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October 9, 2007

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October 9, 2007

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  1. Webcast Session IAn Introduction to Evaluation and Management (EM) CodingAccurate Coding for Evaluation and Management (EM) ServicesA webcast designed for headache and migraine specialistsPresentersStuart B. Black, MDAmerican Headache Society (AHS)Sheila J. Madhani, MA, MPH, CCS-PMARC Associates October 9, 2007

  2. Goals • Introduction to CPT EM codes • Review of CPT coding guidelines and practices • Application of CPT coding guidelines and practices to clinical scenarios relevant to headache specialists

  3. What Will We Discuss? • Importance of accurate coding • CPT codes vs. ICD codes • Components of EM codes • Types of EM codes • How to properly select and report EM codes/services • Use of modifiers • Clinical examples • Coding resources

  4. Importance of Accurate Coding • Full and fair description of services provided • Avoid over-coding (fraud and abuse) and under-coding (not reporting all the services you have provided) • Improve quality of patient care

  5. CPT codes vs. ICD codes

  6. CPT codes vs. ICD codes • CPT codes • CPT is an acronym for Current Procedural Terminology • CPT codes are published by the American Medical Association and are used by CMS and many private insurers to report physician services • A CPT code is a five digit numeric code that is  used to describe medical, surgical, radiology, laboratory, anesthesiology, and evaluation/management services • There are approximately 7,800 CPT codes ranging from 00100 through 99602 • Two digit modifiers may be appended when appropriate to clarify or modify the description of the procedure

  7. CPT codes vs. ICD codes • ICD • ICD stands for International Classification of Diseases • It is a coding system used to code signs, symptoms, injuries, diseases, and conditions

  8. CPT codes vs. ICD codes • Relationship between CPT and ICD • Both types of codes must be reported on claims to Medicare and many private insurers • CPT code • Describes medical procedure or service • ICD code • Describes clinical condition of patient to support the medical necessity of the procedure or service

  9. CPT codes vs. ICD codes • ICD-9-CM • Diagnosis coding classification system used in the delivery of patient care • ICD-10 • Used to track mortality data • ICD-10-CM • Currently under development

  10. Components of EM codes

  11. Components of EM codes • All EM services follow a similar format • Unique code number • Place and/or type of service • Content of service • Nature of the presenting problem • Time typically associated with service

  12. Components of EM codes • Ex. 99213, Office or other outpatient visit, est. patient ¹ Includes hospital outpatient

  13. Categories of EM codes

  14. Categories of EM codes • Physicians use EM codes to report professional services • Documentation in the medical record must support the EM code and ICD-9 code(s) submitted • Submitting a code that is not supported by documentation may be considered fraud

  15. Categories of EM codes

  16. Categories of EM codes • Levels of service • Within each category there are various codes representing the different levels of service • Increased levels of service reflect the increased levels of time, intensity, and complexity of the service • Ex. Office or other outpatient visit, new patient • 99201 – Level 1 • 99202 – Level 2 • 99203 – Level 3 • 99204 – Level 4 • 99205 – Level 5

  17. How to properly select and report EM codes/services

  18. 5 Steps to Selecting Appropriate EM codes/services • Step 1.- Type of Service: What type of service is the patient receiving? (office visit, consultation etc.) • Step 2.- New or Established: If this is an office visit, is this a new or established patient? • Step 3.- Key Components: What level of the key components (history, examination, medical decision making) have been met or exceeded • Step 4.- Time: Will time determine the level of E/M service? • Step 5.- Documentation: Document! Document! Document!

  19. Step 1: Type of Service • What type of service is the patient receiving (office visit, consultation etc.)? • Common EM services performed by headache specialists • Office/Outpatient Services • 99214 • 2005 Medicare utilization by neurologists: 1,768,059 • Consultation Services • 99244 • 2005 Medicare utilization by neurologists: 519,888

  20. Step 1: Type of Service • When is a consultation a consultation? • Consultation • A type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source • Not a Consultation • Ongoing management of the patient by the consultant physician

  21. Step 1: Type of Service • When is a consultation a consultation? • CMS Transmittal 788 – effective 1/17/06 • To bill for a consultation, there must be documentation of the request • If there is no request, an outpatient/office visit (new or established) should be reported • “…a  consultation  request  may  be  verbal  however  the verbal  interaction  identifying  the  request  and  reason  for  a  consult  shall  be  documented  in  the  patient’s  medical record by  the  requesting  physician  or  qualified  NPP,  and also by  the  consultant  physician  or  qualified  NPP  in  the patient’s  medical  record.”   (CMS Transmittal 788) 

  22. Step 1: Type of Service • When is a consultation an office visit? • Transfer of care • A transfer of care occurs when a physician requests another doctor to assume the care of the patient for a specific condition • Once a transfer occurs consultations can no longer be reported • Established patient EM codes must be reported

  23. Step 2: New or Established Patient? • CPT differentiates between new and established patients (office/outpatient) • New patients • More physician work • Greater documentation requirements • Higher reimbursement

  24. Step 2: New or Established Patient? • Is this a new or established patient? • New patient: one who has not been seen by the physician or another physician of the same specialty who belongs to the same group within the past 3 years • Established patient: one who has been seen by the physician or another physician of the same specialty who belongs to the same group within the past 3 years

  25. Step 3: Key Components • There are six components that are used to define the level of an E/M service • History • Examination • Medical Decision Making • Counseling • Coordination of Care • Nature of Presenting Problem • Time

  26. Step 3: Key Components • The three key components must be considered and supported by documentation in the medical record before selecting a code • History • Examination • Medical decision making

  27. Step 3: Key Components History • Elements • Chief complaint • History of the present illness (HPI) • Review of symptoms • Past medical, family, and social history (PFSH) • Levels • Problem focused • Expanded problem focused • Detailed • Comprehensive

  28. Step 3: Key Components History • Chief complaint • “A chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter, usually stated.” American Medical Association. Current Procedural Terminology CPT 2007. Chicago, Ill: AMA press;2007

  29. Step 3: Key Components History • History of Present Illness (HPI) • Must be performed by physician

  30. Step 3: Key Components History • Review of Systems (ROS) • Can be performed by medical extender

  31. Step 3: Key Components History • Past Medical, Family, and Social History (PFSH) • Can be performed by medical extender

  32. Step 3: Key Components History • Summary

  33. Step 3: Key Components Physical Examination • The level of exam is determined by the number of body areas or organ systems documented • Levels • Problem focused • Expanded Problem Focused • Detailed • Comprehensive

  34. Step 3: Key Components Physical Examination • CPT Descriptors For Four Levels of Physical Examination • Problem focused - A limited examination of the affected body area or organ system(s) • Expanded problem focused - A limited examination of the affected body area or organ system and other symptomatic or related organ system(s) • Detailed - An extended examination of the affected body area or organ system and other symptomatic or related organ system(s) • Comprehensive A general multi-system examination or a complete examination of a single organ system American Medical Association. Current Procedural Terminology CPT 2007. Chicago, Ill: AMA press;2007

  35. Step 3: Key ComponentsPhysical Examination • Documentation guidelines for physical examination • 1995 Guidelines (general exams) • 1997 Guidelines (specialty exams) • Single system (specialty) examination • Neurological – recommended for headache specialists • General multisystem examination

  36. Constitutional Eyes Cardiovascular Neurological  Measurement of any 3 of 7 vital signs  General appearance of the patient  Ophthalmoscopic examination  Examination of carotid arteries  Auscultation of heart  Examination of peripheral vascular system  Higher cortical functions  Cranial nerves  Sensation  Muscle strength  Muscle tone  Deep tendon reflexes  Coordination  Gait and station Step 3: Key ComponentsPhysical Examination • 1997 Guidelines – Neurological

  37. Step 3: Key ComponentsPhysical Examination • Summary

  38. Step 3: Key Components Medical Decision Making (MDM) • What is medical decision making (MDM)? • MDM refers to the complexity of establishing a diagnosis and/or selecting a management option • Of the three key components of EM, MDM is the most challenging to meet and document

  39. Step 3: Key Components Medical Decision Making (MDM) • How is MDM measured? • Number of diagnoses or management options • Number of possible diagnoses • Number of options that must be considered • Amount and/or complexity of data to be reviewed • Amount and/or complexity of medical records, diagnostic tests and/or other information that must be obtained, reviewed and analyzed • Risk of complications and/or morbidity or mortality • The risk of significant complications, morbidity and/or mortality associated with the patient’s presenting problem • The risk of comorbidities associated with the patient’s presenting problem • The risk of the diagnostic procedure(s) and/or the possible management options

  40. Step 3: Key Components Medical Decision Making (MDM) • What are the different levels of MDM? • Straightforward • Low complexity • Moderate complexity • High complexity

  41. Step 3: Key Components Medical Decision Making (MDM) • Summary

  42. Step 3: Key Components • Choosing an appropriate level of EM service based on key components • New patient, office/outpatient and office consultations • You must meet or exceed ALL of the requirements to qualify for a particular level of an EM service • Established patient, office/outpatient • You must meet or exceed 2 out of the 3 requirements to qualify for a particular level of an EM service

  43. Step 3: Key Components Summary • New Patient – Office/OP (3 out of 3)

  44. Step 3: Key Components Summary • Office or other Outpatient Consultation (3 out of 3)

  45. Step 3: Key Components Summary • Established Patient – Office/OP (2 out of 3)

  46. Step 4: Time • Time is included in the definition of levels of EM services • Ex. “99213 Office or other outpatient visit…physicians typically spend 15 minutes face-to-face with the patient and/or family.” • This time is considered average time that may be higher or lower depending on specific circumstances

  47. Step 4: Time In certain circumstances the three key components (history, physical examination and MDM) arenot the controlling factor in determining the level of an EM service

  48. Step 4: Time In certain circumstances TIME isthe controlling factor in determining the level of an EM service

  49. Step 4: Time • Time determines the level of E/M service when counseling and/or coordination of care dominate (> 50%) the encounter • Counseling and coordination is separate from the history, physical exam and medical decision making • More common scenario for headache specialists • The extent of counseling and/or coordination of care must be documented in the medical record independent of the three key components

  50. Step 4: Time • Counseling patient and/or family • Diagnostic results, impressions, and/or recommended diagnostic 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 education • Patient and family education American Medical Association. Current Procedural Terminology CPT 2007. Chicago, Ill: AMA press;2007

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