Coding Practice: Chapter 10 CPT Evaluation and Management
In the Evaluation and Management chapter of CPT, locate the subsection Care Plan Oversight Services. Locate the code specific for home health care, 30 minutes, which directs the coder to CPT code 99375. 99375
Care Plan Oversight: Patient Under Care of Home Health Agency, Hospice, or Nursing Facility: A 75-year-old patient was just diagnosed with type 1 diabetes. This means that the patient will have to give himself insulin shots. The physician supervised the coordination of home health care, which required 30 minutes of his time.
99366 In the Evaluation and Management chapter of the CPT manual, locate the subsection for Case Management Services. Since this is a Medical Team Conference service, with 30 minutes of face-to-face meeting with health care professionals, with the patient present, only CPT code 99366 would be appropriate in this scenario.
Case Management Services: A 14-year-old boy twisted his ankle while playing soccer. He received level 3 E/M services from his physician the next morning for which code 99213 was reported on the CMS-1500 claim generated immediately after the visit. The physician ordered an x-ray of the ankle, and the child left the office after the x-ray but did not see the physician. Later that afternoon the patient and his mother came into the office and met with the physician, an orthopedic surgeon, and a rehabilitation therapist. Medical discussion was 45 minutes in duration.
In the Evaluation and Management chapter of the CPT manual, locate the subsection for Case Management Services. Since this is a Medical Team Conference service, with 30 minutes of face-to-face meeting with health care professionals, without the patient present, only CPT code 99367 would be appropriate in this scenario. 99367
Case Management Services: A 72-year-old patient with a history of breast cancer has a suspicious mass in her uterus. A biopsy was done. The determination was that the patient had a carcinoma in situ of the uterus. The physician who conducted the surgery called a face-to-face meeting with his fellow surgeons and discussed the case and the patient's outcome for 30 minutes.
In the Evaluation and Management chapter of the CPT manual, locate the subsection for Domiciliary Care, Rest Home, Assisted Living Visits, which represents CPT code range 99324-99337. Since this is a subsequent encounter, the code range is specified as 99334-99337 within this range. 99335
Domiciliary Care, Rest Home, Assisted Living Visits: A 21-year-old patient with a recent history of drug abuse is admitted to a rehab center for treatment. In the patient's second week of treatment, she complains of back pain and is seen by the same physician who evaluated her medically upon admission. At this time, the physician documents a problem focused interval history, an expanded problem focused examination, and the level of medical decision making is moderate .
In the Evaluation and Management chapter of the CPT manual, locate the subsection for Domiciliary Care, Rest Home, Assisted Living Visits, which represents CPT code range 99324-99337. Since this is a new patient, the code range is specified as 99324-99328 within this range. 99324
Domiciliary Care, Rest Home, Assisted Living Visits: A new patient diagnosed with mild intellectual disabilities and self-abuse is sent to a custodial care facility for admission. The patient's family is no longer able to care for the patient at home. The care facility physician documents a problem focused history with a problem focused exam. The level of medical decision making was straightforward.
In the Evaluation and Management chapter of the CPT manual, locate the subsection for Emergency Department, which represents CPT code range 99281-99285. 99285
Emergency Department Visits: A patient in the emergency department (ED) has a temperature of 103°F and is in acute respiratory distress. Symptoms include shortness of breath, chest pain, and gasping. The physician is unable to obtain a history or perform a comprehensive physical examination because the patient's condition is critical. The level of medical decision making is high.
In the Evaluation and Management chapter of CPT, locate the subsection Care Plan Oversight Services. Locate the code specific for hospice care, 45 minutes, which directs the coder to CPT code 99378. 99378
Care Plan Oversight: Patient Under Care of Home Health Agency, Hospice, or Nursing Facility: A 50-year-old female has brain cancer, and the physician supervised the coordination of hospice services, which required 45 minutes of his time.
In the Evaluation and Management chapter of the CPT manual, locate the subsection for Consultations, which represents CPT code range 99241-99255. Since this is an inpatient consultation, the code range is specified as 99251-99255 within this range. 99255
Consultations: A 13-year-old male was admitted yesterday for a tympanotomy. Postsurgically, the child developed fever and seizures of unknown origin. A pediatric consultation was requested, and the health plan allows CPT consultation codes to be reported. This was done on the second hospital admission day and 24 hours after surgery. The history of present illness (HPI) was extended with a complete review of systems (ROS). A complete past/family/social history (PFSH) was elicited from the mother as part of a comprehensive history. A comprehensive examination was conducted on all body areas and organ systems. The level of medical decision making was high.
In the Evaluation and Management chapter of the CPT manual, locate the subsection for Consultations, which represents CPT code range 99241-99255. Since this is an outpatient consultation, the code range is specified as 99241-99245 within this range. history exam straightforward 99242
Consultations: A 52-year-old patient was sent to a surgeon for an office consultation concerning hemorrhoids, and the health plan allows CPT consultation codes to be reported. An expanded problem-focused history and examination were performed. The consultant recommended treating with medication after a straightforward level of decision making.
Refer to the Evaluation and Management chapter of CPT, and the subsection Critical Care Services. Refer to the table contained in this section, and assign 99291 for the first hour, and 99292 x4 for the additional time as specified in the table. 99291, 99292 x4
Critical Care Services A physician is called to the intensive care unit to provide care for a patient who received second- and third-degree burns over 50 percent of his body due to a chemical fire. The patient is in respiratory distress and is suffering from severe dehydration. The physician provides support for two hours. Later that day, the physician returns and provides an additional hour of critical care support to the patient.
In the Evaluation and Management chapter, locate the Emergency Department subsection. Since Emergency Department encounters are all considered new, only one range of codes 99281-99285 exists. In addition to the emergency room visit, the physician also performed critical care services. Reference the Critical Care Services section of CPT and refer to the table, assigning 99291 for these services based on the 70 minutes of time. 99284-57, 99291
Emergency Department Visits: A patient presents with the complaint of hematemesis. The patient also has a rapid pulse rate and low blood pressure. In the ED, critical care is provided by the ED attending to raise the patient's blood pressure and decrease blood loss. This is done for 70 minutes before the patient is transferred to the surgical suite for an endoscopic procedure to evaluate his esophagus. The ED physician also documents a detailed examination and level of medical decision making is high. Due to the patient's medical condition, he is unable to provide any history; no family is present to provide information.
In the Evaluation and Management chapter, locate the Emergency Department subsection. As the service was not a face-to-face encounter but directing of EMT services, only CPT code 99288 would be appropriate.
Emergency Department Visits: With two-way communication, the physician directs the emergency medical technicians (EMTs) in an ambulance en route to the emergency department with a patient in apparent cardiac arrest.
In the Evaluation and Management chapter of the CPT manual, locate the subsection for Home Visits, which represents CPT code range 99341-99350. Since this is a new/initial encounter, the code range is specified as 99341-99345 within this range. 99343
Home Visits: A 15-year-old new patient has cystic fibrosis and is having problems with her Pulmozyme dosage. This medication is used to thin the mucus that clogs her lungs. The patient is having moderate throat pain and slight tightness in her chest. The physician makes a home visit to gather HPI and ROS and pertinent past personal medical information for a detailed history. The detailed exam focuses on the body systems currently affected by the cystic fibrosis and related organ systems: ears, nose, throat, mouth, respiratory, gastrointestinal, and cardiovascular. The level of medical decision making is moderate.
n the Evaluation and Management chapter of the CPT manual, locate the subsection for Home Visits, which represents CPT code range 99341-99350. Since this is an established/subsequent encounter, the code range is specified as 99347-99350 within this range. 99348
Home Visits: A 64-year-old female patient has diabetes and has been having problems adjusting her insulin doses. She has had an onset of dizziness and sensitivity to light. Her primary care physician, who has treated her for this condition during the past four years, makes a home visit today. At this visit, the physician gathers a brief HPI and a problem pertinent ROS during the problem-focused history. The physical exam focuses on the body systems currently affected by the diabetes. The patient's condition is moderately severe and the level of medical decision making is moderate.
In the Evaluation and Management chapter of the CPT manual, locate the subsection for Hospital Inpatient and Observation Services, subsection Observation, which represents CPT code range 99217-99226. Since this is an initial observation visit, the code range is specified as 99218-99220 within this range. In addition, an observation discharge was also performed, which is assigned CPT code 99217. HISTORY COMPRENSIVE 99219 exam detailed 99218 moderate 99219 level 99218 all components meet
Hospital Inpatient and Observation Services: A 55-year-old female came in with the complaint of severe abdominal pain. The patient was admitted on 05/07 to observation due to the severity and location of her pain. The admitting physician performed a comprehensive history and a detailed examination and documented level of medical decision making is moderate given the amount of possible diagnoses, including appendicitis, gastric ulcer, cholelithiasis, and pyelonephritis. Various diagnostic tests were ordered and done, including barium enema, upper gastrointestinal endoscopy, and KUB (kidneys, ureters, bladder) x-ray. No disease or disorder was found, and the patient was discharged from observation on 05/08. The patient reported a decrease in her pain after 30 hours of IV analgesics and antispasmodics. The physician documented that the patient should follow up with her primary care physician in two days or return to the hospital if the pain worsens. The physician also documented a final detailed examination of the patient and dictated a discharge summary report.
In the Evaluation and Management chapter of the CPT manual, locate the subsection for Hospital Inpatient and Observation Services, subsection Observation, which represents CPT code range 99217-99226. Since this is an initial observation visit, the code range is specified as 99218-99220 within this range. HISTORY COMPRESIVE 99219 EXAM COMPRESIVE 99219 NEW PATIENT X LEVEL ASSIGNED 99219
Hospital Inpatient and Observation Services: A patient was in an automobile accident and is complaining of a minor headache and no other apparent injuries. History gathered from bystanders states that the patient was not wearing a seat belt and hit his head on the windshield. A 15-minute loss of consciousness was noted. The patient was then admitted for 24-hour observation to rule out head injury. A comprehensive history and exam are performed by the physician. The level of medical decision making is moderate.
In the Evaluation and Management chapter of the CPT manual, locate the subsection for Hospital Inpatient and Observation Services, subsection Inpatient, which represents CPT code range 99221-99232. Since this is a subsequent hospital visit, the code range is specified as 99231-99233 within this range. 99233 high, detailed
Hospital Inpatient and Observation Services: An established patient is seen in the hospital on day 2 of his hospital stay. The patient had been admitted through the emergency department with status asthmaticus and had been undergoing extensive respiratory therapy over the past 24 to 30 hours. The physician performs a detailed interval history and a detailed physical exam. The possibility of pneumonia complicating the asthma must be considered. The patient's respiratory condition is still unstable. The level of medical decision making was high.
In the Evaluation and Management chapter of the CPT manual, locate the subsection for Hospital Inpatient and Observation Services, subsection Hospital Inpatient Services, which represents CPT code range 99221-99239. Since this is an initial hospital inpatient visit, the code range is specified as 99221-99223 within this range for the first date of service. Since it was specified as a Level 2 admission, each of these codes correspond to a level, i.e. 99221 is a Level 1, 99222 is a Level 2, 99223 is a Level 3. Therefore, the admission would be assigned 99222. The subsequent levels were also assigned a Level 2, which would be assigned 99232 for the 2 subsequent dates of service. The discharge was documented as 30 minutes, and therefore would be assigned 99238. The 99239 discharge CPT code is assigned only when the time is documented as greater than 30 minutes preparing the patient for discharge. 99222, 99232, 99232, 99238
Hospital Inpatient and Observation Services: Hospital Inpatient and Observation Services: A 50-year-old female patient was admitted to the hospital on 10/10 with a diagnosis of pneumonia due to Staphylococcus aureus, at which time she received level 2 E/M services from her attending physician. On 10/11 and 10/12, the patient received level 2 E/M services. On 10/13, the patient was discharged from the hospital in improved condition to follow up with the physician at home; the physician spent 30 minutes performing discharge day management functions.
Services for Life, Disability and Work-Related Visits are assigned from the Evaluation and Management chapter, subsection Special Evaluation and Management Services, Life/Disability or Work-Related Visits. Since this was a life-disability encounter, CPT code 99455 would be appropriate.
Life/Disability Insurance Eligibility Visits: A 58-year-old man was seen by his private physician for an examination as part of his claim for long-term medical disability. The patient has chronic obstructive lung disease with severe emphysema and has been unable to work during the past year. The physician documents a comprehensive medical history and a detailed examination. The physician reviews the patient's current medical treatment plan and recommends that it continue. All of the necessary documentation required by the insurance company is completed, including the physician's opinion that the patient would be unable to work in the future, as his pulmonary function is markedly impaired in spite of continual respiratory and pharmacologic therapy.
In the Evaluation and Management chapter, subsection Newborn care services is assigned based on initial/subsequent encounters and the location of services. In this instance, an initial service for newborn care was performed in the hospital, which corresponds to CPT code 99460. A subsequent hospital newborn care service was also performed, which corresponds to CPT code 99462. 99460, 99462
Newborn Care Services: A full-term healthy newborn girl received initial and subsequent hospital care services on July 7 and July 8, respectively. ,
In the Evaluation and Management chapter of CPT, locate the Non-Face-to-Face Services. These encounters are not assigned by HPI, Exam, and MDM elements, but based on the type of contact, i.e., phone versus online. Locate the codes for online (digital) non-face-to-face services of 5 minutes duration, which corresponds to CPT code range 99421. 99421
Non-Face-to-Face Physician Services: A patient e-mailed his physician to ask whether taking 500 mg of cinnamon tablets daily would be acceptable, given the prescribed medications he takes. The physician replied (5 minutes), approving his taking 500 mg of cinnamon tablets daily. The patient had previously been seen by the physician in the office 15 days ago, and he is scheduled to receive office E/M services in 60 days as part of his routine care.
In the Evaluation and Management chapter of CPT, locate the Non-Face-to-Face Evaluation and Management Services. These encounters are not assigned by HPI, Exam, and MDM elements, but based on the type of contact, i.e., phone versus online. Locate the codes for phone non-face-to-face services of 5 minutes duration, which corresponds to CPT code range 99441.
Non-Face-to-Face Physician Services: A physician called an established patient to inform her that the results of a chest x-ray were negative. The call was 5 minutes in duration. The patient had previously been seen in the office 10 days ago.
In the Evaluation and Management chapter of the CPT manual, locate the subsections for Nursing Facility Services, Initial which represents CPT code range 99304-99306. Since this is an initial encounter, 3 of the 3 E & M components will be required. history compressive 99306 exam detailed 99304 high 99306 level assigned 99304
Nursing Facility Services: A 72-year-old patient suffered a cerebral vascular accident (CVA). Today the patient is admitted to a skilled nursing facility (SNF) for rehab and medical care. The patient was just discharged from an acute care facility. The SNF medical director documents a comprehensive history, including the patient's chief complaint of paralysis and weakness, an extended HPI, and a complete ROS. A detailed exam of the patient's cardiovascular, respiratory, musculoskeletal, neurological, and genitourinary systems is documented. The physician orders a multidisciplinary rehabilitation care plan for the patient and the continued treatment of the patient's other medical conditions, including hypertension and diabetes. The level of medical decision making is high.
In the Evaluation and Management chapter of the CPT manual, locate the subsection for Nursing Facility Services, which represents CPT code range 99304-99310. Since this is a subsequent nursing facility visit, the code range is specified as 99307-99310 within this range. 99308
Nursing Facility Services: Subsequent follow-up care is provided for a comatose patient transferred to a long-term care center from the hospital two days ago. The resident shows no signs of consciousness on examination but appears to have developed a minor upper respiratory tract infection with a fever and rales heard on auscultation. The physician performs an expanded problem focused history and a problem focused interval examination with respiratory status and status of related organ systems such as cardiovascular. The physician is concerned that the respiratory infection could progress to pneumonia and orders the appropriate treatment. The level of medical decision making is moderate.
In the Evaluation and Management chapter of the CPT manual, locate the subsection for Office or Other Outpatient Visits, which represents CPT code range 99201-99215. Since this is a new patient office visit, the code range is specified as 99201-99205 within this range. Effective 2021, the office/outpatient visits codes are driven by medical decision making or time only. STRAIGHTFORWARD 99202
Office or Other Outpatient Visits: A 16-year-old outpatient who is a new patient to the office complains of severe facial acne. The history and physical examination related to the integumentary system was documented. With a minimal number of diagnoses to consider and a minimal amount of data to review, the level of medical decision making is straightforward
In the Evaluation and Management chapter of the CPT manual, locate the subsection for Office or Other Outpatient Visits, which represents CPT code range 99201-99215. Since this is an established patient office visit, the code range is specified as 99211-99215 within this range. Effective 2021, the office/outpatient visits codes are driven by medical decision making or time only. LOW 99213
Office or Other Outpatient Visits: A 4-year-old female established patient received Evaluation and Management services in her physician's office, which included a low level of medical decision making. The patient is diagnosed with influenza.
In the Evaluation and Management chapter of CPT, locate the subsection Preventive Medicine Services. These encounters are not assigned by HPI, Exam, and MDM elements, but based on age and new versus established patient. Locate the codes for new patient preventive medicine, which corresponds to CPT code range 99381-99387. As the patient is stated as 13 years old, CPT code 99384 would be appropriate in this instance. 99384
Preventive Medicine Services: A 13-year-old new patient presents for a well-check examination. The patient does not report any medical complaints.
In the Evaluation and Management chapter of CPT, locate the Preventive Medicine services. These encounters are not assigned by HPI, Exam, and MDM elements, but based on age and new versus established patient. Locate the codes for established patient preventive medicine, which corresponds to CPT code range 99391-99397. As the patient is stated as 75 years old, CPT code 99397 would be appropriate in this instance. 99397
Preventive Medicine Services: A 75-year-old established patient presents for his annual physical examination. The patient's chronic conditions are well controlled with diet and exercise.
Stand-by delivery services are not coded based on levels; therefore, in the Evaluation and Management chapter, locate the subsection Physician Stand-By Services, which is assigned CPT code 99360. 99360
Prolonged Services: A patient was in the delivery room ready to give birth. When the physician had the patient start pushing, possible complications for the infant were noted and the hospital pediatric neonatal specialist was notified of a possible need for her evaluation of this newborn. The pediatric specialist was notified at 9:20 am. At 10 am, she was informed via phone call from the OB/GYN that the infant had normal Apgar scores of 9 and 9.
In the Evaluation and Management chapter of the CPT manual, locate the subsection for Prolonged Services, which represents CPT code range 99354-99416. Refer to the table in the Prolonged Services section, and assign 99356, 99357, and 99357 for the additional time documented for face-to-face contact with the patient in the observation setting. 99356, 99357, and 99357
Prolonged Services: An observation patient with a history of asthma presents to the hospital with acute bronchospasm and moderate respiratory distress. The physician conducts a comprehensive examination, which shows an elevated respiratory rate of 30. Treatment is initiated: intermittent bronchial dilation and subcutaneous epinephrine. This service requires the physician to have intermittent direct contact with the patient for an additional two-hour period after the observation services encounter. The level of medical decision making is high. In addition to CPT code 99236, which Prolonged Services code is also reported?
