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BASIC REVIEW OF E&M DOCUMENTATION AND OFFICE VISIT CODING
– Two Types
– Evaluation and Management
• ICD
• … and these must make sense together
• Chapter 1: Evaluation and Management Codes
(99201-99499)
• The diagnosis ICD9 code supports the medical necessity of the procedure CPT code.
• Sub-set of the CPT codes.
• Can be used by all providers
• Describes:
– The place of service
– The type of service (new vs. established, consult, preventive, ER, critical care, etc.)
• Defined by 3 components
– Phsical examination
– Medical decision making
• Over coding = Fraud
• Under coding = Lost Revenue and Fraud
• It is the Content, not the volume, of documentation that determines your E&M code!
• The documentation must support medical necessity of the services provided.
• “If it isn’t documented, it wasn’t done!”
• New patient
• Components
– Brief, which includes documentation of one to three HPI elements.
– Extended, which includes documentation of at least four HPI elements or the status of at least three chronic or inactive conditions.
– HPI must be documented by the physician
– Review of Systems (ROS)
– Past Family and/or Social History (PFSH)
• The following “systems” are recognized:
– Psychiatric
– Eyes
– Endocrine
– Ears, nose, mouth, throat
– Neurological
– Cardiovascular
– Allergic/Immunologic
– Respiratory
– Gastrointestinal
– Musculoskeletal
– Integumentary (skin and/or breast)
– Hematologic/Lymphatic
• Past History
• Family History
• Social History
– Pertinent vs. Complete
HISTORY TYPE | HPI | ROS | PFSH |
Problem Focused (1 point) | Brief | None | None |
Expanded Problem Focused (2 points) | Brief | Problem pertinent | None |
Detailed (3 points) | Extended | Extended | Pertinent |
Comprehensive (4 points) | Extended | Complete | Complete |
– Organ Systems
– Neck
– Chest, including breast and axillae
– Abdomen
– Genitalia, groin, buttocks
– Back (including spine)
– Each extremity (separately)
– Eyes
– ENT, Mouth
– Cardiovascular
– Respiratory
– GI
– GU
– Musculoskeletal
– Skin
– Neurologic
– Psychiatric
– Hematologic; Lymphatic; Immunologic
TYPE | Either this | Or this |
Problem Focused (1 point) | < 1 organ system/Body area | 1-5 bulleted elements |
Expanded Problem Focused (2 points) | 2-4 Organ Systems/Body areas | 6 or more Bulleted Elements |
Detailed Exam (3 points) | 5-7 Organ Systems/Body Areas | 2 or more Bulleted Elements from 6 areas or 12 or more Bullets from 2 or more areas |
Comprehensive Exam (4 points) | 8 or more Organ Systems/Body Areas | Complete single system examination or 2 or more Bulleted elements from 9 areas |
– Amount and complexity of data
– Overall risk
• Need documentation of:
– Amount and/or complexity of data
– Risk of complications, morbidity and mortality
• Four types
FINAL MEDICAL DECISION MAKING
Decision Making | Straight Forward | Low | Moderate | High |
Diagnosis and/or Management Options | Minimal (1) | Limited (2) | Multiple (3) | Extensive (4+) |
Amount of Data Reviewed | Minimal (1) | Limited (2) | Multiple (3) | Extensive (4+) |
Table of Risk | Minimal (1) | Low (2) | Moderate (3) | High (4) |
• Documentation of total time needed
• Example:
– Total visit time 25 minutes, counseling time 15 minutes
– 3,3,4 = 3
– Used for new patient, initial consults, initial hospital care and emergency department visits
• 2 of 3 rule
– 3,3,4 = 3
– Used for established patient, subsequent hospital f/u, f/u consult
• Established Patient
Level of Service | History | Examination | Medical Decision Making |
99201 | Problem focused | Problem focused | Straight forward complexity |
99202 | Expanded problem focused | Expanded problem focused | Straight forward complexity |
99203 | Detailed | Detailed | Low complexity |
99204 | Comprehensive | Comprehensive | Moderate complexity |
99205 | Comprehensive | Comprehensive | High complexity |
Code | History | Physical Exam | Medical Decision Making | Time |
99211 | Nursing service only | N/A | Nursing order | 5 |
99212 | Problem focused | Problem focused | Straight forward | 10 |
99213 | Expanded Problem Focused | Expanded Problem Focused | Low complexity | 15 |
99214 | Detailed | Detailed | Moderate complexity | 25 |
99215 | Comprehensive | Comprehensive | High complexity | 40 |
– Reason for consultation
– Report Consultant’s opinion, advice and evaluation of the patient
• Have separate coding for the initial and follow up visits
• Smoking Cessation
• Visit and procedures
• 90472 is for additional administration
• 90406 Greater than 3 minutes, up to 10 minutes
• 99407 Greater than 10 minutes
• Digital Retal Exam G0102
• Visual Acuity Exam 99173