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Evaluation and Management Coding and Medicare Part B

What is documentation and why is it important?. Medical record documentation is required for reporting pertinent findings, facts and observations about a patients health history. The medical record documents patient care showing the chronology of treatment, communication between physicians, quality of care and collection of data..

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Evaluation and Management Coding and Medicare Part B

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    1. Evaluation and Management Coding and Medicare Part B Rachel Mitchell, CPC-H Applied Medical Systems, Inc. August 26, 2003

    2. What is documentation and why is it important? Medical record documentation is required for reporting pertinent findings, facts and observations about a patients health history. The medical record documents patient care showing the chronology of treatment, communication between physicians, quality of care and collection of data.

    3. General principles of documentation Medical record should be complete and legible. Documentation should include: Chief complaint Exam and diagnostic test results Assessment Plan

    4. Components of E&M visits History Exam Medical decision making Counseling and/or coordination of care

    5. Continued. Rationale of ordering diagnostic testing Past and present diagnoses and/or conditions. Health risk factors Progress with regards to treatment

    6. Elements of HPI Location Quality Severity Duration Timing Context Modifying factors Associated signs and symptoms

    7. Elements of ROS Constitutional Eyes Ears, nose, throat, mouth Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary (skin and/or breast) Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergic/Immunologic

    8. Past/Family/Social History Past History: the patient’s history of illnesses, operations, injuries, treatments, medications. Family History: a review of medical events in the patient’s family, including diseases which may be hereditary or place the patient at risk.” Social History: an age appropriate review of past and current activities. Ex: marital status; sexual history; tobacco, alcohol, and drug use history; job/career status. PH: Pt has had their gallbladder removed. May currently be taking coumadin. FH: Pt’s mother died of breast cancer. SH: Smokes 1 pk per day and drinks 1 mixed drink per day.PH: Pt has had their gallbladder removed. May currently be taking coumadin. FH: Pt’s mother died of breast cancer. SH: Smokes 1 pk per day and drinks 1 mixed drink per day.

    9. Physical Exam Problem Focused Limited exam of affected area/system (1 body area or system) Expanded Problem Focused Affected area/organ system + other symptomatic or related systems (2 to 7 systems) Detailed Extended exam of affected area + other symptomatic or related organ systems (2 to 7 systems) Comprehensive General multi-system exam (8 or more systems) or complete exam of a single organ system Is everyone coding their e&m’s based on the 95 or 97 documentation guidelines. 95 guidelines are the easier of the two so if you are using the 97’s then you have it made. Problem focused level 1 for new patients, level 2 for established. Post lesions removal for a wound check. Expanded problem focused level 2 for new patients, level 3 for established. Wrist or ankle sprain. Detailed level 3 for new and level 4 for established. Asthma exacerbation. Comprehensive level 4’s and 5’s for new and level 5 for estab. Chest pain with full work up All but comprehensive may be a combination of areas and systems. Comprehensive must only be organ systems, 8+.Is everyone coding their e&m’s based on the 95 or 97 documentation guidelines.95 guidelines are the easier of the two so if you are using the 97’s then you have it made. Problem focused level 1 for new patients, level 2 for established. Post lesions removal for a wound check. Expanded problem focused level 2 for new patients, level 3 for established. Wrist or ankle sprain. Detailed level 3 for new and level 4 for established. Asthma exacerbation. Comprehensive level 4’s and 5’s for new and level 5 for estab. Chest pain with full work up All but comprehensive may be a combination of areas and systems. Comprehensive must only be organ systems, 8+.

    10. Body Areas vs. Organ Systems BODY AREAS Head, incl. Face Neck Chest, incl. Breasts & axillae Abdomen Genitalia, groin, buttocks Back, incl. Spine Each extremity ORGAN SYSTEMS Constitutional (vitals & general appearance) Eyes ENT, mouth Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic/Lymphatic/Immunologic The exam components are divided up between body areas and organ systems. These can be combined when counting elements for exam. Question?? What would “patient is smiling and has a pleasant demeanor” fall up under. Either general or psychiatric. The exam components are divided up between body areas and organ systems. These can be combined when counting elements for exam. Question?? What would “patient is smiling and has a pleasant demeanor” fall up under. Either general or psychiatric.

    11. Medical Decision Making Diagnoses/Management Options Amount/Complexity of Data Risk of Complication 1. Did the patient have a minor problem, was it serious, did they are more than one problem. Were there labs or xrays ordered. Did the physician have to obtain old records. Does the patient need surgery. Can the problem be managed with prescription drugs.1. Did the patient have a minor problem, was it serious, did they are more than one problem. Were there labs or xrays ordered. Did the physician have to obtain old records. Does the patient need surgery. Can the problem be managed with prescription drugs.

    12. Table of Risk Examples Presenting Problem Minimal – One self-limited or minor problem. Low – Two or more minor problems, one stable chronic illness, acute uncomplicated illness. Moderate – Chronic illness with exacerbation, two of more stable chronic illnesses, undiagnosed new problem with uncertain prognosis, acute illness with systemic pneumonitis, acute complicated injury High – Chronic illness with severe exacerbation, acute or chronic illness that poses threat to life, abrupt change in neurologic status.

    13. Level of Service (cont’d) Time matters! You may code the level based only on time if more than 50% of the visit is spent counseling the pt. The total time must be recorded as well as a statement that more than 50% of the visit was counseling. When a patient is being counseled about lab results, surgery outcome or other test results this should be documented with total time spent and what was discussed. Did and audit for a GI doc last month and the majority of his visits were counseling after colonoscopy or sigmoidoscopy, but his documentation lacked time as well as what exactly he explained to the patient. When a patient is being counseled about lab results, surgery outcome or other test results this should be documented with total time spent and what was discussed. Did and audit for a GI doc last month and the majority of his visits were counseling after colonoscopy or sigmoidoscopy, but his documentation lacked time as well as what exactly he explained to the patient.

    14. Evaluation and Management Codes

    15. 99253 Initial Inpatient Consult New or established Requires detailed history and exam (extended exam of 7 organ systems/body areas) Low complexity medical decision making Presenting problem of moderate severity 55 minutes of bedside or floor time

    16. Clinical Examples * Requested by internal medicine: 45 year old male with 12 day history of incapacitating gout, unable to walk now, not improved by bed rest. * Requested by internal medicine, for treatment recommendations for patient admitted with persistent inability to walk following soft tissue injury to knee.

    17. 99254 Initial Inpatient Consult New or established Required comprehensive history and exam (general multisystem exam of 8 or more systems OR complete exam of single organ system). Moderate complexity medical decision making. Presenting problem of moderate or high severity. 80 minutes of bedside or floor time

    18. Clinical example * Consult request for a 13 year old patient with painless swelling of the thigh with lytic lesion by xray Or * Consult request for a 65 year old 72 hour status post mitral valve replacement who develops acute respiratory distress syndrome.

    19. 99255 Initial Inpatient Consult New or established Required comprehensive history and exam (general multisystem exam of 8 or more systems OR complete exam of single organ system). High complexity medical decision making. Presenting problem of high severity. 110 minutes of bedside or floor time

    20. Clinical Example *Consult request for a 74 year old male with chest pain and massive GI bleed. Or *Consult request for a patient with multiple failed back surgeries continuing to have low back and neck pain.

    21. 99301 – 99303 Nursing Facility Visits All three codes are assessment codes for new or established patients 99301 is used annually for the recertification of the care plan. (30 minutes) 99302 is used when a patient incurs a permanent change in physical condition and the care plan requires a revision. (40 minutes) 99303 is used to establish the medical care plan for a new admission to the nursing facility. (50 minutes)

    22. 99311 – 99313 Subsequent Nursing Facility Care New or established patients Daily care visits 99311 is used when a patient is stable, recovering or improving. (15 minutes) 99312 is used when a patient is responding inadequately to therapy or has developed a minor complication. (25 minutes) 99313 is used when a patient has a serious problem, but is not required to be admitted to a hospital. (35 minutes)

    23. 99331 Domiciliary Care Established visit requiring problem focused history, problem focused exam and low complexity medical decision making. Patient is usually stable, recovering or improving. This code can be used when patients are residents of nursing facilities, assisted living and retirement communities.

    24. 99261 Follow-up Inpatient Consult Established visit requiring problem focused history, problem focused exam and low complexity medical decision making. (2 of 3 components) Patient is stable, recovering or improving. Physician typically spends 10 minutes at bedside or on the unit.

    25. Clinical Examples *Follow-up with a 75 year old female who urinary incontinence to review results of a diagnostic test the day of initial consult. Or *Follow-up with a 94 year old male nursing home resident for re-evaluation of hemorrhoids following conservative treatment on initial consult.

    26. 99262 Follow-up Inpatient Consult Established visit requiring expanded problem focused history, exam and moderate complexity medical decision making. (2 of 3 components) Patient is responding inadequately to therapy or has developed a minor complication. Physician typically spends 20 minutes at bedside or on the unit.

    27. Clinical Example *Follow-up with a 51 year old male for test results from initial consult of the etiology of postop hyponatremia following TURP procedure.

    28. 99263 Follow-up Inpatient Consult Established visit requiring detailed history, exam and high complexity medical decision making. (2 of 3 components) Patient is unstable or has developed significant complication or new problem. Physician typically spends 30 minutes at bedside or on the unit.

    29. Clinical Example *Follow-up of 62 year old male who was initially evaluated for pansinusitis now with sudden onset of proptosis.

    30. 99344 Home Services New patient visit which requires a comprehensive history, exam and moderate medical decision making. Presenting problems are usually of high severity. Physician typically spends 60 minutes face to face with the patient and/or family.

    31. 99345 Home Services New patient visit requiring comprehensive history, exam and high complexity medical decision making. Patient is unstable or has developed a significant new problem requiring immediate physician attention. Physician typically spends 75 minutes face to face with the patient and/or family.

    32. 99348 Home Services Established visit requiring expanded problem focused history, exam and low complexity medical decision making. (2 of 3 components) Presenting problem(s) are of low to moderate complexity. Physicians typically spend 25 minutes face to face with patient and/or family

    33. 99356 Prolonged Services Physician services within the inpatient setting that requires direct patient contact. First hour. This CPT is to be listed in addition to the evaluation and management service.

    34. ICD9CM Coding Medical necessity is an important factor. Can code from signs and symptoms. Will no longer use Volume 3. Utilize the Medicare Local Medical Review Policies website. Code to the highest specificity

    35. CMS-1500 a.k.a HCFA-1500

    37. Patient Information Block 1 Type of Insurance Indicator Block 1a Insured ID # Block 2 Patient Name Block 3 Patient’s DOB Block 4 Policy Holder Block 5 Patient Address Block 6 Relationship to the Insured Block 7 Policy Holder’s Address

    38. Patient Information Continued Block 8 Patient Status Block 9 Medigap Info Block 10 Accident Indicator Block 11 Primary to Medicare Insurance Block 12 Patient Authorization Block 13 Insured Authorization Block 14 Illness Date Block 15 (not required by Medicare Block 16 Unable to Work Date

    39. Treatment Information Block 17 Referring Physician Block17a UPIN # Block 18 Hospitalization Dates Block 19 Local Use Block 20 Outside Lab Block 21 Diagnosis Codes Block 22 Medicaid Resubmission Code (not required by Medicare) Block 23 Authorization #

    40. Treatment Information Continued Block 24b Place of Service Block 24c Type of Service Block 24a Treatment Date Block 24d CPT’s and Modifiers Block 24e Diagnosis Code Reference Block 24f Charges Block 24g Units/Days Block 24h, i and j not required by Medicare Block 27k Provider Number (individual)

    41. Provider Information Block 25 Provider Tax ID# Block 26 Patient Account Number Block 27 Accept Assignment Indicator Block 28 Total Charges Block 29 Amount Paid Block 30 Balance Due (not required by Medicare) Block 31 Physician Signature and Printed Name Block 32 Services Rendered Name and Address Block 33 Physician Billing Address

    42. Place of Service Codes 11 Office 12 Home 13 Assisted Living Facility 21 Inpatient Hospital 22 Outpatient Hospital 23 Emergency Room 31 Skilled Nursing Facility 32 Nursing Facility 33 Custodial Care Facility 34 Hospice 51 Inpatient Psychiatric Facility 72 Rural Health Clinic

    43. Type of Service Codes 01 Medical Care 02 Surgery 03 Consultation

    44. Part B Billing Billed on a HCFA-1500 (CMS-1500) Does not require revenue codes Provides payment for physician and outpatient hospital services as well as medical equipment. $100 per year calendar deductible Sent to a “carrier” in Nashville, Tennessee Primary diagnosis code is the main code recognized. Providers can choose whether or not to participate.

    45. Websites for Claim Filing,etc. www.payerpath.com www.easyhcfa.com www.ezclaim.com www.softlookup.com www.justclaims.com www.hcfaware.com www.claimsbpo.com ICD9CM look-up www.flashcode.com www.unicormed.com Medicare Local Medical Review Policies www.lmrp.net

    46. Physician Billing Software Websites www.medisoft.com www.a4healthsystems.com www.perfectpracticemd.com www.pmsi.com www.misyshealth.com

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