©2010 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care.. Provided.

©2010 Coventry Health Care. All rights reserved.

Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care..

Provided by Coventry Health Care®

California Medical Bill Reviewer Re-Certification

Unit 2: Official Medical Fee Schedule

Module 3: Evaluation and Management

CA Regulations Training – E & M March 2010

OverviewHi! 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...

Classification of Evaluation and Management Services

New and Established Patients Hospital Visits Emergency Department Services Consultations and Referrals Same Day E & M Services

Classification of Evaluation and Management Services


Evaluation and Management Guidelines

Evaluation and Management services focus on the initial understanding and diagnosis of an illness or injury, as well as facilitating the necessary treatment to cure the illness or injury.

In the OMFS, the E & M section ranges from

99201-99499.

You might recall from the Physician’s Services module that only physicians can bill for E &

M services.


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…



There are seven different components that can be considered when differentiating levels of service.

The following levels of service can be assigned:

Comprehensive Detailed Expanded Problem focused

Components include: History Examination Medical decision-making Counseling Coordination of Care Nature of Presenting Problem Time

Incr

easi

ng Inte

nsi

ty



But different levels of service are determined primarily by three key components.

The following levels of service can be assigned:

Comprehensive Detailed Expanded Problem focused

Levels of service are determined

primarily by:

History Examination Medical decision-making

Incr

easi

ng Inte

nsi

ty

Each component of an evaluation is assigned a level of service.



You should be aware that some E & M services only require two of the three key components to meet or exceed the requirements to qualify for a specific level of service.

These services include:

Established patient office visits Subsequent hospital care Follow-up inpatient consultations Subsequent nursing facility care Established patient home visits


Example:


In some instances, a provider spends the majority of the appointment counseling the patient or coordinating care.

If at least 50% of the visit time is taken up in counseling or coordination of care, time

becomes the criteria for service level. Documentation must note

the time spent and a description of the counseling

or care coordination.



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 level of service. Also, utilization review

departments working on behalf of the payors and 3rd party administrators will look for patterns of abuse in provider coding.


New vs. Established Patients

There are two types of patients within evaluation and management office visits:

New Patients Established Patients



New Patients

A new patient is one who is new to the physician, or an established

patient with a new injury or condition.

New Patients


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.

However, per the fee schedule, 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.


Established Patients

An established patient is one who has been seen for the same injury or

illness. Established Patients


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 second initial visit.

2. If a second initial visit is billed, the processor should substitute

with a comparable subsequent

visit code.


Hospital Visits

Similar to office visits, there are two categories of patients within hospital visits:

Initial Visits Subsequent Visits



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.


Example:

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.




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.


Subsequent Hospital Visits

Subsequent visits occur when the physician visits a hospitalized patient on subsequent days.

If the same physician, or a physician from the same specialty group visits the patient, the visit should

be billed as a subsequent visit.

Hi Mr. Jones, you are looking better today.Reimbursement for

subsequent visits differs depending on

who provides the subsequent visit.


Subsequent Hospital Visits

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.

Dr. Meyer says that your

symptoms are improving.

This means that only one initial hospital visit

can be billed per patient.


Observation Services

Prior to being admitted to the hospital, a patient is occasionally placed under observation. In these cases, observation codes are used.

There are two types of observation services:

Initial Discharge



Initial Observation Codes

Like other evaluation and management services, observation codes are not to be charged for post-operative care in connection with a surgical service.

Initial observation services 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.


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.


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.


Emergency Department Services

Emergency Department Services: services rendered in a 24-hour hospital-based facility designed to accommodate immediate medical care to patients requiring unscheduled treatments.

There is no distinction between new or

established patients in the emergency department.

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. 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.


Emergency Department Services

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 visits vary with:

The number of patient encounters

Time waiting for test results

Medication Patient observation Care of other patients


Emergency Department Codes

Instead, emergency department visits are coded by key components and the nature of the presenting problem.


Emergency department codes vary by:

The severity of the injury or illness.

The extent of treatment.

As a result, like evaluation and management codes, emergency department codes also vary.


Example 2Example 1 CPT 99285

CPT 99281

Emergency Department Codes

Corresponds to minor injuries or illnesses that require straightforward

examination and treatment, such as:

Emergency department visit for the treatment of poison

ivy.

Emergency department visit for the diagnosis and wrap of a sprained ankle.

Corresponds to severe injuries or illnesses that

pose an immediate threat to the patient’s life, such

as:

Emergency department visit for internal bleeding.

Emergency department visit for severe chest pain.


Critical Care Services

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 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.


Consultations and Referrals

Evaluation and Management services are also distinguished by:

Consultations Referrals



Consultations

A consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.

Consultations

The physician may order diagnostic tests in order to form an opinion regarding the

patient’s diagnosis.


Consultations

In order for a visit to be classified as a consultation, the three “ROs” must be met.

pinion

equest for an pinion endering an pinion

eport of an


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.

Referrals


Referrals

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.


Where might you find documentation of the

referral?

Referrals

Sometimes, a physician refers a patient to another physician without a written or verbal request for a consultation.

The patient referral should be documented in

the patient’s records.

In these instances, the referral should be reported using office codes, outpatient codes (99201-99215), or subsequent hospital care codes.


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.


Same Day E & M Visits

“I am glad he came in

again…we should be able to repair the damage…”

“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.


Same Day E & M Visits

A modifier indicates subsequent E & M services on the same calendar day.

Modifier –19: Subsequent E & M services within the same calendar day.

This modifier must be used with the associated E & M

code to bill for subsequent visits.

An explanation An explanation that documents that documents

the the circumstances circumstances must also be must also be included with included with

the bill.the bill.


Summary

How E & M services are classified and who can bill them.

The difference between new and established patients.

Emergency department service codes.

Same day E & M services: What is allowable?

The difference between consultations and referrals.

Patients seen by multiple physicians.

©2010 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care.. Provided.

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