a checkup, which is a Preventive Medicine Service. In the CPT® Index look for Preventive Medicine/Established Patient. Preventive Medicine Service codes are age specific. Although the child has a cold and thrush, additional history and exam elements beyond what is performed in the preventative exam are not documented. It would be inappropriate to bill for an additional E/M service with the modifier 25. See Appendix A for a description of modifier 25.

A 10 year-old girl is scheduled for her yearly physical with her pediatrician. At the time of the visit, the patient complains of watery eyes, scratchy throat and stuffy nose for the past two days. The provider performs the physical. He also performs an expanded problem history and exam and treats the patient for a URI. What CPT® code(s) is/are reported for this visit?

99393, 99213-25 Rationale: The physical exam code is selected from the Preventive Medicine Services and selected based on whether the patient is new or established and by age. The pediatrician also evaluates and treats the URI. The additional work for the URI allows us to report an established patient office visit. Modifier 25 is appended to the office visit to show it is a significant and separately identifiable service from the preventive visit.

Where are clinical examples for evaluation and management codes found in the CPT® code book?

Appendix C Rationale: Appendix C of the CPT® code book contains clinical examples of evaluation and management codes. The appendix may be used in addition to the E/M code descriptors.

When tissue glue is used to close a wound involving the epidermis layer how is it reported?

As though it was a simple closure Rationale: The Guidelines for Repair (Closure) include tissue adhesive along with sutures and staples, either singly or in combination with each other can be reported with the repair codes. In this case the tissue glue (adhesive) is a one-layer closure and can be reported with a simple repair code. Wound closure utilizing adhesive strips as the sole repair material is coded using the appropriate E/M code.

What category of codes should be used to report an evaluation and management service provided to a patient in a psychiatric residential treatment center?

Nursing facility services Rationale: The guidelines for Nursing Facility Services state, "These codes should also be used to report evaluation and management services provided to a patient in a psychiatric residential treatment center."

A 65 year-old was admitted in the hospital two days ago and is being examined today by his primary care physician, who has been seeing him since he has been admitted. Primary care physician is checking for any improvements or if the condition is worsening. CHIEF COMPLAINT: CHF INTERVAL HISTORY: CHF symptoms worsened since yesterday. Now has some resting dyspnea. HTN remains poorly controlled with systolic pressure running in the 160s. Also, I'm concerned about his CKD, which has worsened, most likely due to cardio-renal syndrome. REVIEW OF SYSTEMS: Positive for orthopnea and one episode of PND. Negative for flank pain, obstructive symptoms or documented exposure to nephrotoxins. PHYSICAL EXAMINATION: GENERAL: Mild respiratory distress at rest VITAL SIGNS: BP 168/84, HR 58, temperature 98.1. LUNGS: Worsening bibasilar crackles CARDIOVASCULAR: RRR, no MRGs. EXTREMITIES: Show worsening lower extremity edema. LABS: BUN 56, creatinine 2.1, K 5.2, HGB 12. IMPRESSION: 1. Severe exacerbation of CHF 2. Poorly controlled HTN 3. Worsening ARF due to cardio-renal syndrome PLAN: 1. Increase BUMEX to 2 mg IV Q6. 2. Give 500 mg IV DIURIL times one. 3. Re-check usual labs in a.m. Total time: 20 minutes. What E/M category is used for this visit?

Subsequent Hospital Visit (99231-99233) Rationale: This is a subsequent hospital visit which is reported with code range 99231-99233. The patient was admitted in the hospital two days ago and the primary care physician has been seeing the patient since he has been admitted to the hospital. Initial Hospital Visit (99221-99223) is when the doctor is initially admitting the patient to the hospital. Inpatient Consultation (99251-99255) is when the provider requests for another provider to see the patient to recommend care for a specific condition or to accept ongoing management for the patient's condition. Established Patient Office/Outpatient Visit (99211-99215) is when the patient is being seen in the office setting, not the hospital.

A patient is diagnosed as having both acute and chronic tonsillitis. How is this reported in ICD-10-CM?

The acute tonsillitis is reported first; the chronic tonsillitis is reported second Rationale: Coding acute and chronic conditions in ICD-10-CM follows the coding guidelines I.B.8. If the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute or (subacute) code first.