E&M Coding & Documentation

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E&M CODING AND DOCUMENTATION
BASIC REVIEW OF E&M DOCUMENTATION AND OFFICE VISIT CODING

ACMSS CONTINUING SCRIBE EDUCATION

TYPES OF “CODES”

• Procdure codes

– What I did during the visit
– Two Types

– CPT
– Evaluation and Management

• ICD

– The actual diagnosis code

• … and these must make sense together

CPT: CURRENT PROCEDURAL TERMINOLOGY

• A CPT code is a five digit numeric code that is used to describe medical, surgical, radiology, laboratory, anesthesiology, and evaluation/management services of physicians, hospitals, and other health care providers.

• Chapter 1: Evaluation and Management Codes
(99201-99499)

CPT AND ICD-9

• The diagnosis ICD9 code supports the medical necessity of the procedure CPT code.

WHAT ARE EVALUATION & MANAGEMENT (E&M) CODES?

• Sub-set of the CPT codes.
• Can be used by all providers
• Describes:

– Complexity of care
– The place of service
– The type of service (new vs. established, consult, preventive, ER, critical care, etc.)

• Defined by 3 components

– Medical history
– Phsical examination
– Medical decision making

WHY DO WE NEED TO CODE?

• REIMBURSEMENT by insurance
• Over coding = Fraud
• Under coding = Lost Revenue and Fraud
• It is the Content, not the volume, of documentation that determines your E&M code!

DOCUMENTATION

• The documentation must support the E&M code
• The documentation must support medical necessity of the services provided.
• “If it isn’t documented, it wasn’t done!”

NEW PATIENT

• New patient

– Any patient who has not received professional services, within the previous 36 months, from a provider within the same group of the same specialty

HISTORY

• Components

– History of Present Illness (HPI)

– Chief Complaint Required
– 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)

REVIEW OF SYSTEMS

• The following “systems” are recognized:

– Constitutional (fever, weight loss)
– Psychiatric
– Eyes
– Endocrine
– Ears, nose, mouth, throat
– Neurological
– Cardiovascular
– Allergic/Immunologic
– Respiratory
– Gastrointestinal
– Musculoskeletal
– Integumentary (skin and/or breast)
– Hematologic/Lymphatic

HISTORY — PFSH

• Past History

– Past experience with illnesses, operations, injuries and treatments

• Family History

– Review of medical events in patients family, including hereditary disease

• Social History

– Age appropriate review of past and current activities
– Pertinent vs. Complete

HISTORY ALGORITHM

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

PHYSICAL EXAM

• Organized by:

– Body Areas, or
– Organ Systems

PHYSICAL EXAM

• Body areas:

– Head (including face)
– Neck
– Chest, including breast and axillae
– Abdomen
– Genitalia, groin, buttocks
– Back (including spine)
– Each extremity (separately)

• Organ Systems:

– Constitutional
– Eyes
– ENT, Mouth
– Cardiovascular
– Respiratory
– GI
– GU
– Musculoskeletal
– Skin
– Neurologic
– Psychiatric
– Hematologic; Lymphatic; Immunologic

PHYSICAL EXAMINATION ALGORITHM

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

MEDICAL DECISION MAKING

• Based upon:

– Number of diagnoses or management options
– Amount and complexity of data
– Overall risk

MEDICAL DECISION MAKING (MDM)

• The complexity of determining a diagnosis and/or treatment
• Need documentation of:

– Number of diagnoses and/or management options
– Amount and/or complexity of data
– Risk of complications, morbidity and mortality

• Four types

– Straightforward, Low Complexity, Moderate Complexity, and High Complexity.

MEDICAL DECISION MAKING
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)

TIME…AS ANOTHER FACTOR

• Appropriate in cases where counseling and/or coordination of care dominates (>50%) of the patient and/or family encounter
• Documentation of total time needed
• Example:

– A/P: Depression. Had long discussion w/patient and counseled him on exacerbating factors and treatment options. Rx ordered (list)
– Total visit time 25 minutes, counseling time 15 minutes

THE CONSTANTS OF CODING (WILL MAKE SENSE IN LATER SLIDES)

• 3 of 3 rule

– Go to the lowest component

– i.e., 2,3,4 = 2
– 3,3,4 = 3

– Used for new patient, initial consults, initial hospital care and emergency department visits

• 2 of 3 rule

– Go the the middle component

– 2,3,4 = 3
– 3,3,4 = 3

– Used for established patient, subsequent hospital f/u, f/u consult

NEW VS. ESTABLISHED PATIENTS

• New Patient

– All key components must et or exceed stated requirements to qualify for a particular level

• Established Patient

– Two key components must et or exceed stated requirements to qualify for a particular level

NEW PATIENT CODE MATRIX

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

ESTABLISHED PATIENT CODE MATRIX

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

CONSULTATION CODES

• Documentation MUST include:

– Request for consultation
– Reason for consultation
– Report Consultant’s opinion, advice and evaluation of the patient

• Have separate coding for the initial and follow up visits

OTHER BILLABLE SERVICES

• Injections / Immunizations
• Smoking Cessation
• Visit and procedures

INJECTIONS / IMMUNIZATIONS, SMOKING, OTHER SERVICES

• 90471 is for first administration
• 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