CPC CHAPTER 19
What modifier is used to report an evaluation and management service mandated by a court order?
32 Response Feedback: 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.
HISTORY OF PRESENT ILLNESS A 73-year-old man who is a veterinarian is seen here for the first time today. He has a history of squamous cell carcinoma on the left arm and a basal cell carcinoma on the right forehead near the temple, both in January 20XX. He says he has had a lesion on his forehead for approximately one year. He is concerned about what it is and thinks it may be another skin cancer. He is also concerned about another lesion that has been present for a while, just lateral to his right eye. He would also like a full skin check today. He uses a hat for sun protection. He has lived in California and has had significant sun exposure in the past. REVIEW OF SYSTEMS: Otherwise well, no other skin complaints. PAST MEDICAL HISTORY Coronary artery disease status post bypass surgery, history of squamous and basal cell carcinomas as noted above, hay fever, and hyperlipidemia. He has had lipomas removed. MEDICATIONS: Tylenol, tramadol, thyroxin, fish oil, flax seed oil, simvastatin, Zyrtec®, 5% saline in eyes. ALLERGIES: No known drug allergies. FAMILY HISTORY: No family history of skin cancer or other skin problems. SOCIAL HISTORY: Patient is a veterinarian. He recently moved to the Rochester area from Pennsylvania. He is married. What is the level of history?
Expanded problem focused
Emergency Department A 47 year-old white male presents to the emergency department after the four-wheeler he was operating struck a ditch and rapidly came to a halt. This threw him against the windshield where he struck the mid part of his face and lower lip. This resulted in lip and chin lacerations. He is evaluated by Dr. Jones and a CT scan suggests a hyper dense abnormality within the brain. A bleed could not be ruled out and an inpatient hospital admission is recommended. His past history includes previous tonsillectomy, previous hospital admission for a syncopal episode associated with pain in the groin area, and hypercholesterolemia. He has no known allergies. His current medications are Zocor® and Accutane®. He is a non-smoker and a moderate drinker of alcohol. The review of systems is negative for nausea, vomiting, blurred vision, or headache. What is the level of history?
Expanded problem focused
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 Response Feedback: 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.
New Patient History & Physical CHIEF COMPLAINT: Right inguinal hernia. HISTORY OF PRESENT ILLNESS: This 44 year-old athletic man has been aware of a bulge and a pain in his right groin for over a year. He is very active, both aerobically and anaerobically. He has a weight routine which he has modified because of this bulge in his right groin. Usually, he can complete his entire workout. He can swim and work without problems. Several weeks ago in the shower he noticed there was a bulge in the groin and he was able to push on it and make it go away. He has never had a groin operation on either side. The pain is minimal, but it is uncomfortable and it limits his ability to participate in his physical activity routine. In addition, he likes to do a lot of exercise in the back country and his personal provider, Dr. X told him it would be dangerous to have this become incarcerated in the back country. PAST MEDICAL HISTORY: Serious illnesses: Reactive airway disease for which he takes Advair. He is not on steroids and has no other pulmonary complaints. Operations: None. MEDICATIONS: Advair. ALLERGIES: None. REVIEW OF SYSTEMS: He has no weight gain or weight loss. He has excellent exercise tolerance. He denies headaches, back pain, abdominal discomfort, or constipation. PHYSICAL EXAMINATION: VITAL SIGNS: Weight 82 kg, temperature 36.8, pulse 48 and regular, blood pressure 121/69. GENERAL APPEARANCE: He is a very muscular well-built man in no distress. SKIN: Normal. LYMPH NODES: None. HEAD AND NECK: Sclerae are clear. External ocular eye movements are full. Trachea is midline. Thyroid is not felt. CHEST: Clear to auscultation. HEART: Regular rhythm with no murmur. ABDOMEN: Soft. Liver and spleen not felt. He has no abnormality in the left groin. In the right groin I can feel a silk purse sign, but I could not feel an actual mass. I am quite sure he has by history and by physical examination a rather small indirect inguinal hernia. His cord and testicles are normal. IMPRESSION: Right indirect inguinal hernia. PLAN: We discussed observation and repair. He is motivated toward repair and I described the operation in detail. I gave him the scheduling number, and he will call and arrange the operation. What CPT® and ICD-10-CM codes are reported?
99203, K40.90 Response Feedback: Rationale: This is a new patient office visit which is coded from range 99201-99205. For a new patient office visit, all three key components must be met in order to support the level of visit. We have a detailed history (Extended HPI + Extended ROS + Pertinent History), Comprehensive exam (Const, Skin, Lymphatic, Eyes, Respiratory, Cardiovascular, Gastrointestinal, Genitourinary) and moderate MDM (New problem, no additional work up, no tests, elective surgery). The level of visit is 99203. In the ICD-10-CM Alphabetic Index look for Hernia, hernial/inguinal (indirect). Indirect is a nonessential modifier listed for Hernia, hernial/inguinal. You are directed to K40.90. Verify code in the Tabular List.
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 Response Feedback: 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 - PF (HPI-Brief, ROS-None, PFSH-Pert), Exam - Problem Focused, MDM - Moderate (Mgmt 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.
Mr. Flintstone is seen by his oncologist just two days after undergoing extensive testing for a sudden onset of petechiae, night sweats, swollen glands and weakness. After a brief review of history, Dr. B. Marrow re-examines Mr. Flintstone. The exam is documented as expanded problem focused and the medical decision making of moderate complexity. The oncologist spends an additional 45 minutes discussing Mr. Flintstone's new diagnosis of Hodgkin's lymphoma, treatment options and prognosis. What is/are the appropriate procedure code(s) for this visit?
99213, 99354 Response Feedback: Rationale: This is an established patient. Two of the three key elements are required for an established patient. An expanded problem focused exam and moderate MDM meet or exceed the requirement for code 99213. The provider spent an additional 45 minutes with the patient discussing the patient's new diagnosis. Prolonged Service codes 99354-99357 are used when provider or other qualified heath care professional provides prolonged service involving direct patient contact that is provided beyond the usual service. The codes reported based on the place of service and total time. Codes 99213 and add-on code 99354 are used to report the services.
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 Response Feedback: 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.
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 Response Feedback: 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.
A 33 year-old male was admitted to the hospital on 12/17/XX from the ER following a motor vehicle accident. His spleen was severely damaged and a splenectomy was performed. The patient is being discharged from the hospital on 12/20/XX. During his hospitalization the patient experienced pain and shortness of breath, but with an antibiotic regimen of Levaquin, he improved. The attending provider performed a final examination and reviewed the chest X-ray revealing possible infiltrates and a CT of the abdomen ruled out any abscess. He was given a prescription of Zosyn. The patient was told to follow up with his PCP or return to the ER for any pain or bleeding. The provider spent 20 minutes on the date of discharge. What CPT® code is reported for the 12/20 visit?
99238 Response Feedback: Rationale: The patient is being discharged from the hospital. Hospital discharge codes are determined based on the time documented the provider spent providing services to discharge the patient. The provider documented 20 minutes which is reported with 99238.
The attending provider at the hospital spent 25 minutes with the patient in the morning and another 15 in the afternoon examining the patient, writing discharge orders and giving discharge instructions to the patient. What CPT® code is reported for the discharge?
99239 Response Feedback: Rationale: In the CPT® Index look for Hospital Services/Inpatient Services/Discharge Services and you are directed to code ranges 99238-99239 and 1110F-1111F. Codes 1110F-1111F are Category II supplemental codes used for performance measurement. They may not be used as a substitute for Category I codes. Codes 99238-99239 are based on time. All of the time spent by the discharge provider on the discharge date is included in the time. The provider spent a total of 40 minutes with the patient on the discharge date. 99239 is the correct code choice.
A 45 year-old patient is seeing the neurologist, Dr. Williams, at the request of his family physician to evaluate complaints of weakness, numbness, and pain in his left hand and arm. The pain started last year after rocks fell on him while mining. He still has significant, sharp, burning wrist pain and reports the problems are continuing to get worse. He is limited in his job as a machinist for a mining company due to the pain and numbness. He has no swelling in his hand, no neck pain, or radiating pain. His past medical history is negative for significant diseases. He has had carpal tunnel surgery. He has a family history of hypertension, heart disease, and stroke. He is married with children and smokes one pack of cigarettes/day. A detailed exam is performed of the mental status, cranial nerves, motor nerves, DTRs, sensory nerves, and head and neck. After performing an EMG and nerve conduction study, Dr. Williams determines the patient has left ulnar neuropathy, at the cubital tunnel region, as well as an ongoing carpal tunnel syndrome. Repeat carpal tunnel surgery is recommended, along with a possible cubital tunnel surgical procedure. If the patient does not have surgery, he risks permanent nerve damage. A report is sent back to the physician requesting the consult. What is the appropriate E/M consultation code for this visit?
99243 Response Feedback: Rationale: A consultation requires all three key components be met to support the level of visit. History - HPI (extended), ROS (Extended), PFSH (complete) = Detailed Exam - Detailed MDM - New problems no additional work-up, one data point given (review/order of test in medicine section) for the EMG or Nerve conduction study. The level of risk is moderate (elective major surgery). The documentation supports a 99243.
Subjective: 6 year-old girl twisted her arm on the playground. She is seen in the ED complaining of pain in her wrist. Objective: Vital Signs: stable. Wrist: Significant tenderness laterally. X-ray is normal Assessment: Wrist sprain Plan: Over the counter Anaprox. Give twice daily with hot packs. Recheck if no improvement. What is the E/M code for this visit?
99281 Response Feedback: Rationale: Emergency Department services must meet or exceed three of the three key components. The provider performed a problem focused history (brief HPI, no ROS, no PFSH), a problem focused exam (one body area is examined) and low MDM (for one new problem to the examiner, one data point for the X-ray, and low level of risk). The problem focused history and exam lead us to select 99281 as the appropriate code.
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 Response Feedback: 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.
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: 96/60, 112, 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 Response Feedback: 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.
An infant is born six weeks premature in rural Arizona and the pediatrician in attendance intubates the child and administers surfactant in the ET tube while waiting in the ER for the air ambulance. During the 45-minute wait, he continues to bag the critically ill patient on 100 percent oxygen while monitoring VS, ECG, pulse oximetry and temperature. The infant is in a warming unit and an umbilical vein line was placed for fluids and in case of emergent need for medications. How is this coded?
99291-25, 31500, 36510, 94610 Response Feedback: Rationale: When neonatal services are provided in the outpatient setting, Inpatient Neonatal Critical Care guidelines direct the coder to use critical care codes 99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes and 99292 ... each additional 30 minutes (List separately in addition to code for primary service). Care is documented as lasting 45 minutes with the physician in constant attendance. The physician also administered intrapulmonary surfactant (94610), placed an umbilical vein line (36510) and intubated the patient (31500). According to CPT® Critical Care Services guidelines these procedures are not included in the critical care codes. Therefore, they can be reported separately in addition to critical care services with modifier 25 appended to code 99291.
Mrs. Standerfer's family physician visits her in the nursing home after a spell of dizziness and confusion reported by the staff at the nursing home. She sat down after lunch and stated she was dizzy. She slept for two hours after the spell. She states she is doing much better now. She has a known history of electrolyte imbalance and is on fluid restriction at the nursing home. She has not experienced any chest pain, Dyspnea, unexplained weight changes, or intolerance to heat or cold. No complaints of head or neck pain. During the exam, the physician takes her BP both supine and standing, and notes her pulse and temperature. A detailed exam of the eyes, ears, nose, and throat is performed along with a detailed neurological exam. The physician orders blood work to determine if her electrolytes are out of balance again. What is the appropriate E/M code for this visit?
99309 Response Feedback: Rationale: For subsequent nursing facility care codes, 2 of three key components must be met. History - (Extended), ROS (Extended), PFSH (1-Pertinent) = Detailed Exam - Detailed exam of eyes, ENT, Neuro. MDM - New problem with additional workup, lab ordered, moderate risk (undiagnosed new problem with uncertain prognosis) = moderate medical decision making. The documentation supports 99309.
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 Response Feedback: 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.
A patient is in the hospital after a wedge resection of the left lung due to cancer. He has not been able to keep the lung inflated without a ventilator. A 45-minute team conference between the general surgeon who performed the surgery, a pulmonologist, an oncologist and a neurologist is held to discuss the best treatment for the patient. The patient and/or patient's family is not present. What CPT® code is reported?
99367 Response Feedback: Rationale: In CPT® Index, look for Conference/Interdisciplinary Medical Team and you are directed to codes 99367, 99368. 99367 is reported for a medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more; participation by physician. All providers listed in the scenario are physicians; 99367 is the correct code.
After moving across country, Ms. Robbins took her 2 year-old daughter to a new pediatric clinic for an annual physical. The provider completed an age / gender appropriate history, exam, and provided anticipatory guidance. He ordered no additional tests or immunizations. What CPT® code is reported?
99382 Response Feedback: Rationale: This is a new patient to the pediatric clinic. Look in the CPT® Index for Preventive Medicine/New Patient and you are directed to code range 99381-99387. The code selection is based on age. Code 99382 is for ages 1-4 making it 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 hasn't 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 Response Feedback: 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 3 year-old critically ill child is admitted to the PICU from the ER with respiratory failure due to an exacerbation of asthma not manageable in the ER. The provider starts continuous bronchodilator therapy and pharmacologic support along with cardiovascular monitoring and possible mechanical ventilation support. The provider documents a comprehensive history and exam and orders are written after treatment is initiated. What is the CPT ® code for this encounter?
99475 Response Feedback: Rationale: This visit meets the criteria for Inpatient Neonatal and Pediatric Critical Care. Codes 99471 - 99476 are used to report the direction of the inpatient care of a critically ill infant or young child from 29 days through less than 6 years. Codes are further divided by initial and subsequent care. This is the initial care of a critically ill 3 year-old. Services provided in the ER by the admitting provider may not be coded. When a neonate, infant or child requires initial critical care services on the same day the patient has already received hospital care or intensive care services by the same provider, only the initial critical care service code (99468, 99471, 99475) is reported. Code 99475 is the correct code for this service.
Where are clinical examples for evaluation and management codes found in CPT®?
Appendix C Response Feedback: Rationale: Appendix C of CPT® 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 Response Feedback: 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.
Physical Exam: CONSTITUTIONAL: Vital Signs: Pulse: 161. Resp: 30. Temp: 102.4. Oxygen saturation 90% GENERAL APPEARANCE: The patient reveals profound mental retardation. Tracheostomy is in place. EYES: Conjunctivae are slightly anemic. ENT: Oral mucosa is dry. NECK: The neck is supple and the trachea is midline. Range of motion is normal. There are no masses, crepitus or tenderness of the neck. The thyroid gland has no appreciable goiter. RESPIRATORY: The lungs reveal transmitted upper airway signs and bilateral rales, wheezes and rhonchi. CARDIOVASCULAR: The chest wall is normal in appearance. Regular rate and rhythm. No murmurs, rubs or gallops are noted. There is no significant edema to the lower extremities. GASTROINTESTINAL: The abdomen is soft and nondistended. There is no tenderness, rebound or guarding noted. There are no masses. No organomegaly is appreciated. SKIN: The skin is pale and slightly diaphoretic. NEUROLOGIC: Cranial nerves appear intact. The patient moves all 4 extremities symmetrically. No lateralizing signs are noted. Gross sensation is intact to all extremities. LYMPHATIC: There are no palpable pathologic lymph nodes in the neck or axilla. MUSCULOSKELETAL: Gait and station are normal. Strength and tone to the upper and lower extremities are normal for age with no evidence of atrophy. There is no cyanosis, clubbing or edema to the digits. What is the level of exam?
Comprehensive Response Feedback: Rationale: Organ Systems: Constitutional, Eyes, ENMT, Respiratory, Cardiovascular, Gastrointestinal, Integumentary, Neurologic, Lymphatic, Musculoskeletal. Ten organ systems were examined. The level of exam is Comprehensive.
Physical Exam: GENERAL: His physical exam shows an intubated male. He is at times somewhat combative. There is a brace on the right shoulder. SKIN: His skin is warm and dry. No rashes, ulcers or lesions. LUNGS: The lungs are diminished breath sounds, though no crackles are noted. CARDIAC: Cardiac exam is tachycardic, no distinct murmurs appreciated. Extremities show no significant edema. ABDOMEN: Abdominal exam is soft. No masses or tenderness. No hepatosplenomegaly. EXTREMITIES: No clubbing or cyanosis. Bilateral lower. No misalignment or tenderness. Based on the 1995 documentation guidelines, what is the level of exam?
Detailed Response Feedback: Rationale: Organ Systems: Constitutional, Skin, Respiratory, Cardiovascular, Gastrointestinal, and Musculoskeletal. There are six organ systems examined with detailed documentation. The level of exam is Detailed.
According to CPT® guidelines what is the first step in selecting an evaluation and management code?
Determine the category or subcategory Response Feedback: Rationale: According to the CPT® guidelines the first step to determining a level of evaluation and management visit is to determine the category or subcategory of service.
A 77 year-old Medicare beneficiary has a digital rectal examination for prostate cancer screening and the provider orders a PSA. How would this be reported?
G0102 Response Feedback: Rationale: CMS has very specific guidelines on eligibility and coding of preventive services. There is no specific CPT® code for a digital rectal exam. Code 45990 is a diagnostic exam that includes a diagnostic anoscopy and rigid proctoscopy. Neither service is documented nor is it stated that the patient received an annual exam. The service provided is best represented by HCPCS code G0102. (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/PreventiveServices.html)
ED Visit: Data: BUN 74, creatinine 8.8, K 4.9, HGB 10.8, Troponin 0.01. I reviewed the EKG which shows some LVH but no ST changes. I also reviewed the chest x-ray, which showed moderate pulmonary vascular congestion, but no infiltrate. Impression: New problem of pulmonary edema due to hypervolemia. No evidence of acute MI or unstable angina. The patient also has ESRD which is stable and poorly controlled HTN, which is most likely due to hypervolemia. Plan: I spoke with the dialysis unit. We can get him in for an early treatment this afternoon as opposed to having to wait for his usual shift tomorrow. For that reason, it is okay to discharge him from the ED, to go directly to the unit. What is the level of medical decision making?
High Response Feedback: Rationale: New problem to examiner, additional workup - dialysis (four points); Labs, EKG, and X-ray reviewed (three points); risk is High (chronic illness posing a threat to life). The medical decision making is High.
Subsequent Hospital Visit 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: 20minutes. What is the level of medical decision making?
High Response Feedback: Rationale: Three problems worsening (six points); labs reviewed (one point); chronic illnesses posing a threat to life (exacerbation of congestive heart failure, poorly controlled hypertension, worsening acute renal failure due to cardio-renal syndrome). The medical decision making is High.
A PCP transfers a patient to a cardiologist for management of the patient's congestive heart failure. The cardiologist examines the patient, discusses treatment options and schedules a stress test for this new patient. A report is sent to the PCP detailing the findings of the office visit, results of the stress test and intent to manage and treat the congestive heart failure. An E/M code would be selected from what subcategory for the cardiologist?
New patient office visit Response Feedback: Rationale: The PCP transferred the patient to the cardiologist to manage/treat the congestive heart failure. The cardiologist accepted the transfer of care of the patient and sent a letter to the PCP with findings of the first visit and stress test. This would be coded as a new patient since the cardiologist accepted the patient and is taking over the care of a specific problem.
Dr. Hedrick, a neurosurgeon, was asked to assist in a surgery to remove cancer from the spinal cord. He acted as a co-surgeon working with an orthopedic surgeon. Dr. Hedrick followed up with the patient during his rounds at the hospital the next day. From what category or subcategory of evaluation and management services would Dr. Hedrick's follow up visit be reported?
Non-billable Response Feedback: Rationale: The follow-up visit from the neurosurgeon the day following surgery is bundled in the surgical procedure and is not billable. The visit is within the global period of the procedure.
A mother takes her 2-year-old back to Dr. Denton for an annual well child exam. The patient has a comprehensive check-up and vaccinations are brought up to date. Which category or subcategory of evaluation and management codes would be selected for the well child exam?
Preventive medicine, established patient Response Feedback: Rationale: The mother "takes her 2-year-old back to Dr. Denton" indicates this is an established patient. This is a well child exam with no complaints and a code from preventive medicine, established patient, would be selected. The preventive medicine, individual counseling codes are used for risk reduction such as diet and exercise, substance abuse, family problems, etc.
A provider admits Mrs. Smith to the hospital. She is there for five days. The provider sees her each day she's in the hospital. What subcategory of E/M codes would be used for days two, three and four?
Subsequent Hospital Care Response Feedback: Rationale: Codes from the Subsequent Hospital Care subcategory would be used for days two, three and four. The code for the first day would be from the Initial Hospital Care subcategory. Day five could be reported with either subsequent hospital care or hospital care discharge depending on the role of the provider.
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. What E/M Category is used for this visit?
Subsequent Hospital Visit (99231-99233) Response Feedback: Rationale: This is a subsequent hospital visit which is reported with code range 99231-99233; because 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 physician is 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.
