CPT E/M codes

The 2 types of Non-Face-To-Face Physician Services

1. Telephone Services 2. On-line Medical Evaluation

What are the two instances that time is considered for E/M services?

1. Time based codes (eg. Hospital D/C) 2. When 50% or more of time is spent in counseling/coordinating care.

What are the three years that Documentation Guidelines were published?

1995 1997 2000

How many key components must be present to code a given level of Office/Other Outpatient Services, Established Patient?

2 of 3

How many elements are required to qualify for a given level of medical decision making?

2 of 3 (Majority is the choice.

What modifier is used, per payer request, when reporting non-bundled services into the Critical Care codes

25

How many key components must be present to code a given level of Office/Other Outpatient Services, New Patient?

3 of 3

E/M services represent which percent of all services provided to Medicare and Medicaid patients?

50%

Contributory Factors to E/M Level of Service Counseling

Coordination of Care Nature of Presenting Problem Time

This type of Preventive Medicine Services code is used when a patient is seen specifically to promote health, for example a diet/exercise program.

Counseling Risk Factor Reduction and Behavior Change Intervention.

Counseling One of 3 Contributing Factors

Discussion of diagnosis, test results, impressions, and/or recommendations, prognosis, treatment options, follow-up, etc.

The Documentation Guidelines apply only to this group of codes.

E/M Codes

Define "unlisted service"

E/M service may be provided that is possibly not listed in this section of the CPT codebook. •When reporting such a service, the appropriate "unlisted" code may be used to indicate the service, identifying it by "special report" example 99429 or 99499

Codes from this subsection are used by a hospital-based departments that are open 24 hours a day. They are often combined with Critical Care Services.

Emergency Department Services

Name and define the four types of history #2

Expanded problem focused: chief complaint; brief history of present illness; problem pertinent system review.

Standby service may be coded for time spent by a physician proctoring another physician.

False.

True or False: While reporting standby services for a patient, a physician may provide care/services to other patients.

False.

Coordination of Care One of 3 Contributing Factors

For example, arranging admission to rehabilitation hospitals and nursing facilities. Nature of the Presenting Problem One of 3 Contributing Factors

Inpatient neonatal and pediatric critical care codes are based on what factor?

The age of the patient. Neonate = 28 days or younger. Pediatric = 29 days through 24 months or 2-5 years.

concurrent care

The care given to the patient by more than one physician at the same time. For example, a pulmonologist and a cardiologist both treating the patient for different conditions at the same time.

High-complexity MDM Level equates to:

extensive dx/mgt options (4+ problem points) extensive data (4+ data points) high risk

Neurological Symptoms

faintness blackouts seizures paralysis tingling tremors memory loss

Musculoskeletal symptoms

joint pain/stiffness arthritis gout backache muscle pain cramps swelling redness limitation in motor activity

Low-complexity MDM Level equates to:

limited dx/mgt options (2 problem points) limited data (2 data points) low risk

Moderate-complexity MDM Level equates to:

multiple dx/mgt options (3 problem points) moderate data (3 data points) moderate risk

What type of problem as the highest number of MDM points?

new problem, additional followup planned

3 Key Components to E/M Level of Service History

phi Examination Medical Decision Making Complexity

Integumentary symptoms

rashes eruptions dryness cyanosis jaundice changes in skin/hair/nails breast lumps/dimpling/discharge

Associated signs and symptoms

s What other symptoms occur when main symptom occurs

Endocrine Symptoms

thyroid trouble heat/cold intolerance excessive sweating/thirst/hunger/urination blood sugar levels

True or False: If a significant problem is encountered during a preventive examination, additional E/M codes are used to report further services

true

New patient

- Has not received any professional service in last _ years from: -T he same physician - - From another physician of the exact same Specialty and subspecialty and in same group - New patients more labor intensive for physician and staff

What are the seven components used in selecting the level of E/M services?

- History - Examination - Medical decision making -Counseling -Coordination of care -Nature of presenting problem -Time

Instructions for Selecting a Level of E/M Service

- Identify the category(23) and subcategory(32) of service (see page 6 of CPT 2007 -Review the Reporting Instructions (guidelines) for the Selected Category or Subcategory -Review the level of E/M service descriptors and examples in the selected category or subcategory

How is the E/M section divided?

- Office visits - Hospital Observation svcs - Hospital Inpatient svcs - Consultations - Emergency Dept Svcs - Pediatric Critical Care Patient Transport - Critical Care Services - Inpatient neonatal and pediatric critical care svcs - Inpatient pediatric critical care - Inpatient neonatal critical care - Continuing ICU - Nursing Facility Svcs - Domiciliary, Rest Home or Custodial Care Svcs - Home Services - Prolonged Services - Case Management Svcs - Care plan oversight svcs - Preventive Medicine svcs - Special evaluation and management svcs - Other evaluation and management svcs

Chief complaint

- Reason for encounter - Patient's current complaint - Usually presented in patient's own words - Documented in medical record for each encounter - Required for all levels of service - May not be stated as "CC" but is inferred from documentation

Of the seven components, which 3 are considered the KEY components?

-History -Examination -Medical decision making

Make the distinction between testing/results/reports

-Testing leads to results; -Results - technical component of a service results lead to interpretation -Reports are the work product of the interpretation of numerous test results

Codes from this subsection are used to report the length of time the physician spends providing care to a critically ill patient

. Critical Care Services

Codes from this subheading cannot originate from an E/M service that was provided within the previous seven days and cannot lead to an E/M service within the next 24 hours or the next available appointment. The services are reported based on the time documented in the medical record

. Non-Face-To-Face Physician Services

This subsection has one code, 99499, that is used to indicate that there is no other code that accurately represents the services provided to the patient

. Other Evaluation and Management Services

History Levels Four history levels:

1 - Problem focused 2 - Expanded problem focused 3 - Detailed 4 - Comprehensive

Give two examples of physicians who can admit patients to a hospital

1. PCP 2. Hospitalist

Three subheadings under the Prolonged Services subsection.

1. Prolonged Physician Service With Direct Patient Contact 2. Prolonged Physician Service Without Direct Patient Contact 3. Physician Standby Services

This subsection is used to report coordination of care with other health professionals or in warfarin therapy management and coordination of care with other health care professionals

Case Management Services

CMS stands for

Centers for Medicare and Medicaid Services

Which government group is responsible for the Medicare program?

Centers for Medicare and Medicaid Services

Respiratory Symptoms

Chest Pain wheezing cough dyspnea sputum (color and quantity) hemoptysis asthma bronchitis emphysema pneumonia tuberculosis pleurisy last chest xray shortness of breath

cardiovascular symptoms

Chest pain rheumatic fever tachycardia palpitation high blood pressure edema vertigo faintness varicose veins thrombophlebitis

What subsection is used when a neonate or infant is not considered critically ill but still needs intensive observation?

Initial and Continuing Intensive Care Services VLBW Very Low Birth Weight (less than 1500 grams) LBW Low Birth Weight (1500-2500 grams)

consultant

A physician whose opinion and advice is requested by another physician, but does not take responsibility for the patient.

Examples of Type of Service Consultation

Admission Newborn Care Office Visit

Coding Preventive Medicine Services is largely based on what factor?

Age of the patient.

review of systems

An inventory of body systems obtained through a series of questions in which the patient reports signs or symptoms they are currently having or has had in past

Hematologic/Lymphatic Symptoms

Anemia easy bruising/bleeding past transfusions

Expanded Problem Focused History -

Brief history focused on CC - Brief HPI - Less than 3 of 8 elements or 1-2 chronic problems - ROS as it pertains to Presenting Problem - No PFSH

Problem Focused History -

Brief history focused on CC - Brief HPI - No ROS - No PFSH - Brief history includes 1-3 of the eight elements of the HPI

Name and define the four types of history #4

Comprehensive: general multisytem exam or complete exam of a single organ performed as part of the preventive medicine E/M service but its extent is based on age and risk factors identified.

Codes from this subsection are used when one physician asks another physician for an opinion about a patient

Consultation Services

The codes within this subsection are used to report physician supervision of a patient under the care of a home health agency in a home, domiciliary, or equivalent environment and supervision of care for patients in a hospice or nursing facility.

Care Plan Oversight Services

Name and define the four types of history #3

Detailed: chief complaint, extended history of present illness; problem pertinent system review extended to include a review of a limited number of additional systems

Established patient

Has received professional services in last 3 years from: - The same physician or - Another physician of exact same specialty and subspecialty in same group - Medical record available with current, relevant information

Family History -

Health status of family members: - Parents - Siblings - Children - Family history items related to CC

Elements of History Chief Complaint

History of Presenting Illness Review of Symptoms Past/Family/Social History

Codes from this subsection are for care provided in the patient's home.

Home Services

Examples of Place of Service Office

Hospital ED Nursing Home

Initial hospital care, Subsequent hospital care, and Discharge services are all types of what E/M Service?

Hospital Inpatient Services.

If the physician thinks the patient is not ill enough to be formally admitted but still needs to be observed, this code subsection will be used.

Hospital Observation Services.

Hospitalist

Hospital-based physician who only sees patients in the hospital and assumes the responsibility of the PCP for hospitalized patients. True or False: Services for a pt who is not critically ill but is in a critical care unit are reported using Critical Care codes. False. Use other appropriate E/M codes.

Name and define the four types of history #1

Problem focused:chief complaint; brief history of present illness or problem

Define Chief complaint

Is a concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter, usually stated in the patient's words.

Define counseling

Is a discussion with a patient and /or family concerning one or more of the following areas: - Diagnostic results, impressions, and/or recommended studies - Prognosis - Risks and benefits of management (treatment) options - Instructions for management (treatment) and/or follow up - Risk factor reduction - Patient and family education - Importance of compliance with chosen management (treatment) options

Define concurrent care

Is the provision of similar services example: hospital visits, to the same patient by more than one physician on the same day -when provided, no special reporting is provided

4 Levels of Medical Decision

Making Straightforward Low Moderate High

Straightforward MDM Levelequates to:

Minimal dx/mgt options (1 problem point) Minimal/no data (1 data point) Minimal risk

Severity of Chief Complaint

Name the two types of time that a physician spends in the care of the patient 1. Direct/face to face 2. Unit/floor time

Use codes from this subheading to report evaluation and management services provided to a normal newborn infant. These services may be provided in a hospital or in a birthing center. The services are reported on a per day basis of initial or subsequent service.

Newborn Care Service

Do you get multiple points if labs or xrays are ordered and/or reviewed?

No. One data point regardless of number of tests.

If a patient was seen in the office by his physician on Monday and during the appointment the physician decided to admit the patient to the Observation Unit of the local hospital, would you code both the office service and the observation service?

No. Services immediately prior to admission are bundled into the observation service and therefore not coded separately.

Nursing Facility

Not a hospital, but has inpatient beds and professional health care staff.

This subsection is used by non-hospital settings with a professional staff that provides continuous health care services to patients who are not acutely ill.

Nursing Facility Services

This subsection of codes could be the physician's office or other ambulatory facility, such as the outpatient surgery center at a hospital. These codes cannot be used once the patient has been admitted to a health care facility

Office and Other Outpatient Services

Inpatient

One who has been formally admitted to a health care facility (e.g., hospital, nursing facility, etc.) - Attending physician dictates: - Admission orders - H & P - Requests consultations

Outpatient

One who has not been formally admitted to a health care facility - Example: Patient receives service at clinic or same-day surgery center - Example: Patient admitted to "observation" status

History contains

Past, Family, and/or Social History (PFSH) - Past and Social relevant information about past: - Major illnesses/injuries - Operations - Hospitalizations - Allergies - Immunizations - Dietary status - Social history contains relevant information about: - Sexual history - Other relevant social factors (Example: Employment) - Past-present medications - Social tobacco/alcohol use

The codes within this subsection are used to report services when the patient is not currently ill but receives services.

Preventive Medicine Services

What is the exception to the key component concept?

Services that consist predominantly of counseling or coordination of care • NOTE; the nature of the presenting problem and the time are provided in some levels to assist in determining the appropriate level of E/M service

Lowest level of nursing facility

Skilled Nursing Facility (SNF) Staffed with physicians/nurses.

A patient comes into your physician's office for a physical examination for a life insurance policy. What group of codes would you use to report this service?

Special evaluation and management services

What must always accompany an unlisted E/M service code?

Special report

History of Present Illness (HPI)—

Subjective - Description of development of current illness e.g., date of onset - Patient describes HPI - If patient cannot answer for themselves, a parent, guardian, or other may provide - Eight elements in HPI - Provider must document

attending physician

The physician who admits the patient and is responsible for the patient during the stay in the inpatient facility.

What is the determining factor in assigning a level of Critical Care Service?

Time per day Subtract non-critical service time If less than 30 minutes, use other E/M code

True or False: Many Critical Care codes have other services bundled into the code

True.

Patients require more care than in standard nursing facility. True or False: Prolonged service of less than 30 minutes total duration on a given date is not separately reported.

True. The work involved is included in the total work of the E/M code.

Context

Under what circumstances a symptom occurs

Constitutional Symptoms

Usual weight, weight changes, fever, weakness, fatigue

Modifying Factors

What circumstances make symptom better or worse

Can Critical care and other E/M servcies may be provided to the same pt on the same day by the same physician?

Yes.

Do you get multiple points if labs are ordered AND reviewed?

Yes. One point for an ordered test, one point for a reviewed test.

Gastrointestinal Symptoms

appetite thirst nausea vomiting hematemesis rectal bleeding change in bowel habits diarrhea constipation indigestion food intolerance flatus hemorrhoids jaundice

Is there a distinction of new and established patient made in the ER department?

• No • E/M services in the ER department category may be reported for any new or established patient who presents for treatment in the ER.

How are the broad categories further divided?

• Subcategories •Levels of E/M svcs

Why is this classification important in how it is organized?

•Because physician work varies by - type of service, - place of service - the patient's status

What is the definition of a New and established Patient?

•New = is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years. •Established = is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.

What is the guideline when a patient receives services from the physician who is on call or a covering physician?

•The patient's encounter will be classified as it would have been by the physician who is not available

What is the basic format of the E/M service levels? General Format

•Unique code number is listed •The place and/or type of service is specified (ie office consultation •Content of the service is defined (ie comprehensive history and comprehensive examination •Nature of presenting problem(s) usually associated with a given level •The time typically required to provide the service