1 Evaluation and Management Strategies For Success American Academy of Professional Coders Woodland Hills California Chapter Meeting July 2010.

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Evaluation and ManagementStrategies For Success

American Academy of Professional CodersWoodland Hills California Chapter Meeting July 2010

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Part TwoFundamentals of Coding Evaluation

and Management Services

Presented by: Elizabeth McAllister, CPC, CPC-H, CPC-I, CEMC

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Evaluation & ManagementComponents

KEY COMPONENTS History Examination Medical Decision Making

Counseling Coordination of Care Nature of Presenting Problem Time*

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History History Four ElementsFour Elements

The selection of the level of history obtained will

depend on the following factors:

Chief Complaint History of Present Illness Review of Systems Past, Family & Social History

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History of Present IllnessHPI

Eight ElementsEight Elements

1. Location2. Quality3. Severity4. Duration5. Timing6. Context7. Modifying Factors8. Associated Signs &

Symptoms

Brief and Extended HPIs are distinguished by the amount of detail needed to accurately characterize the clinical problem(s).

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ROSCMS/AMA Systems

Constitutional Symptoms Eyes Ears, Nose, Mouth & Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentatry System Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergic/Immunologic

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Past (Medical) Family and/or Social History (PFSH)

Past History - Review of patient’s previous illness, injuries, hospitalization, current medications, allergies, immunization status.

Family History – Review of patient’s family health status or cause of death of parents, siblings, children. Also includes a review of any diseases that may be hereditary, that may put patient at risk.

Social – Review of current activities, may include alcohol, tobacco use, marital status, occupation, sexual history.

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Evaluation and ManagementExamination - Four Levels

Problem Focused -- a limited examination of the affected body area or organ system.

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(s) and other symptomatic or related organ system(s).

Comprehensive -- a general multi-system examination or complete examination of a single organ system.

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Examination

For purposes of examination, the following body areas are recognized:

Head, including the face Neck Chest, including breasts and axillae Abdomen Genitalia, groin, buttocks Back, including spine Each extremity

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Examination

The following organ systems are recognized:

Constitutional (e.g., vital signs, general appearance) Eyes Ears, nose, mouth and throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic/lymphatic/immunologic

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Medical Decision MakingLevels

Straightforward is the lowest level of Medical Decision-Making.  It is impossible not to qualify for it. 

Low Complexity Medical Decision-Making requires only slightly more intellectual energy than straightforward MDM. 

The degree of risk remains quite low and corresponds to a patient with one chronic illness which is completely stable. 

If there is an acute problem, it should be an uncomplicated clinical issue such as allergic rhinitis, cystitis or a sprained ankle.

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Medical Decision MakingLevels

Detailed Complexity Medical Decision-Making describes a patient with one chronic illness with a mild exacerbation or two stable chronic illnesses would satisfy the risk requirement for this level of medical decision-making. 

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Medical Decision MakingLevels

High Complexity Medical Decision-Making truly is complex.  Either the patient is quite ill or the physician must review a significant amount of primary data.

The patient would need to have a severe exacerbation of a chronic problem or an acute illness which threatens life or bodily function to qualify for this level of risk. 

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Observation ServicesCPT Code Range 99217 - 99220

Observation codes are used to identify evaluation and management services delivered to a patient for a condition that isn’t serious enough for admission into the hospital, but the patient is not well enough to go home.

Only the physician who admitted the patient to observation and was responsible for care during the stay may submit the hospital observation codes.

Observation codes may not be utilized for post-op recovery These services are a perennial favorite on the OIG Work plan

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Observation Services

Medicare Reimbursement Guidelines

The patient must be admitted to observation status for a minimum of 8 hours.

Observation services paid for the following conditions:

Congestive Heart Failure Asthma Chest Pain

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Initial Observation Care99218 – 992203 of 3 Key Components Required

Includes initiation of observation status

Supervision of the care plan

Performance of Periodic Reassessments

Observation Care Discharge 99220 Reports all services on

day of discharge.

Observation Services

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Observation Codes Admission/Discharge on Different Dates of Service(3 out of 3 Key Components Required)

CPT Code History Exam Medical Decision Making

99218 Detailed Detailed Straight forward or Low Complexity

99219 Comprehensive Comprehensive Moderate Complexity

99220 Comprehensive Comprehensive High Complexity

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ObservationAdmission & Discharge on Same Date of Service

Initial Observation Care

99234 – 99236

3 of 3 Key Components

Required

Includes all evaluation and management services provided by the admitting physician related to the initiation of “observation” status.

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Observation Codes Admission and Discharge on Same Date of Service(3 out of 3 Key Components Required)

CPT Code History Examination Medical Decision Making

99234 Detailed or Comprehensive

Detailed or Comprehensive

Straight forward or Low Complexity

99235 Comprehensive Comprehensive Moderate Complexity

99236 Comprehensive Comprehensive High Complexity

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Coding Flow Services Rendered by Same Physician

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Initial Inpatient Hospital Care(3 of 3 Key Components Required)

Evaluation and Management Services provided on the same day, in different sites that are related to the inpatient admission should not be reported separately.

CPT CODE

HISTORY EXAMINATION MEDICAL DECISION MAKING

99221 Detailed or Comprehensive

Detailed or Comprehensive

Straight Forward or Low Complexity

99222 Comprehensive Comprehensive Moderate Complexity

99223 Comprehensive Comprehensive High Complexity

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Subsequent Inpatient Hospital Care(2 of 3 Key Components Required)

Includes review of medical record, diagnostic test results, and changes in the patient’s status since last visit.

CPT CODE

HISTORY EXAMINATION MEDICAL DECISION MAKING

99231 Problem Focused Problem Focused Straight Forward or Low Complexity

99232 Expanded Problem Focused

Expanded Problem Focused

Moderate Complexity

99223 Detailed Detailed High Complexity

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Inpatient Discharge Management

Report the total duration of time spent by a physician for the final discharge of patient. Time does not need to be continuous.

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Inpatient Discharge Management

Includes: Final Examination Discussion of Hospital

stay Instructions for continuing

care Preparation of discharge

records Prescriptions and Referral

Forms

99238 Discharge Management 30 Minutes or Less

99239 Discharge Management More than thirty Minutes

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Time

Face-to-face (office and other outpatient visits) – Defined as only that time that the physician spends face-to-face with the patient and/or family.

Work spent pre/post encounter involved in such activities as reviewing records and tests, arranging further tests and treatment, communicating further with other professionals and the patient through either written reports of telephone contact.

Unit/floor time (hospital observation and other inpatient care) includes the time that the physician is present on the patient’s hospital unit and a the bedside rendering services for the patient.

This includes the time in which the physician established and/or reviews the patient’s chart, examines the patient, writes notes and communicates with other professionals and the patient’s family.

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Office Consultation(3 of 3 Key Components Required)

CPT Code

History Examination Medical Decision Making

99241 Problem Focused Problem Focused Straight Forward

99242 Expanded Problem Focused

Expanded Problem Focused

Straight Forward

99243 Detailed Detailed Low Complexity

99244 Comprehensive Comprehensive Moderate Complexity

99245 Comprehensive Comprehensive High Complexity

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Emergency Department Services 99281 - 99285

An Emergency Department is a hospital based facility that is open 24 hours a day for the purpose of providing unscheduled services to patients who present for immediate medical attention.

The Emergency Department services do not distinguish between new and established patients.

Time is not a factor in code selection.

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Emergency Department Services(3 of 3 Key Components Required)

CPT Code

History Examination Medical Decision Making

99281 Problem Focused Problem Focused Straight Forward

99282 Expanded Problem Focused

Expanded Problem Focused

Low Complexity

99283 Expanded Problem Focused

Expanded Problem Focused

Moderate Complexity

99284 Detailed Detailed Moderate Complexity

99285 Comprehensive Comprehensive High Complexity

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Critical Care

Critical Care is provided to a critically ill or injured patient during a life threatening medical crisis or trauma requiring immediate intervention and life saving measures.

Critical Care can be provided in any location.

Care by the physician is constant, but does not need to be continuous.

Time includes floor time, consulting with other medical staff and documentation in medical record.

Codes are patient age sensitive.

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Critical Care

99291 – 99292 Critical Care Patients are 24 months and older

For neonates and pediatric critical care see code range 99471 - 99476

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Critical Care Codes

99291 Used to report the first 30-74

minutes of critical care on a given date.

Less than 30 minutes should be reported with an E & M code.

Coded only once per day. Physician must devote entire to

time to the patient (cannot be seeing other patients at the same time).

+99292 Reports each additional 30

minutes beyond the first 74 minutes.

Can be reported for the final 15 minutes (other 15 minute increments are not reported)

32 Elizabeth McAllister, CPC, CPC-H, EMS 32

Critical Care 99291 - 99292Bundled Codes – Not Separately Reported

Elizabeth McAllister, CPC, CPC-H, EMS 32

Bundled Service(s) Rendered CPT Code(s)

Vascular Access Procedures 36000, 36410, 36540, 36600

Gastric Intubation 43752, 91105

Chest x-rays 71010, 71015, 71020

Temporary Transcutaneous Pacing

92953

Interpretation of cardiac output measurements

93561, 93562

Ventilator Management 94656, 94657, 94660, 94662

Pulse oximetry 94760, 94761, 94762

Blood gasses & information data stored in computers (ECG’s, BP)

99090

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Critical CareTime Includes

Patient care at bedside Review of test results

on unit or floor Discussion of patient

care Documentation of

critical care including patient’s condition

Documentation of Time

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Critical Care – Transport Coding

Physical attendance and direct face-to-face care during the inter facility transport of a critically ill or injured patient are time (and age) based codes.

The time begins when the physician assumes primary responsibility of the patient at the referring hospital and concludes when the receiving hospital accepts responsibility for the patient.

Codes are reported in thirty minute increments

99466, +99467 24 months of age or younger

99291, +99292 older than 24 months

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Newborn Care

Code 99460: Initial Evaluation of the normal newborn infant. Hospital or birthing room. Includes initiation of diagnostic and treatment programs, and preparation of hospital records.

Code 99461: Normal Newborn Care outside the hospital or birthing room. Includes physical examination and conference with parents.

Code 99462: Subsequent Hospital care (per day), evaluation and management of a normal newborn

Code 99463: Evaluatin and management of a normal newborn that is delivered and discharged on the same date of service.

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Newborn Care

99464 Attendance at Delivery and initial stabilization of the newborn.

99465 Delivery/Birthing room resuscitation, (provision of positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output.

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Pediatric and Newborn Care

99468 – 99476 Initial and Subsequent

inpatient neonatal critical care

99477 Initial hospital care, per day

for the evaluation and management of neonate 28 days or less who requires intensive observation, frequent interventions and other intensive care services.

99478 – 99480

Subsequent intensive care, per day, evaluation and management recovering low and very low birth weight infant

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Preventive Care ServicesCode Range 99381-99397Used to code for routine

examinations or asymptomatic patients of all ages

Examinations are age appropriate

Divided into new and established patients

Age & Gender Specific– Counseling/Anticipatory

guidance/Risk factor reduction interventions

Documentation Requirements– Comprehensive History &

Exam History does not contain

a CC or HPI Does require a complete

ROS Not synonymous with the

comprehensive requirements of an E/M service

Preventive Medicine Services Do Not Have Medical Decision Making.

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Preventive MedicineNew Patient Examination

99381 Initial exam - infant age 1 and under 99382 Initial exam - ages 1-4 99383 Initial exam - ages 5-11 99384 Initial exam - ages 12-17 99385 Initial exam - ages 18-39 99386 Initial exam - ages 40-64 99387 Initial exam - age 65 years and over

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Evaluation & ManagementCategories & Sub-Categories

Prolonged Services

With Direct Patient Contact 99354 - 99357

Without Direct Patient Contact 99358 - 99359 Standby Services 99360 Anticoagulant Management 99363 - 99364 Medical Team Conferences 99366 – 99368 Care Plan Oversight 99374 - 99380

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Preventive MedicineCounseling Service

Individual: New or Established Patient: 99401 Preventive Medicine Counseling - 15 minutes 99402 Preventive Medicine Counseling - 30 minutes 99403 Preventive Medicine Counseling - 45 minutes 99404 Preventive Medicine Counseling - 60 minutes

Group Counseling and or Risk Factor Reduction 99411 Approximately 30 minute session 99412 Approximately 60 minute session

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Evaluation & ManagementCategories & Sub-Categories

Nursing Facility Services 99304 - 99318Domiciliary, Rest Home 99324 - 99337Oversight Services 99339 - 99340Home Services 99341 - 99350

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Coding resources

AAPC website CMS – Medical Learning Network Associates and colleagues

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