E&M Coding

1. E&M Coding

2. E&M Coding • Cover office visits • Hospital visits • Physicals • Counseling

3. 99211 • “an office or other outpatient visit that may or may not require the presence of a physician” • presenting problem is simple • 5 minutes • no documentation needed for hx, px or complexity of medical decision making. Use a flow sheet! • E.g B-12 shot, suture removal, dressing change, allergy injections

4. Depo-Provera Flow Sheet Name:__________________ DOB:_____/_____/_______ MRN:__________________ Drs. order to give Depo-Provera 150mg 150mg IM q3 mo: ________________________________________ MD/DO

5. You can’t bill for the administration of an injectable medication (90782), or the for the administration of an immunization (90471, 90472) and a nurse visit at the same time. You can either bill for the 99211 plus the medications or bill for the injection plus the medication.

6. 99201 • The 99201 code has more specific requirements than the 99211!!! • 99201 cannot be used for nurse visits. • 99201 requires a problem focused history, a problem focused exam and straightforward decision making • e.g. an out of town patient needing a refill of her NSAID.

7. 99201 quick reference • 99201 • Key components (need all three)Elements Minimum requirements • Problem-focused history HPI 1 1 • ROS 0 0 • PFSH 0 0 • Problem-focused exam Body areas/organ systems 1 • Straightforward medical decision making (need at least two) • Diagnoses/management options 1 point (minimal) • Amount/complexity of data 0-1 point (minimal or none) • Risk 1 (minimal) • Unlike code 99211, which has no specific documentation requirements, code 99201 for the evaluation and management of a new patient requires a problem-focused history, a problem-focused examination and straightforward decision making, as outlined in the table at right.

8. 99212 • For the evaluation an management of an established patient, which requires at least 2/3 of these components: • a problem focused history • a problem focused exam • straightforward decision making 10 minutes

9. 99202 • Office or other outpatient visit for the evaluation and management of a new patient which requires all three: • expanded problem focused history • expanded problem focused exam and • straightforward decision making 20 minutes

10. 99213 • For an established patient and requires 2/3 components of: • an expanded problem focused history • expanded problem focused exam • medical decision making of low complexity • 15 minutes average

11. 99203 • For new patient and requires all three components: • a detailed history • a detailed examination • low complexity decision making • 30 minutes

12. 99214 • For the evaluation and management of an established patient and requires 2/3 of: • a detailed history • a detailed examination • medical decision making of moderate complexity • 25 minutes

13. 99204 • Evaluation and management of new patient which requires all 3 components: • a comprehensive history • a comprehensive exam • medial decision making of moderate complexity • 45 minutes

14. 99215 • Evaluation and management of an established patient which requires 2/3 components: • a comprehensive history • a comprehensive exam • medical decision making of high complexity • 40 minutes

15. 99205 • Evaluation and management of a new patient which requires all three components: • a comprehensive history • a comprehensive exam • medical decision making of high complexity • 60 minutes

16. A point threshold is the minimum Number of documentation points to attain a code level • CC: No points • HPI: 1 point per element • ROS: 1 point per element • PMH, FH, SH: 1 point for each • PE: 1 point per element • Data from testing/imaging or sources such as reports and old medical records: 1 point • Diagnosis: 1 point each • Plans/Management options: 1 point for each

17. Documentation elements include: • The HPI: 10 possible elements such as location, quality, severity, duration, etc. • ROS: 15 possible elements based on organ systems reviewed. • The PMH, FH, SH are each an element.

18. Data Elements Can Include: • Test results • Imaging, ECG, PFT results • Old Records

19. Diagnosis can include: • New Diagnoses • Chronic problems that are either stable or getting worse.

20. Management Options Can Include: • Prescription or OTC meds • Activity recommendations • PT, OT, etc • Referrals • Immunization other parental needs

21. Total E&M Point Thresholds

22. “2 out of 3 will do” E&M Point Thresholds by Category for Established Patients

23. Established patients • “Two out of three will do” for established patients • Total points for established patients are less important than the point thresholds for each category because the point thresholds only need be met for 2 of the 3 categories. • For example, if the history is 2 points (limited), the examination is less than 6 points (problem focused), but the decision making is 5 points (low complexity), then 99213 may be used even though the total of 13 was not reached.

24. 3 are required E&M Point Threshold for New Patients

25. Coding Time • Three types of time: • face-to-face: physician meets directly with the patient or family. Outpatient/office visits only. • Floor/unit time: physician is physically present on the hospital floor delivering bedside service. It includes time spent with the patient & time spent charting, discussing care with nurses/others. • Non-face-to-face: work related to pt care that occurs before or after face to face time

26. The greater than 50% rule: “If a physician spends more than 50% of a face-to-face visit counseling or coordinating a patient’s care, the physician can code the visit on the basis of time, even if the history, exam or medical decision making are lacking.”

27. Prolonged Services Codes: Prolonged services codes are reported in addition to the E/M code when the length of time spent with a patient goes at least 30 minutes beyond what is typical for that service. Use 99354 for the fist 30 - 74 min beyond what is typical, 99355 for each half hour after that. Prolonged services can also be coded using a modifier-21.*

28. Document the time: “Time spent with the individual patient should be recorded in the patient’s chart” E.g. “20 minutes face-to-face; counseling/coordination of care>50% of visit”

29. Undercoding and Overcoding: Family physicians overcode new patient evaluation and management visits 82% of the time and undercode established patients 33% of the time.* *Journal of the American Board of Family Practice; May/June 2002

30. Averageand Recommended Code Distributions