Illinois Medical Bill Reviewer Training Program

1. Illinois Medical Bill Reviewer Training Program Unit 1: Professional Services Module 1: Evaluation and Management

2. Hi! In this module, you will learn about evaluation and management services, how they are classified, and the difference between new and established patients. Then, you will learn about emergency department codes, the difference between consultations and referrals, and how same day E & M services are reimbursed. Let’s start by discussing how E & M services are classified... Overview • Classification of Evaluation and Management Services • New and Established Patients • Hospital Visits • Emergency Department Services • Consultations and Referrals • Same Day E & M Services

3. Evaluation and Management Guidelines • Evaluation and Management servicesfocus on the initial understanding and diagnosis of an illness or injury, as well as facilitating the necessary treatment to cure the illness or injury. The E & M section ranges from 99201-99499.

4. Classification of Services • Evaluation and management services are classified differently depending on the type of service as well as where the service is rendered. Evaluation and Management can be classified as: • Office visits • Hospital visits • Consultations • Evaluation and management services can also be classified by intensity. Let’s take a look…

5. Evaluation and Management services that have different intensities are considered different levels of service. Classification of Services Increasing Intensity The following levels of service can be assigned: • Comprehensive • Detailed • Expanded Problem Focused • Problem Focused

6. Classification of Services • Different levels of services are determined primarily by three key components. Increasing Intensity The following levels of service can be assigned: Levels of services are determined primarily by: • Comprehensive • Detailed • Expanded Problem Focused • Problem Focused • History • Examination • Complexity of Medical Decision-making • Each component of an evaluation is assigned a level of service.

7. New vs. Established Patients Now that you understand how evaluation and management services are classified, we can discuss how patients are classified. Let’s take a look…

8. New vs. Established Patients • There are two types of patients within evaluation and management office visits: New Patients Established Patients Let’s take a look…

9. A new patient isone who is new to the physician, or an established patient with a new injury or condition. New Patients New Patients

10. New Patients Seen By Multiple Physicians • If a patient sees different specialists within a multi-specialty medical group, each specialist is entitled to use a new patient code on the initial visit. Only one physician per specialty may charge as a new patient visit for the same injury or condition. If a different physician within the same specialty is on call and sees a patient, the visit is billed as it would have been by the regular treating physician.

11. An established patient is one who has been seen for the same injury or illness. Established Patients Established Patients

12. Established Patients • Established patients may return for a follow-up visit regarding the status of the initial illness or injury. • Follow-up visits by established patients are automated in the bill review system. 1. If a second initial visit is billed, the bill review system suspends the bill and prompts the processor to evaluate whether the same provider is billing for a secondinitial visit. 2. If a second initial visit is billed, the processor should substitute with a comparable subsequent visit code.

13. Now that you are familiar with the basics of E & M services, let’s discuss how hospital visits are reimbursed. Hospital Visits • Classification of Evaluation and Management Services • New and Established Patients • Hospital Visits • Emergency Department Services • Consultations and Referrals • Same Day E & M Services • Hospital Visits

14. Hospital Visits • Similar to office visits, there are two categories of patients within hospital visits: Initial Visits Subsequent Visits Let’s take a look…

15. Initial Hospital Visits • The other services are not to be billed separately. If a patient is admitted to a hospital in the course of being seen elsewhere, including... • Emergency department • Observation • Physician’s office • Nursing facility ...all E/M services provided for that condition are included in the initial hospital visit.

16. Example: Initial Hospital Visits Suppose Mr. Johnson is seen by Dr. Gade in the office for a possible back injury. The physician sends him to the hospital for x-rays, then sees Mr. Johnson in the ER. Mr. Johnson is admitted to the hospital for a vertebral fracture. Dr. Gade can charge for an initial hospital visit, but the office visit and the ER visit are included. The work and time involved in the first two encounters are considered as part of the initial visit service level.

17. Initial Hospital Visits • In some instances, physicians admit patients to the hospital by phone. If a physician admits a patient by phone, they report the initial hospital visit code on the day they actually see the patient.

18. Subsequent Hospital Visits • Subsequent visits occur when the physician visits a hospitalized patient on subsequent days. Hi Mr. Jones, you are looking better today. Reimbursement for subsequent visits differs depending on who provides the subsequent visit. If the same physician, or a physician from the same specialty groupvisits the patient, the visit should be billed as a subsequent visit.

19. Subsequent Hospital Visits Dr. Meyer says that your symptoms are improving. This means that only one initial hospital visit can be billed per patient. However, if a physician from a different specialty group visits the patient, the service may be billed with initial inpatient consultation codes or subsequent hospital care codes.

20. Observation Services • Prior to being admitted to the hospital, a patient is occasionally placed under observation. In these cases, observationcodes are used. • There are two types of observation services: Discharge Initial Let’s take a look…

21. Initial Observation Codes • Initialobservationservices are reported per day. It is expected that a decision will be made within a day to send the patient home or admit him to the hospital. • Like other evaluation and management services, observation codes are not to be charged for post-operative care in connection with a surgical service.

22. Example Initial Observation Codes If the patient is admitted to the hospital, the observation charges are rolled into the initial hospital visit. But, if the patient is admitted to observation and discharged on the same day, the only code used would be an initial admit code from 99218-99220.

23. Discharge Observation Services • Discharge observation services are only reported when the patient is discharged from the hospital on a different day than they were admitted. • Discharge observation services are indicated by CPT 99217: Observation care discharge.

24. Prolonged Service Code Characteristics: Prolonged Service Codes • Prolonged Service Codes are codes used when a physician provides a service beyond the typical service time for a specific E & M code. • The service provided and the length of time required must be identified and documented.

25. Prolonged Service Codes • There are two types of prolonged service codes: Direct (Face to Face) Contact Without Direct Contact Let’s take a look…

26. Direct (Face to Face) Contact Direct (Face to Face) Contact Outpatient setting: Inpatient setting: • CPT 99354: 31 to 74 minutes. • CPT 99355: Each additional 30 minute increment. • CPT 99356: 31 to 74 minutes. • CPT 99357: Each additional 30 minute increment.

27. Without Direct Contact Without Direct Contact CPT 99358: used to report the first hour spent (30-74 minutes) reviewing records and tests, or communicating with other medical professionals, during or following direct contact with a patient.

28. Emergency Department Emergency department codes are reimbursed slightly differently than other E & M services. Let’s take a look... • Classification of Evaluation and Management Services • New and Established Patients • Hospital Visits • Emergency Department Services • Consultations and Referrals • Same Day E & M Services • Emergency Department Services

29. Emergency Department Services: services rendered in a 24-hour hospital-based facility designed to accommodate immediate medical care to patients requiring unscheduled treatments. Emergency Department Services Emergency department (ED) codes are only to be billed for services in the ED. Services provided elsewhere, including an urgent care center, are not eligible for emergency room coding. There is no distinction between new or established patients in the emergency department. In addition, for any single ED patient visit, only one physician can report an ED E/M code. If two physicians see the patient, one may code for an ED visit and the other for another appropriate visit.

30. Like other types of evaluation and management services, emergency department visits tend to vary with intensity. Because of the extensive variability, time is not a descriptive component of an emergency department visit. Emergency Department Services Emergency department visits vary with: • The number of patient encounters • Time waiting for test results • Medication • Patient observation • Care of other patients

31. Emergency Department Codes • Instead, emergency department visits are coded by key components and the nature of the presenting problem. • As a result, like evaluation and management codes, emergency department codes also vary. Emergency department codes vary by: • The severity of the injury or illness. • The extent of treatment. Let’s take a look…

32. CPT 99281 CPT 99285 Emergency Department Codes Example 1 Example 2 Corresponds to minor injuries or illnesses that require straightforward examination and treatment, such as: Corresponds to severe injuries or illnesses that pose an immediate threat to the patient’s life, such as: Emergency department visit for the treatment of poison ivy. Emergency department visit for internal bleeding. Emergency department visit for the diagnosis and wrap of a sprained ankle. Emergency department visit for severe chest pain.

33. If services provided in the emergency department are of a critical nature, and meet certain criteria, a critical service code may be billed in addition to the appropriate evaluation and management code(s). Critical Care Services Critical care services may be billed for direct delivery of care in the ED to a critically ill or injured patient. Critical care service criteria: • Total time delivering critical care services must be greater than 30 minutes. • Physician must be in constant attendance, or involved in treatment directly. • Separate documentation of critical care services must be included. Separate documentation is important because unlike other ED services, critical care services are paid by time rather than key components and the presenting problem.

34. Consultations and Referrals Evaluation and Management services can be billed differently if the physician provides advice regarding a diagnosis, or facilitates the transfer of a patient to a different physician. Let’s take a look…

35. Consultations and Referrals • Evaluation and Management services are distinguished by: Consultations Referrals Let’s take a look…

36. A consultation is a type of service provided by a physician whose opinion oradvice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. Consultations Consultations The physician may order diagnostic tests in order to form an opinion regarding the patient’s diagnosis.

37. In order for a visit to be classified as a consultation, the three “ROs” must be met. Consultations equest for an endering an pinion pinion eport of an pinion

38. Referrals Referrals • A referral constitutes the transfer of the total or specific care of a patient from one physician to another. Referrals do not constitute a consultation.

39. If the referring physician writes “eval and treat” they are, in essence, referring the patient to the other physician and not asking for an opinion. This is true even if the specialist sends a report to the referring physician, which is considered only a professional courtesy. Referrals

40. Sometimes, a physician refers a patient to another physician without a written or verbal request for a consultation. Referrals • In these instances, the referral should be reported using office codes, outpatient codes (99201-99215), or subsequent hospital care codes. Where might you find documentation of the referral? The patient referral should be documented in the patient’s records.

41. Same Day E & M Services Occasionally, the same patient receives multiple E & M services on the same day... Let’s take a look…

42. Same Day E & M Services • There are instances when a provider bills for an E&M twice on the same day. Before denying the charge as a duplicate, you must check the provider’s documentation carefully. There are instances when the charges are allowable. Let’s take a look…

43. Same Day E & M Visits “You should be fine…come back in if you continue to experience symptoms…” Subsequent E & M visits are allowable if: • Charges are for different specialists in the same group. • The patient experienced difficulties or complications that required a second trip to the office or emergency room. “I am glad he came in again…we should be able to repair the damage…”

44. Providers are relied upon to code their visits accurately and fairly. However, during the review of a bill, any office visit on that bill may be evaluated for correctness of the assigned type and level of E/M service. E&M Coding Accuracy • Also, utilization review departments working on behalf of the payors and 3rd party administrators will look for patterns of abuse in provider coding.

45. How E & M services are classified and who can bill them. The difference between new and established patients. The difference between consultations and referrals. Patients seen by multiple physicians. Emergency department service codes. Same day E & M services: What is allowable? Summary