Outpatient Coding: CPT, Evaluation and Management (E/M) and Modifiers

1. Outpatient Coding: CPT, Evaluation and Management (E/M) and Modifiers Kathryn DeVault, MSL, RHIA, CCS, CCS-P, FAHIMA Manager, HIM Consulting Services, UASI Laura Barron, RHIA, CCS Vice President, Coding Services, UASI

2. Objectives Review documentation requirements in the Outpatient setting Discuss the guidelines for E/M code assignment Review the components of the Outpatient Code Editor, including the use of modifiers Review the codeable procedures in the Outpatient setting

3. Outpatient Coding

4. Assignment of Codes • Appropriate diagnosis and procedure codes are extracted from the medical record • Encoder helps with bundling issues and assignment of APCs • Codes may also be assigned in different clinical departments • Charges, and some procedure codes, are added by through the ‘charge description master’ (CDM)

5. Outpatient Coding Guidelines Guidelines in Section I, Conventions, general coding guidelines and chapter-specific guidelines, should also be applied for outpatient services and office visits. Selection of first-listed condition: In determining the first-listed diagnosis the coding conventions of ICD-10-CM, as well as the general and disease specific guidelines take precedence over the outpatient guidelines. Diagnoses often are not established at the time of the initial encounter/visit. It may take two or more visits before the diagnosis is confirmed.

6. Outpatient Coding Guidelines Signs and symptoms Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the provider. Conditions that are an integral part of a disease process Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification

7. Outpatient Coding Guidelines Signs and symptoms, continued Conditions that are NOT an integral part of a disease process Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present.

8. Outpatient Coding Guidelines Use of Sign/Symptom/Unspecified Codes Signs/symptom and ‘unspecified’ code have acceptable, even necessary, uses. While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter. Each healthcare encounter should be coded to the level of certainty known for that encounter.

9. Outpatient Coding Guidelines Use of Sign/Symptom/Unspecified Codes, continued If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and symptom(s) in lieu of a definitive diagnosis. When sufficient clinical information isn’t known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate “unspecified” code (e.g., a diagnosis of pneumonia has been determined, but not the specific type). Unspecified codes should be reported when they are the codes that most accurately reflect what is known about the patient’s condition at the time of that particular encounter. It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code.

10. Outpatient Coding Guidelines ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit List first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions. In some cases the first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician.

11. Outpatient Coding Guidelines Uncertain diagnosis Do not code diagnoses documented as “probable”, “suspected,” “questionable,” “rule out,” or “working diagnosis” or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit. Chronic diseases Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s)

12. Outpatient Coding Guidelines Code all documented conditions that coexist Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.

13. Outpatient Coding Guidelines Patients receiving diagnostic services only For patients receiving diagnostic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses. For encounters for routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnosis, assign Z01.89, Encounter for other specified special examinations. If routine testing is performed during the same encounter as a test to evaluate a sign, symptom, or diagnosis, it is appropriate to assign both the Z code and the code describing the reason for the non-routine test. For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses.

14. Outpatient Coding Guidelines Patients receiving therapeutic services only For patients receiving therapeutic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses. The only exception to this rule is that when the primary reason for the admission/encounter is chemotherapy or radiation therapy, the appropriate Z code for the service is listed first, and the diagnosis or problem for which the service is being performed listed second.

15. CPT and HCPCS CPT (Current Procedural Terminology) codes used to report outpatient services including surgery, therapeutic treatment, diagnostic testing and other medicine services HCPCS (Healthcare Common Procedural Coding System) codes are used to report non-surgical outpatient procedures, supplies, products and services Level II HCPCS codes, 5 position alpha-numeric codes, are used to report medical supplies, items and non-physician services not represented by CPT

16. CPT and HCPCS CPT and HCPCS codes are used by physicians and healthcare facilities to report the services provided Accurate and appropriate assignment of CPT and HCPCS codes requires an understanding of the specific rules and guidelines associated with their use Complete, accurate and timely documentation is necessary to ensure services are captured and reported

17. CPT System Structure • Evaluation & Management (E/M) 99201 – 99499 • Anesthesia 00100 – 01999 • Surgery 10021 – 69990 • Radiology 70010 – 79999 • Pathology and Laboratory 80047 – 89398 • Medicine 90281 – 99067 • Category II Codes 0001F – 0407T • Each section of CPT has specific guidelines for use

18. Surgery Section • General • 10021-10022 • Integumentary • 10030-19499 • Musculoskeletal • 20005-29999 • Respiratory • 30000-32999 • Cardiovascular • 33010-37799 • Digestive • 40490-49999 • Urinary • 50010-53899 • Male Genital • 54000-55899 • Female Genital • 56405-58999 • Nervous • 61000-64999 • Eye and Ocular Adnexa • 65091-68899 • Auditory • 69000-69979

19. Code Examples Excision – Malignant Lesions 11600 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.5 cm or less • 11601 excised diameter 0.6 to 1.0 cm • 11602 excised diameter 1.1 to 2.0 cm • 11603 excised diameter 2.1 to 3.0 cm Endoscopy 45330 Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed • 45331 with biopsy, single or multiple • 45332 with removal of foreign body(s) • 45333 with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps

20. Evaluation & Management (E/M) Codes

21. Evaluation and Management (E/M) Used to report provider services during a patient encounter Used primarily by providers to report services including office, hospital and observation visits, and other related patient encounters including consultations, wellness/preventative medicine visits and telephone or telehealth encounters E/M codes for physician services are assigned as supported by the documentation of key elements of history, examination and medical decision making or, under certain circumstances; codes may be assigned on the basis of the of time required for the encounter E/M codes for physician visits must have documentation to support the care rendered and level of service billed

22. E/M Point of Service Clinic or Office Visits – (99201-99215) Inpatient admissions and subsequent care Nursing homes Critical care Emergency department Psychiatric services

23. Key Components of E/M Codes • History • Chief Complaint (CC) • History of Present Illness (HPI) • Past Family Social History (PFSH) • Review of Systems (ROS) • Examination • 1995 documentation guidelines • 1997 documentation guidelines • Medical decision making (MDM) • Number of diagnoses • Data to be reviewed • Risk • Time

24. Chief Complaint With the exception of Preventive Medicine services AllE/M services should contain a “valid” Chief Complaint

25. History

26. Common Documentation Deficiencies Lack of chief complaint Completely negative ROS in sick patient Use of “noncontributory” Missing family history Documenting PMH as ROS Inappropriate references to secondary documents Template issues Contradicting information Copy paste / cloned notes

27. Examination

28. Common Documentation Deficiencies All normal templates Copy paste / cloned notes Canned verbiage Multiple system header with only one system documented Counting body areas as systems for comprehensive exam (’95 guidelines) Documentation of exam by ancillary staff Teaching physician attestations

29. Medical Decision Making

30. Common Documentation Deficiencies • Missing diagnoses • Copy paste / cloned notes • Inpatient services • Rule out, possible, probable, suspect

31. Time • Time spent must be documented • Total time • Time spent in counseling/coordination of care • More than 50% must be documented as counseling/coordination of care • Documentation must include a synopsis of what was discussed

32. Common Documentation Deficiencies Time documentation missing or incomplete Time documented does not meet criteria Missing elements necessary to code based on time Calculating time for multiple units (critical care, prolonged care, therapy, etc.)

33. E/M - 2021 Proposed Changes • Eliminate history and exam elements - providers should perform a “medically appropriate history and/or examination”. • Allow physicians to choose whether their documentation is based on Medical Decision Making (MDM) or Total Time: • MDM: No material changes to the three current MDM sub-components with extensive edits to the elements for code selection • Time: Represents total physician time on the date of service. The use of date-of-service time builds on the movement over the last several years by Medicare to better recognize the work involved in non-face-to-face services like care coordination. These definitions only apply when code selection is primarily based on time and not MDM

34. E/M - 2021 Proposed Changes • Deletion of code 99201:99201 and 99202 are both straightforward MDM and only differentiated by history and exam elements. • Creation of a shorter Prolonged Services code: Shorter prolonged services code that would capture physician time in 15-minute increments. This code would only be reported with 99205 and 99215 and be used when time was the primary basis for code selection.

35. Evaluation & Management (E/M) Codes Facility-based

36. E/M – Facility-based The same E/M codes are also used by hospitals and other healthcare settings to report facility resources utilized The April 2000 OPPS final rule instructed hospitals to develop and apply internal hospital guidelines to determine the level of service reported for each patient encounter The 2008 final rule further instructs hospitals that “each hospital’s internal guidelines should follow the intent of the CPT code descriptors, in that the guidelines should be designed to reasonably relate the intensity of hospital resources to the different levels of effort represented by the codes.” Facilities should have methodology for determining the appropriate clinic visit code based on documentation. This is often times done electronically.

37. E/M – Facility-based • Describe use of space • Describe use of supplies • Describe involvement of hospital staff in E/M services • Cannot be used if… • Patient admitted within 48 hours • Patient taken to surgery • Patient receives other global service (i.e. Dialysis)

38. Status V Codes • Only codes used in outpatient settings • Outpatient clinic • Office or Other Outpatient Service (99201 – 99215) • Office or Other Outpatient Consult (99241 – 99245) • Confirmatory Consult (99271 – 99275) • HCPCS exams (G0101, G0175, G0245, G0246, G0264) • Ophthalmology codes for appropriate exams (92002 – 92014) • Patients in observation status • Hospital Observation Services (99217 – 99220 and 99234 – 99236) • Emergency Room • Emergency Department Services (99281 – 299285)

39. Choosing Level of Service • Systems for choosing the level of E/M are developed by each facility • Facilities must follow their own systems/guidelines • Facility codes would not often match providers • “New" and "established" pertain to whether the patient already has a medical record • Use 99281 for screening services in the ER when no treatment is furnished

40. Observation Care • Separate payment allowed for 3 diagnostic categories: • Chest pain • Asthma • Congestive heart failure • May use admitting diagnosis • Patient must be in observation for at least 8 hours and no more than 48 hours

41. Critical Care • Critical care is classified as a "significant procedure" (APC 0620) under OPPS • Hospitals use code 99291 to report outpatient critical care services • Used in place of a code for a medical visit or emergency department service. • Use CPT definition of "critical care" and coding guidelines • Exceptions • Facilities only paid for one period time with code 99291 • Services usually bundled into Critical Care codes may be billed separately when furnished on the same day

42. Annual Updates and Changes • Required by law and may change • APC groupings • Payment adjustments • Conversion factor • Payment weights • Changes to APCs may result from • Changes in technology • Changes in CPT codes • Codes removed from Inpatient Only List • New procedures or services • CMS publishes Proposed Rule for comments • Final Rule is issued after comment period and any adjustments

43. Ambulatory Patient Classifications (APCs)

44. What are APCs? • Outpatient Payment Groups • Groups of codes with a fixed payment amount • Based on HCPCS codes • Level I (CPT) and Level II codes • Codes in the same APC must have • Comparable clinical aspects • Comparable resource consumption

45. Why APCs? • Cost control • Efficiency • Facilitate payment • Address beneficiary coinsurance issues

46. How are APC Groups Created? CPT/HCPCS codes are grouped together . . . • Similar clinical aspects • Pacemakers can’t be grouped with bronchoscopies even if resource usage is similar • Comparable resource consumption • Clinically similar codes are grouped by cost to perform the service

47. What are the Key Components of APCs? • APC payment structure • Comprehensive/Composite APCs • Packaging/Discounting • Payment status indicators • Outpatient Code Editor (OCE) • OCE Edits • NCCI edits • Modifiers • Charge Description Master (CDM)

48. APC Payment Structure • Relative weight • OPPS conversion factor • Status indicator • Packaging • Discounts • Annual updates affect APC groups, payment adjustments, conversion factor, and payment weights

49. APC Payment Structure • Calculated by multiplying APCs relative weight by the OPPS conversion factor with a minor adjustment for geographic location • The payment is divided into Medicare’s portion and patient co-payment • Multiple APCs can be applied to one account

50. Packaging/Discounting • Packaging • Services including laboratory, most supplies, anesthesia, intraocular lenses, and observation care are included in the APC payment • Drugs, pharmaceuticals, and biologicals usually not bundled • Discounting • Multiple procedures provided during the same encounter are provided at lower cost than they would be if provided at separate encounters • Applies to services with status indicator T