Physician Coding II Evaluation and Management Codes

1. Physician Coding IIEvaluation and Management Codes E. Douglas Norcross, MD FACS Professor of Surgery Medical University of South Carolina

2. For most surgeons, procedure codes provide the bulk of codes used for billing.

3. However, surgeons perform Evaluation and Management services as well.

4. What are E and M codes anyway? Procedure codes are descriptors of specific procedures and activities Evaluation and Management Codes (E & M codes) are those used to describe patent encounters

5. E and M Service Types Commonly Used by Surgeons • Initial inpatient hospital visit • Subsequent inpatient hospital visit • New outpatient visit • Established patient outpatient visit • Observation/Inpatient visit: Admitted/Discharged on Same Date • Inpatient Hospital Discharge Service • Outpatient consultation • Inpatient consultation • Critical Care

6. What follows is going to seem almost unbelievably complicated! • That’s because it is! • Unfortunately, these are the rules nonetheless

7. But there are easy tools available one can carry in one’s pocket to help figure out the appropriate level of coding.

8. Each coding category is associated with a number of “levels of care”An example • 99221 Initial Hospital Care for the evaluation and management of a patient which requires these 3 components: • A detailed or comprehensive history • A detailed or comprehensive examination • Medical decision making that is straightforward or of low complexity • 99222 Initial Hospital Care for the evaluation and management of a patient which requires these 3 components: • A comprehensive history • A comprehensive examination • Medical decision making of moderate complexity • 99223 Initial Hospital Care for the evaluation and management of a patient which requires these 3 components: • A comprehensive history • A comprehensive examination • Medical decision making of high complexity

9. Another ExampleSubsequent Hospital Care • 99231 Subsequent Hospital Care, per day, for the evaluation and management of a patient, which requires at least two of these three components • A problem focused interval history • A problem focused examination • Medical decision making that is straightforward or of low complexity • 99232 Subsequent Hospital Care, per day, for the evaluation and management of a patient, which requires at least two of these three components • An expanded problem focused interval history • A expanded problem focused examination • Medical decision making of moderate complexity • 99233 Subsequent Hospital Care, per day, for the evaluation and management of a patient, which requires at least two of these three components • A detailed interval history • A detailed examination • Medical decision making of high complexity

10. So, to bill an Evaluation and Management Code, a physician must decide not only what type of service was provided, but also at what level.

11. So how does one decide which level to use?

12. Picking a Coding Level • Level of E and M service depends primarily upon 4 components • History • Physical Examination • Complexity of Decision Making • Time(Applies only for certain codes and/or special circumstances)

13. This is important!! The ONLY thing that matters is how much you document in each of these areas. What you actually do is irrelevant if it isn’t documented!

14. History • Level of history depends upon extent of documentation of: • History of Present Illness • Past Medical History/Family History/Social History • Review of Systems

15. A chief complaint must ALWAYS be documented or you can not send a bill!

16. Physical Examination • Level of physical examination depends upon the extent of documentation of the completeness of a physical examination performed.

17. Complexity of Medical Decision Making • Level of history depends upon extent of documentation of: • Number of Diagnoses • Amount of information reviewed • Risk of Morbidity and mortality

18. Determining Level of Code Code level Physical Examination History Medical Decision Making # diagnoses Data reviewed M & M risk HPI PFSH ROS

19. Let’s talk about the patient history first

20. HistoryFour recognized levels • Problem Focused History • Expanded Problem Focused History • Detailed History • Comprehensive History

21. So how do we decide if this is a problem focused history, an expanded problem focused history, a detailed history, or a comprehensive History?

22. History • Problem Focused • Chief Complaint • Brief history of present illness or problem • Expanded Problem Focused • Chief Complaint • Brief history of present illness or problem • Problem pertinent system review • Detailed • Chief Complaint • Extended history of present illness or problem • Problem pertinent system review extended to include a review of a limited number of additional systems • Pertinent past, family, and/or social history directly related to the patient’s problems • Comprehensive • Chief Complaint • Extended history of present illness or problem • Review of systems that is directly related to the problem(s) identified in the history of present illness plus a review of all additional body systems • Complete past, family, and social history

23. So there are levels for each component of the history • History of Present Illness • Past medical Surgical History/Family History/Social History • Review of Systems

24. Let’s start with the History of Present Illness

25. History • Problem Focused • Chief Complaint • Brief history of present illness or problem • Expanded Problem Focused • Chief Complaint • Brief history of present illness or problem • Problem pertinent system review • Detailed • Chief Complaint • Extended history of present illness or problem • Problem pertinent system review extended to include a review of a limited number of additional systems • Pertinent past, family, and/or social history directly related to the patient’s problems • Comprehensive • Chief Complaint • Extended history of present illness or problem • Review of systems that is directly related to the problem(s) identified in the history of present illness plus a review of all additional body systems • Complete past, family, and social history

26. So the HPI can be either brief or extended

27. So what the heck is the difference between a brief History of Present Illness and an extended History of Present Illness?

28. That depends on how many of the following components are documented. • Location • Duration • Timing • Severity • Quality • Context • Modifying Factors • Associated Signs/symptoms

29. History of Present Illness Components

30. History of Present Illness

31. Remember. You MUST have a chief complaint documented. It can be contained in the HPI or a narrative history but it has to be there.

32. An Example Patient is a 25 yo F with abdominal pain. Chief Complaint There is no HPI component. Therefore, according to the rules which require at least a brief HPI for any level of history, no billable history is documented for this patient encounter.

33. That may be OK for some E and M codes which require that only two of the three billing components (History, Physical Examination, and Complexity of Decision Making) are documented. For example, inpatient follow up visits only require two of the three components.

34. But any new patient encounter requires all three components! So, if this is all that is documented for a new patient you are seeing in the ER, you just provided an unbillable service no matter how extensive your documentation of physical examination, and no matter how complex the medical decision making!

35. You are now working for free!!!

36. An ExampleLet’s document a bit better! Patient is a 25 yo F with 24 hrhx of worsening, continuous, moderately severe, dull, RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting.

37. Patient is a 25 yo F with 24 hr hx of worsening continuous moderately severe dull RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting.

38. Patient is a 25 yo F with 24 hr hx of worsening continuous moderately severe dull RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting.

39. Patient is a 25 yo F with 24 hr hx of worsening continuous moderately severe dull RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting.

40. Patient is a 25 yo F with 24 hr hx of worsening continuous moderately severe dull RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting.

41. Patient is a 25 yo F with 24 hr hx of worsening continuous moderately severe dull RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting.

42. Patient is a 25 yo F with 24 hr hx of worsening continuous moderately severe dull RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting.

43. Patient is a 25 yo F with 24 hr hx of worsening continuous moderately severe dull RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting.

44. Patient is a 25 yo F with 24 hr hx of worsening continuous moderately severe dull RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting.

45. Patient is a 25 yo F with 24 hr hx of worsening continuous moderately severe dull RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting.

46. This is an extended HPI with all 8 components and is only two sentences long! Seriously… how hard is that?

47. So, on the sample coding tool……

48. Now let’s talk about the Past Medical History, Social History and Family History Components of the overall History

49. There are three components(And this one is easy!) • Past Medical/Surgical History • Family History • Social History

50. Past Medical History, Family History, Social History