Transcript Detailed - the Woodland Hills Chapter Website Creating Coding

Evaluation and Management
Strategies For Success
American Academy of
Professional Coders
Woodland Hills California Chapter
Meeting July 2010
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Part Two
Fundamentals of Coding Evaluation
and Management Services
Presented by:
Elizabeth McAllister, CPC,
CPC-H, CPC-I, CEMC
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Evaluation & Management
Components
KEY COMPONENTS
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History
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Examination
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Medical Decision Making
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Counseling
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Coordination of Care
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Nature of Presenting Problem

Time*
History
Four Elements
The selection of the level of history obtained will
depend on the following factors:
Chief Complaint
 History of Present Illness
 Review of Systems
 Past, Family & Social History
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History of Present Illness
HPI
Eight Elements
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3.
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6.
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Location
Quality
Severity
Duration
Timing
Context
Modifying Factors
Associated Signs &
Symptoms
Brief and Extended HPIs are
distinguished by the amount
of detail needed to
accurately characterize the
clinical problem(s).
ROS
CMS/AMA Systems
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Constitutional Symptoms
Eyes
Ears, Nose, Mouth & Throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentatry System
Neurological
Psychiatric
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic
Past (Medical) Family and/or Social History (PFSH)
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Past History - Review of patient’s previous illness, injuries,
hospitalization, current medications, allergies, immunization
status.
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Family History – Review of patient’s family health status or
cause of death of parents, siblings, children. Also includes a
review of any diseases that may be hereditary, that may put
patient at risk.
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Social – Review of current activities, may include alcohol,
tobacco use, marital status, occupation, sexual history.
Evaluation and Management
Examination - Four Levels
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Problem Focused -a limited examination
of the affected body
area or organ system.
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Expanded Problem
Focused -- a limited
examination of the
affected body area or
organ system and
other symptomatic or
related organ
system(s).
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Detailed -- an
extended examination
of the affected body
area(s) and other
symptomatic or related
organ system(s).
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Comprehensive -- a
general multi-system
examination or
complete examination
of a single organ
system.
Examination
For purposes of examination, the following
body areas are recognized:
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Head, including the face
Neck
Chest, including breasts and axillae
Abdomen
Genitalia, groin, buttocks
Back, including spine
Each extremity
Examination
The following organ systems are recognized:
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Constitutional (e.g., vital signs, general appearance)
Eyes
Ears, nose, mouth and throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
Neurologic
Psychiatric
Hematologic/lymphatic/immunologic
Medical Decision Making
Levels
Straightforward is the lowest level
of Medical Decision-Making. It is
impossible not to qualify for it.
Low Complexity Medical
Decision-Making requires only
slightly more intellectual energy
than straightforward MDM.
The degree of risk remains quite
low and corresponds to a patient
with one chronic illness which is
completely stable.
If there is an acute problem, it
should be an uncomplicated clinical
issue such as allergic rhinitis,
cystitis or a sprained ankle.
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Medical Decision Making
Levels
Detailed Complexity
Medical Decision-Making
describes a patient with one
chronic illness with a mild
exacerbation or two stable
chronic illnesses would
satisfy the risk requirement
for this level of medical
decision-making.
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Medical Decision Making
Levels
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
High Complexity Medical
Decision-Making truly is
complex. Either the patient is
quite ill or the physician must
review a significant amount of
primary data.
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The patient would need to have
a severe exacerbation of a
chronic problem or an acute
illness which threatens life or
bodily function to qualify for this
level of risk.
Observation Services
CPT Code Range 99217 - 99220

Observation codes are used to identify evaluation and
management services delivered to a patient for a condition that
isn’t serious enough for admission into the hospital, but the
patient is not well enough to go home.
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Only the physician who admitted the patient to observation
and was responsible for care during the stay may submit
the hospital observation codes.
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Observation codes may not be utilized for post-op recovery
These services are a perennial favorite on the OIG Work plan
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Observation Services
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Medicare Reimbursement Guidelines
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The patient must be admitted to observation
status for a minimum of 8 hours.
Observation services paid for the following
conditions:
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Congestive Heart Failure
Asthma
Chest Pain
Observation Services
Initial Observation Care
99218 – 99220
3 of 3 Key Components
Required
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Includes initiation of
observation status
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Supervision of the care
plan
Performance of Periodic
Reassessments
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Observation Care Discharge
99220
Reports all services on
day of discharge.
Observation Codes
Admission/Discharge on Different Dates of Service
(3 out of 3 Key Components Required)
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CPT Code
History
Exam
Medical Decision
Making
99218
Detailed
Detailed
Straight forward or
Low Complexity
99219
Comprehensive
Comprehensive
Moderate Complexity
99220
Comprehensive
Comprehensive
High Complexity
Observation
Admission & Discharge on Same Date of Service
Initial Observation Care
99234 – 99236
3 of 3 Key Components
Required
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Includes all evaluation and
management services
provided by the admitting
physician related to the
initiation of “observation”
status.
Observation Codes
Admission and Discharge on Same Date of Service
(3 out of 3 Key Components Required)
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CPT Code
History
Examination
Medical Decision
Making
99234
Detailed or
Comprehensive
Detailed or
Comprehensive
Straight forward or Low
Complexity
99235
Comprehensive
Comprehensive
Moderate Complexity
99236
Comprehensive
Comprehensive
High Complexity
Coding Flow
Services Rendered by Same Physician
Office or
Other
Outpatient
Services
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Emergency
Department
Services
Observation
Services
Inpatient
Services
Initial Inpatient Hospital Care
(3 of 3 Key Components Required)
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Evaluation and Management Services provided on the same
day, in different sites that are related to the inpatient admission
should not be reported separately.
CPT
CODE
HISTORY
EXAMINATION
MEDICAL
DECISION MAKING
99221
Detailed or
Comprehensive
Detailed or
Comprehensive
Straight Forward or
Low Complexity
99222
Comprehensive
Comprehensive
Moderate Complexity
99223
Comprehensive
Comprehensive
High Complexity
Subsequent Inpatient Hospital Care
(2 of 3 Key Components Required)
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Includes review of medical record, diagnostic test results, and
changes in the patient’s status since last visit.
CPT
CODE
HISTORY
EXAMINATION
MEDICAL
DECISION
MAKING
99231
Problem Focused
Problem Focused
Straight Forward or
Low Complexity
99232
Expanded Problem
Focused
Expanded Problem
Focused
Moderate
Complexity
99223
Detailed
Detailed
High Complexity
Inpatient Discharge Management
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Report the total duration of time spent by a physician for
the final discharge of patient. Time does not need to be
continuous.
Inpatient Discharge Management
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Includes:
Final Examination
Discussion of Hospital
stay
Instructions for continuing
care
Preparation of discharge
records
Prescriptions and Referral
Forms
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99238
Discharge Management
30 Minutes or Less
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99239
Discharge Management
More than thirty Minutes
Time
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Face-to-face (office and other
outpatient visits) – Defined as
only that time that the physician
spends face-to-face with the
patient and/or family.
Work spent pre/post encounter
involved in such activities as
reviewing records and tests,
arranging further tests and
treatment, communicating
further with other professionals
and the patient through either
written reports of telephone
contact.
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Unit/floor time (hospital
observation and other inpatient
care) includes the time that the
physician is present on the
patient’s hospital unit and a the
bedside rendering services for
the patient.
This includes the time in which
the physician established
and/or reviews the patient’s
chart, examines the patient,
writes notes and communicates
with other professionals and the
patient’s family.
Office Consultation
(3 of 3 Key Components Required)
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CPT
Code
History
Examination
Medical Decision
Making
99241
Problem Focused
Problem Focused
Straight Forward
99242
Expanded
Problem Focused
Expanded Problem
Focused
Straight Forward
99243
Detailed
Detailed
Low Complexity
99244
Comprehensive
Comprehensive
Moderate Complexity
99245
Comprehensive
Comprehensive
High Complexity
Emergency Department Services
99281 - 99285
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An Emergency Department is a hospital based facility that is
open 24 hours a day for the purpose of providing unscheduled
services to patients who present for immediate medical
attention.
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The Emergency Department services do not distinguish
between new and established patients.
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Time is not a factor in code selection.
Emergency Department Services
(3 of 3 Key Components Required)
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CPT
Code
History
Examination
Medical Decision
Making
99281
Problem Focused
Problem Focused
Straight Forward
99282
Expanded Problem
Focused
Expanded Problem
Focused
Low Complexity
99283
Expanded Problem
Focused
Expanded Problem
Focused
Moderate Complexity
99284
Detailed
Detailed
Moderate Complexity
99285
Comprehensive
Comprehensive
High Complexity
Critical Care
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
Critical Care is provided to a critically ill or injured patient during a life
threatening medical crisis or trauma requiring immediate intervention
and life saving measures.
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Critical Care can be provided in any location.
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Care by the physician is constant, but does not need to be continuous.
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Time includes floor time, consulting with other medical staff and
documentation in medical record.
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Codes are patient age sensitive.
Critical Care
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
99291 – 99292 Critical Care
Patients are 24 months and
older
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For neonates and pediatric
critical care see code range
99471 - 99476
Critical Care Codes
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99291
Used to report the first 3074 minutes of critical care
on a given date.
Less than 30 minutes
should be reported with an
E & M code.
Coded only once per day.
Physician must devote
entire to time to the patient
(cannot be seeing other
patients at the same time).
+99292
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Reports each additional 30
minutes beyond the first 74
minutes.
Can be reported for the final
15 minutes (other 15 minute
increments are not reported)
Critical Care 99291 - 99292
Bundled Codes – Not Separately Reported
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Bundled Service(s) Rendered
CPT Code(s)
Vascular Access Procedures
36000, 36410, 36540, 36600
Gastric Intubation
43752, 91105
Chest x-rays
71010, 71015, 71020
Temporary Transcutaneous
Pacing
92953
Interpretation of cardiac output
measurements
93561, 93562
Ventilator Management
94656, 94657, 94660, 94662
Pulse oximetry
94760, 94761, 94762
Blood gasses & information data
99090
CPC, CPC-H,
Elizabeth McAllister, CPC,
CPC-H,EMS
EMS
stored in computers
(ECG’s, BP)
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Critical Care
Time Includes
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Patient care at bedside
Review of test results
on unit or floor
Discussion of patient
care
Documentation of
critical care including
patient’s condition
Documentation of Time
Critical Care – Transport Coding
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Physical attendance and
direct face-to-face care
during the inter facility
transport of a critically ill or
injured patient are time (and
age) based codes.
The time begins when the
physician assumes primary
responsibility of the patient
at the referring hospital and
concludes when the
receiving hospital accepts
responsibility for the patient.
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Codes are reported in thirty
minute increments
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99466, +99467 24 months of
age or younger
99291, +99292 older than
24 months
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Newborn Care
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Code 99460: Initial Evaluation of the normal newborn infant.
Hospital or birthing room. Includes initiation of diagnostic and
treatment programs, and preparation of hospital records.
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Code 99461: Normal Newborn Care outside the hospital or
birthing room. Includes physical examination and conference
with parents.
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Code 99462: Subsequent Hospital care (per day), evaluation
and management of a normal newborn
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Code 99463: Evaluatin and management of a normal newborn
that is delivered and discharged on the same date of service.
Newborn Care
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99464 Attendance at Delivery and initial stabilization of the
newborn.
99465 Delivery/Birthing room resuscitation, (provision of positive
pressure ventilation and/or chest compressions in the presence
of acute inadequate ventilation and/or cardiac output.
Pediatric and Newborn Care
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99468 – 99476
Initial and Subsequent
inpatient neonatal critical
care
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99477
Initial hospital care, per day
for the evaluation and
management of neonate 28
days or less who requires
intensive observation,
frequent interventions and
other intensive care services.

99478 – 99480
Subsequent intensive care, per
day, evaluation and
management recovering low
and very low birth weight infant
Preventive Care Services
Code Range 99381-99397
Used to code for routine
examinations or
asymptomatic patients of
all ages
Examinations are age
appropriate
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Divided into new and
established patients
Age & Gender Specific
– Counseling/Anticipatory
guidance/Risk factor
reduction interventions
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Documentation Requirements
– Comprehensive History &
Exam
 History does not contain a
CC or HPI
 Does require a complete
ROS
 Not synonymous with the
comprehensive
requirements of an E/M
service
Preventive Medicine Services Do
Not Have Medical Decision Making.
Preventive Medicine
New Patient Examination
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99381 Initial exam - infant age 1 and under
99382 Initial exam - ages 1-4
99383 Initial exam - ages 5-11
99384 Initial exam - ages 12-17
99385 Initial exam - ages 18-39
99386 Initial exam - ages 40-64
99387 Initial exam - age 65 years and over
Evaluation & Management
Categories & Sub-Categories
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Prolonged Services
With Direct Patient Contact
Without Direct Patient Contact
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Standby Services
Anticoagulant Management
Medical Team Conferences
Care Plan Oversight
99354 - 99357
99358 - 99359
99360
99363 - 99364
99366 – 99368
99374 - 99380
Preventive Medicine
Counseling Service
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Individual: New or Established Patient:
 99401 Preventive Medicine Counseling - 15 minutes
 99402 Preventive Medicine Counseling - 30 minutes
 99403 Preventive Medicine Counseling - 45 minutes
 99404 Preventive Medicine Counseling - 60 minutes
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Group Counseling and or Risk Factor Reduction
 99411 Approximately 30 minute session
 99412 Approximately 60 minute session
Evaluation & Management
Categories & Sub-Categories
 Nursing
Facility Services
 Domiciliary, Rest Home
 Oversight Services
 Home Services
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99304 - 99318
99324 - 99337
99339 - 99340
99341 - 99350
Coding resources
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AAPC website
CMS – Medical Learning Network
Associates and colleagues
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