HCA Encounter Form Education May 2006

1. HCAEncounter Form EducationMay 2006 Office / Outpatient Visits Documentation Requirements Billable Time 99211 Services Consultations Preventative Medicine Visits Screenings Modifiers

2. Office Visits New vs. Established A “new” patient (99201-99205) is someone who has not seen a provider (MD, PA, NP) within same group; same specialty; same group payor ID number within the last 3 years. An “established (99211-99215) patient is someone that has seen a provider (MD, PA, NP) within same group; same specialty; shared group payor ID # within the last 3 years. New/Established designation is regardless of location of initial service. If a patient is seen in the hospital by Dr. A and later continues care with Dr. A in his/her office, they are established. If you are a new physician who has taken over patients from a retiring physician and the patient has seen either that provider or another provider in the same group; same specialty; same payor ID number within the last 3 years, they will be established to you.

3. Documentation • The medical record is a “legal” document. • The medical record should be complete and legible • The reason for the visit should be clear • The date and legible identify of the observer clearly noted • The rationale for ordering diagnostic and other ancillary services should be easily inferred. • The patient’s progress, response to and changes/revisions in Treatment/diagnosis or need for continued treatment should be well documented.

4. Documentation One of 2 things will happen when you provide an E&M office, outpatient consultation or inpatient service to a patient. Either: • You will spend 50% or more of the visit in a discussion;counseling; discussing mgmt options, coordinating care whereby then you need to document “time spent in these activities” or • You will spend 50% or more of the visit securing an HPI, Exam and determining the assessment and plan (eg. workup, treatment). If this occurs, a notation of time spent performing this review is NOT required. Instead elements of HPI, Exam and medical decision making will support your code selection.

5. Billable Time (>50% of the total visit time) When the patient is present, counseling includes discussions on: Diagnostic results, impressions, and/or recommended studies; prognosis; risks and benefits of management (treatment) options; Instructions for management (treatment) and/or follow-up; Importance of compliance with chosen management (treatment) options; Risk factor reduction; and patient and family education. Coordination of Care w/other health care professionals *Remember to “document time” spent in discussion.

6. The Documentation ProcessE&M Coding – when HPI, Exam and MDM predominant (>50% of total visit time) A provider note is broken up into 3 key sections • History • Exam • Medical Decision Making

7. The Documentation ProcessE&M Coding The HPI and Examination are described as: • Problem Focused • Expanded Problem Focused • Detailed • Comprehensive The MDM (Medical Decision Making) is described as: • Straightforward/Minimal • Low • Moderate • High Complexity Mgmt

8. The Documentation ProcessE&M Coding - HPI The HPI requires: • Reason for the Visit • Present Factors (timing, location, modifying factors, signs/symptoms, duration, quality, context, and/or severity) • Review of Systems • Past, Family, Social History

9. The Documentation ProcessE&M Coding - Exam The Exam requires: • 1995 or • 1997 guidelines

10. 1995 Exam Guidelines Body Areas (ea. are a count of 1) • Head/Face • Neck • Abdomen • Chest, including breast & Axillae • Genitalia, groin, buttocks • Back, including spine • “Each” extremity

11. 1995 Exam Guidelines Systems (ea. are a count of 1) • Constitutional • Eyes • Ears, Nose, Mouth, Throat • Cardiovascular • Respiratory • GI • GU • Musculoskeletal • Skin • Neuro • Psych • Hematologic • Lymphatic • Immunologic

12. 1997 Exam Guidelines In 1997 the AMA and CMS proposed a different set of guidelines for documentation of the provider exam. 9 specialties participated and developed individual specialty templates to represent what they believed incorporated elements of their exam. Single System (S) Multi-Specialty (M) • Cardiovascular Anyone • ENT • GI • GU • Skin • Neuro • Muscloskeletal • Psych • Skin

13. Difference between 1995 & 1997 Exam 1995 You could and still say: HEENT: Normal 1997 You would have to state the elements reviewed within a system/body area – eg. Oropharnyx is clear, TM’s are normal

14. Medical Decision Making 1 of 3 Key Categories Category 1: Self-limiting/minor problem (stable, improved) 1 pt Established problem (stable, improved) 1 pt Established problem (worsening, not optimally responding) 2 pts New Problem w/o workup 3 pts New problem with workup 4 pts 1pt=minimal; 2pt=low risk; 3pt=moderate risk; 4+pts= high risk Note: Please list all problems affecting your decision making on that visit. Please indicate if problem is new; worsened; stable, mild/serious exacerbation and/or life-threatening.

15. Medical Decision Making 2 of 3 Key Categories Category 2: Review/order labs (regardless of # ordered/reviewed) 1 pt Review/order radiology tests (regardless of # ordered/reviewed) 1 pt Review.order EEGs, EKGS (regardless of # ordered/reviewed) 1 pts Discuss results w/interpreting provider 1 pt Obtain old records other then from pt 1 pt Review/Summarize old records and or obtain history from someone Other then patient and/or discussion of case w/another healthcare Provider 2 pts Independent Review of image/specimen/tracing 2 pts 1=minimal 2=low risk 3=moderate risk 4+= high risk

16. Medical Decision Making 3 of 3 Key Categories Category 3: Minimal (reassurance, no OTC, no medication mgmt) • Colds • URI w/o Fever • Bug bite Low risk (1 stable Chronic problem, acute uncomplicated illness) • Sinusitis • Vaginitis • URI w/Fever • Bronchitis (not serious/pneumo) • Headache w/o nausea vomiting • Low back pain

17. Medical Decision Making 3 of 3 key areas continued Moderate risk (2+ stable CI, 1 CI w/mild exacerbation; undiagnosed new problem) • Hard node in breast w/workup • Headache/migraine w/nausea/vomiting • Blood in stools • 3+ stable chronic problems • Mild exacerbation of 1 chronic illness High risk (significant exacerbation of a CI, threat to life/self) • Chest pain • Significant Shortness of Breath; COPD pt. • Multiple Chronics evaluated (HTN, Diabetes, Renal Failure, COPD, Hyperlipidemia) • Significant exacerbation of 1 chronic illness

18. New Patient Visit (99201-05)Consultations (99241-45) HPIExam MDMCode 1PF,0ROS,OPFS 1 body area/system (95) Straight 99201 (10 min) Update 1 CI (97) 1 element (97) 99241 (15 min) 1PF;1ROS;OPFS 2-7 Ltd sys/areas (95) Straight 99202 (20 min) Update 1 CI (97) 6-11 elements (97) 99242 (30 min) 4PF;2-9ROS;1PFS 2-7 Ext sys/areas (95) Low 99203 (30 min) Update 3 CI (97) 12 elements (97) 99243 (40 min) 4PF;10ROS;2PFS 8 sys/areas (95) Moderate 99204 (45 min) Update 3 CI (97) All Boxed Areas (97) 99244 (60 min) 4PF;10ROS;2PFS 8 sys/areas (95) High 99205 (60 min) All Boxed Areas (97) 99245 (80 min)

19. Established Office Visit (99211-99215) HPIExam MDMCode Does not require the presence of a physician 99211 (5 min) 1PF,0ROS,OPFS 1 body area/system (95) Straight 99212 (10 min) Update 1 CI (97) 1 element (97) 1PF;1ROS;OPFS 2-7 Ltd sys/areas (95) Low 99213 (15 min) Update 1 CI (97) 6-11 elements (97) 4PF;2-9ROS;1PFS 2-7 Ext sys/areas (95) Moderate 99214 (25 min) Update 3 CI (97) 12 elements (97) 4PF;10ROS;2PFS 8 sys/areas (95) High 99215 (40 min) Update 3 CI (97) All Boxed Areas (97)

20. 99211 Billable Services Examples of office/clinic visits generally billable using 99211: • A blood pressure eval for an est pt whose physician requested a f/u visit to ck blood pressure • Refilling medication for a patient whose prescription has run out to hold him over until her can get an appointment (pt must be present in office suite) • Discussion with patient in person following laboratory tests that indicate the need to adjust medications or repeat order of tests • Suture removal following placement by a different physician/physician group • Visit for instructions/patient education on how to use a peak flow meter • Diabetic counseling • Dressing change for an abrasion/injury

21. 99211 Non Billable Services Examples of services generally not billable using 99211: • Blood draw - should be billed using CPT 36415 • Laboratory tests - the lab performing the test should bill the appropriate codes • Monitoring of cardiology tests, such as thallium stress tests, where such monitoring is inherent in the performance of the test • Injection of medication - use CPT drug administration code and drug code  • Influenza vaccination - use vaccination code and administration code only

22. Consultations (99241-45)Place of Service: office/outpt/ER Documentation Criteria: • Document name of referring physician name • Indicate in HPI that the visit is a result of a “request for consultation” • Provide a written report to the requesting provider unless there is a shared record situation (aka inpatient; or same specialty consult)

23. Consultations CPT Codes 99241-99245 If a provider requests (verbal or written) a consultation. If you are a specialist and you hold a particular expertise a member of your group can refer a patient for consultation to you. If you see a patient in the “outpatient” setting of a hospital per the request of a provider of another specialty or same specialty and your expertise is required. Code for a consultation in the ER, if the ER physician calls you in to evaluate whether or not a patient should be admitted. If they are not admitted by the provider or a member of his/her specialty group then submit code 99241-99245. If they are admitted and you are the admitting provider then you can only code for the admission (99221-99223).

24. Preventative Medicine Visits CPT Code 99381-87 (new) 99291-97 (est) Preventative Medicine Visit Codes include payment for: • The review of “stable” chronic problems • Routine Screenings (eg. Pap smear, breast & pelvic, manual rectal exam) • Risk Factor Counseling Billable Separately When Billed on Same Day as Physical are: • 99211-99215 E&M Office Visit codes (for re-management of existing problems or new problems (need mod 25) • Do not bill 2 new E&M’s in same day • Injections, Immunizations • Procedures Performed (exception Medicaid – they will only pay for procedure) • Some Screenings • Labs (Indicate signs/symptoms or diagnosis to support testing)

25. Physicals - Medicare • MC does not pay for physicals (99381-87; 99391-97) other then new mc beneficiaries (next slide) • They will pay for 99211-99215 services (eg. medically necessary follow-up or new problems addressed during a physical. • They will pay for problems addressed during a physical when a modifier 25 is affixed. • MC will pay for screenings performed during a physical if the service is performed during a covered period. (eg. paps covered every 2 yrs).

26. Physicals Medicare “New MC Beneficiary” • G0344: Effective 1/1/05 MC will pay physical / new MC enrollee / within 6 mths • G0366: EKG (global) • G0367 (EKG tracking only) • G0368(EKG Inter & Rep Only) • Medicare does not pay for routine annual physicals (99381-87; 99391-97) • Medicare will pay for 99211-99215 services (eg. medically necessary follow- up or new problems) billed w/physicals. Mod 25 needs to be affixed to 99211-15 codes.

27. Medicare – “New MC Beneficiary” Required Documentation Initial Exam includes review of: HPI • Attention to risk factors for disease detection • Past medical, Social & Surgical history • Experiences w/illnesses • Hospital stays • Operations • Allergies • Injuries & treatments • Current medication & supplements • FH (hereditary or place the individual at risk) History of alcohol, tobacco, illicit drug use • Diet • Physical activities Psych Eval - Depression • Individual’s potential (risk factors) for depression including current or past experiences w/depression or other mood disorders. • Refer to appropriate screening instrument for persons without a current diagnosis of depression recognized by a National Professional Medical Organizations.

28. Medicare – “New MC Beneficiary” Required Documentation EKG • Performance and interpretation of an EKG. Functional Abilities / Level of Safety • Mininum review must include assessment of: • Hearing impairment • Activities of daily living • Falls risk • Home safety Examination • Measurement of individual’s height, weight, blood pressure • Visual acuity screen • Other age-appropriate factors as deemed appropriate by the provider based on the individual’s med/social history and current clinical standards.

29. Medicare – “New MC Beneficiary” Required Documentation Risk Factor Counseling • Education, counseling and referral as deemed appropriate by the provider based on results of the review Provide Brief Written Plan • A checklist or alternative provided to the individual for obtaining the appropriate screening and other preventive services which are covered separately under Medicare Part B. 11 points checklist: • Immunizations (pneumococcal, Influenza, Hep B and their administration. • Mammography screening • Pap smear & pelvic examination screening • Prostate cancer screening tests • Colorectal cancer screening tests • Diabetes outpatient self-mgmt training services • Bone mass measurements • Glaucoma screening • Medical nutrition therapy for individuals with diabetes or renal disease • Cardiovascular screening blood tests • Diabetes screening tests

30. Physicals - Medicaid • Will pay for physicals if pt ONLY has Medicaid • Will not pay for physical if billed AFTER Medicare denial. • Will not pay for physicals billed with screenings on same day. • They do not recognize modifier 25 at all.

31. Physicals – HMO’s “Managed Care Plans” Tufts/HPHC/HMOBlue • Will pay for physicals • Will also pay for problems addressed during a physical (eg. UTI dx 599.0 billed with 99213-25) • They will not pay for screenings if billed in conjunction with an annual physical unless high risk or abnormal dx submitted. • They will however pay for screenings if billed with an E&M office visit code (99201-05 or 99211-15) vs. a physical cpt code.

32. Screenings – Pap Smear • Code a Q0091 for the collection of the pap smear. • Code diagnosis code V76.2 (low risk of malignant neoplasm) or V15.89 (high risk) • Coverage every 2 yrs.

33. Screenings – Breast & Pelvic • Code G0101 if “both” the breast & pelvic exam are performed. • Code Dx. code V76.10 • If G0101 is billed with a Physical it will reject as a “bundled” service for Tufts, HPHC (blues pays) • It is reimburseable when it is billed by itself as the “sole” service or with an E&M office visit code. • Coverage every 2 years. • G0101 requires the review and documentation of 7 out of 11 areas in GU system.

34. Screening – Breast & Pelvic Documentation RequirementsG0101 requires documentation of 7/11 elements: • Inspection and palpation of breasts for masses or lumps, tenderness, symmetry or nipple discharge. • Digital rectal examination including sphincter tone, presence of hemorrhoids, and rectal masses. • Pelvic examination (w/or w/out specimen collection for smears and cultures) including: · External genitalia (general appearance, hair distribution, or lesions) · Urethral meatus (size, location, lesions, or prolapse) · Urethra (masses, tenderness, or scarring). · Bladder (fullness, masses, or tenderness). · Vagina (general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, or rectocele) · Cervix (general appearance, lesions, or discharge). · Uterus (size, contour, position, mobility, tenderness, consistency, descent, or support) · Adnexa/parametria (masses, tenderness, organomegaly, or nodularity) Anus and perineum.

35. Screenings – Blood Occult Routine • Code G0107 with diagnosis code V76.51 • Annual benefit • Do not use “82270” in the absence of signs/symptoms or it will reject.

36. Screenings – Digital Rectal Exam • Code G0102 with diagnosis code V76.44 • Annual benefit. Note: not covered when billed with annual physical (eg. preventive medicine code) • It is reimburseable if billed with an office visit.

37. Screenings – Routine Labs • (eg. 81002, 81000, 82270) • In the absence of signs/symptoms these services will reject. • It is critical that you link a diagnosis code (eg. definitive or signs/symptoms) when ordering a lab test when applies.

38. Modifiers Modifiers are 2 digit codes which accompany a 5 digit CPT code in order to further describe a situation to support additional payment when more then one service is being reported in the same session on the same day. Primary Care Modifiers 25

39. Modifier 25 Modifier –25 Should only be appended to evaluation and management (E/M) service codes HCPCS codes G0101(Breast & Pelvic Screening) and Procedures You do not need a modifier 25 when billing an office visit and also billing for: 1) Diagnostics (eg. EKG) 2) Immunizations 3) Screenings

40. Modifier 25 Examples Modifier 25 Examples When the patient presents for a planned procedure and has a different problem that requires an E/M service (two different diagnoses would be used to distinguish the services) the patient presents with a "minor" problem and after evaluation the decision is made to perform a procedure. In the second example –25 is used if the procedure is minor in nature, meaning that the post-operative period is less than 90 days and the primary diagnosis would be the same for both.