Basic CPT Evaluation & Management (E/M) Coding ED Coding Irene Mueller, EdD, RHIA Montana Hospital Association MT-NC Tele-Video Spring 2008 February 20,

Basic CPT Evaluation & Management (E/M)

CodingED Coding

Irene Mueller, EdD, RHIA

Montana Hospital

Association

MT-NC Tele-Video

Spring 2008

February 20, 2008 1– 3 pm MST

ObjectivesAssign correct CPT codes by applying

knowledge of

• Basic CPT E&M coding conventions, and

• Basic CPT coding process for ED

2/06/08 Schedule • 1pm – 1:05

– Overview of session

• 1:05 – 1:50 pm – CPT E/M Coding

• 1:50 – 2 pm Break

• 2:00 - 2:45– CPT Coding for ED

• 2:45- 3:00 pm– Questions

Identifiable procedures and E/M

• Any procedure id with specific CPT code performed on/subsequent to the date of initial/subsequent E/M services SHOULD BE reported separately– Performing/interpreting dx test/studies– -26 for professional component only – E/M related to procedures is part of their codes– -25 indicates that E/M services were above and

beyond those associated w/procedure (do not need different dx code)

Most E/M Codes reflect Cognitive Services

• Provider must – Acquire information from patient, exam, tests, etc.– Use reasoning skills to process information– Interact with pt to provide feedback– Respond by creating a plan

• Do NOT include significant procedures• Do include cleaning traumatic lesions, adhesive strip

closures, applying dressings, counseling/education

E/M “work”• Work not easy to measure, so other measures

used to establish work• Intraservice times

– F2F = office, other outpt visits• With patient/family• Valid indication of total work done before, during,

after visit– Unit/Floor = hospital, other inpt visits

• On floor and at bedside• Valid indication of total work done before, during,

after visit

Medicine and E/M Sections• Medicine section has some codes that describe

procedures and specialty services that include E/M– Allergy testing, immunotherapy, osteopathic

manipulation, PT services, neuro/vascular testing

– General/special ophthalmologic – General/special dx and tx psychiatric

• When Medicine procedural specialty codes are assigned, do NOT also assign an E/M code

• IF significant, sep. id E/M service provided, assign E/M code with -25 modifier

E/M Section

• Appears at beginning of code book

• 99201-99499

• Items are used by most physicians in reporting a significant portion of their services.

• E/M codes are specific to a SETTING (Place of Service (POS)

E/M Section• Categories (by setting, etc.)

– Subcategories – Ex: Office visits subcategories of new pt, est. pt– Ex: Hospital visits – initial and subsequent

–Levels of E/M services–3-5 levels (last digit)

• Physician’s work varies by– Type of service (TOS)– Place of service (POS)– Patient’s status– Misc. services (eg prolonged, care plan oversight)

New vs. Established Patient

• Distinguished by Professional Services– F2F services rendered by a physician and

reported via CPT codes

• New – one who has NOT received any professional services from the Dr (or another Dr of the SAME specialty who is in the SAME group practice), within the past 3 years

New vs. Established Patient• Established – one who has received

professional services from the Dr or another Dr of the SAME specialty who belongs to the SAME group practice, within the past 3 years.

• On call/Covering physician – encounter is classified as if it would have been performed by the physician who is NOT available.

• *Decision Tree in E/M Guidelines

Concurrent Care

• USUALLY, one E/M code reported for one day for one patient by one provider

• Provision of similar services to the same pt on the same day by more than one provider is CONCURRENT CARE

• Be sure to assign different dx codes to avoid claim denial

Concurrent Care

• EX: Pt adm for AMI on 2/15. On 2/17, cardiologist requested consult for anxiety and depression.

• Cardiologist’s coder assigns AMI dx code(s)• Psychiatrist’s coder assigns Anxiety/depression

dx• IF both bill for AMI, 1st claim is paid, 2nd claim

denied

Unlisted E/M services

• Only 2

• 99429

• 99499

• Requires special report to demonstrate the medical appropriateness of service

Special Report

• Complexity of symptoms• Description of nature, extent, need for

service• Dx and Tx procedures• Follow-up care• Pt’s final dx and concurrent problems• Pertinent physical findings• Time, effort, equipment required

Clinical Examples

• Appendix C– Examples, not descriptors

Levels of E/M Services

• 3-5 levels within each category/subcategory• Levels NOT interchangeable between categories• Include

– Exams, Evaluations, Tx, conferences with/about pts, health supervision, other medical services

– Medical screening• Hx, exam, medical decision-making• Required to determine need/location for

appropriate care/tx• Each level may be used by all physicians

E/M components

• Seven – Hx, Exam, Medical Decision-making (KEY)– Counseling, Coordination, Nature of

presenting problem (Contributory) – Time

• Contributory components may not be provided at every encounter

• Coordination w/out pt encounter = Case Mgt Codes

Key Components• New Pt – All 3 components must be at a level to

justify assignment• Established Pt – 2 of 3 components to justify level

assignment

• Some E/M categories don’t distinguish between New/Est pts

• Documentation MUST support the key components used to select E/M code– (Handout)

CMS Documentation Guidelines for E/M Services

• Guidelines and notes perceived as insufficient for consistent coding and reliable review by payers

• CMS Doc Guidelines for elements of comprehensive multisystem/single-system exams.

• 1995 – providers felt single-system exams unclear

• 1997 – providers felt confusing and burdensome (extensive counting)

• CMS policy– Providers to use whichever set of guidelines is

most advantageous for reimbursement• AMA and CMS still working on developing an

acceptable approach

Documentation and Coding

• Provider does NOT have to re-document Hx, ROS during a previous encounter IF review and location of the information is documented in current note.

• Provider then should update information that is no older than one to two years.

E/M Coding Process

• ID Category/Subcategory of service (POS)

• ID TOS provided

• ID if pt new/established if necessary

• Review Reporting Instructions

• Review Level of E/M Services provided– Key components – Counseling/coordination of care different

• Apply CMS Documentations Guidelines

Office or Other Outpt Services• When a Dr provides two E/M services for the same

pt on the same day for the same problem, report just ONE E/M code (highest level)– Critical Care Services is an exception to this

• When a Dr provides multiple E/M services in this setting to same pt on the same day for DIFFERENT problems, report multiple E/M codes– Be sure to link different dx to relevant E/M codes– Add -25 to 2nd and subsequent E/M codes

• When pt receives Office E/M services and is admitted as inpt the SAME day by the SAME Dr, report the initial hospital care E/M code ONLY

Office or Other Outpt Services

• When pt receives Office E/M services and is admitted as inpt the SAME day by the SAME Dr, report the initial hospital care E/M code ONLY

• When Dr performs comprehensive exam in office and on a later day the pt is admitted to hospital as a PLANNED admission, report a lower-level-of-service initial hospital care E/M code

• When pt’s admission is UNPLANNED on a later day, report the appropriate E/M codes for each episode of care

99211

• “Nurse visit”• Code can be reported by any other provider

– NP, PA, Physician

• CMS guidelines – “incident to”– Physician must be PHYSICALLY PRESENT in

offices when service provided

• Documentation – CC and service description– Hx and Exam documentation NOT required

Nursing Facility Services• Provided AT an NF, SNF, intermediate care

facility/mentally retarded (ICF), LTCF, or psychiatric residential tx facility

• NFs provide convalescent, rehab, or LT care for pts • Comprehensive assessment must be completed on

each pt– Medical, nursing, mental, psychological needs– Pt’s functional capacity, ID of potential problems,

nursing plan– Required on admission/readmission/substantial

change

NF Services

• When a pt is discharged from hospital or observation and admitted to a NF, SNF, ICF, or LTCF on the SAME day, code for both types of E/M services

• Do NOT code ED or office E/M with initial NF care when provided on SAME day for SAME pt by SAME physician.

NF services

• Do NOT code NF care and initial hospital care on the same date for the same pt by the same physician, code ONLY the initial hospital care.

• Code subsequent NF care when – evaluation of pt’s assessment plan is NOT

required– pt has not had a major/permanent change of

health status

NF Services

• NF discharge – 99315 or 99316

• Pronouncement of death, completion of death summary, and discussion with family – 99315 or 99316– Provider MUST personally visit pt and

document pronouncement of death BEFORE midnight on date of death

Misc.1. Application of casts and strapping

If sole procedure and not to treat a fracture; use appropriate E/M code and 99070 for supplies.If to treat fracture without reduction; assign code that states "closed treatment without manipulation".

2. Closure of wounds with adhesive strips is included in E/M code. p.

3. Maternity care/deliveryIf physician does NOT perform delivery, but

proved some antepartum/postpartum care, use E/M codes ONLY.

4. Vaginal foreign bodyIf removal is done WITHOUT anesthesia, use E/M codes ONLY.

Examples• Dr. Smith provided a level 3 E/M service to new pt

in office for anxiety. The pt returns 4 hours later with anxiety problem, and Dr. Smith provides a level 2 E/M service.– Code(s)?

• Dr. Jones provides level 3 services to an est. pt. for HTN. The pt returns 5 hours later for level 4 E/M services related to hip pain caused by a fall at home.– Code(s)?

• Dr. Green provides level 4 E/M services in office. Pt is later admitted to hospital, where Dr. Green performs level 3 initial hospital care E/M services.– Code(s)?

Examples

• Based on standing orders, Office nurse administers monthly B12 injection after taking and recording vital signs.

• Based on standing orders, Office nurse administers testosterone injection. Physician provided level 3 E/M services last week.

Examples

• 10/14 – 97 y/o female pt transferred from hospital to NF in stable condition. Attending provided hospital discharge day mgt services and provided a level 2 initial NF service.

• 11/14 – Physician provided level l subsequent NF care.

• 11/30 – Pt expired. Physician was not in attendance.

Break Time

Fluid Exchanges

ED Coding

• E/M exam documentation guidelines can be the 1995 or the 1997 guidelines, whichever is preferable to the provider.

• Evaluation and Management Services Guide (2007)

• “prepared as a tool to assist providers” “is a general summary…, but is not a legal document”

• “does not replace content found in ’95/’97 guidelines”

ED Services• Provided in a hospital• Open 24 hrs/day• Unscheduled episodic service to pts needing

immediate medical attention

• Emergency – the sudden and unexpected onset of medical

condition or – the acute exacerbation of a chronic condition

that is threatening to life, limb, or sight and that requires immediate medical treatment

– or that manifests painful symptomology requiring immediate palliative effort to relieve suffering.

ED Services

• Any physician who provides services to a pt REGISTERED in the ED may report the ED services codes.

• The physician does NOT have to be assigned to the ED

• If services provided in the ED are determined NOT to be actual emergency, ED services codes are STILL reportable IF ED services were provided.

• Typically, the hospital will report lower level ED services code for non-emergency conditions.

ED Services• When emergency services are provided in

the office, DO NOT assign ED E/M codes.

• If PCP meets pt in ED and the pt is NOT registered in ED, then report an Office or Other Outpt E/M code

• When ED services are provided the same day by the same physician as a comprehensive nursing facility assessment, do NOT report ED E/M code.

E/M Components in ED

• Time is NOT a component for the ED levels

Hospital E/M Coding for ED

• Since the MC hospital outpt PPS (HOPPS) began in 2000, hospitals have been coding clinic/ED visits using CPT

• E/M codes often do NOT fit the type of services provided by hospitals

• CMS requires hospitals to develop a methodology with internal guidelines for code assignment that maps to E/M levels of effort that refer to facility resources consumed by staff

Hospital E/M coding for ED

• CMS requirements – Services must be documented– Medically necessary– Reasonably reflect intensity of resources– Based on resource consumption that is NOT

separately payable (x-rays, labs, etc)

• Lack of standardization– Poor data for APC reimbursement– Possible violation of HIPAA code set requirements– Coder confusion– Less effective compliance programs

ED and Clinic E/M coding Model

• See Handouts

Hospital Established Pt

• If a patient has a medical record that was created within the past 3 years, the patient is considered an established patient to the hospital.

CMS Requirements for Hospital OPPS

• 2008 Hospital Clinic Visits– Continue using E/M outpatient visit codes– Continue differentiating between new, est. pts– Type of service is not differentiated

– Consultation E/M codes will not be recognized– Use new/est visit code

CMS Requirements for Hospital OPPS

• 2008 Hospital ED Visits– Type A ED visits – ED meets CPT definition, must be open 24/7.– Continue to use CPT ED codes– Type B ED visits – ED does not meet CPT definition, open less

than 24 hours/day– Use following codes– G0380, G0381, G0382, G0383, G0384

• Critical Care– Must provide a minimum of 30 minutes to report 99291– < 30 minutes, used clinic/ED visit code

G0380• G0380   Level 1 hospital emergency department visit provided in a

type b emergency department; (the ED must meet at least one of the following requirements: (1) It is licensed by the state in which it is located under applicable state law as an emergency room or emergency department; (2) it is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment; or (3) during the calendar year immediately preceding the calendar year in which a determination under 42 CFR 489.24 is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one-third of all of its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment)

CMS Guidelines Principles

• Hospitals should continue to report visits according to own internal guidelines

• CMS has 11 principles that internal guidelines should follow

• First 6 reaffirmed,• Five new ones this year

• Principles/Clarification available in • AHA Coding Clinic for HSCPS, v 7, #4, Fourth

Quarter, 2007, pp. 1-3

Hospital E/M Coding for ED

• Example - Handout

http://adam.about.com/encyclopedia/Sewing-a-wound-closed-series.htm

Resources• AMA CPT Web Site

– www.ama-assn/org/go/cpt (early releases)

• CPT 2008 Professional Edition. AMA

• Green, Michelle. (2007). 3-2-1 Code It! Thomson Delmar Learning. ISBN 1-4180-1255-6

• Hospital E/M Coding Panel. Recommendation for Standardized Hospital Evaluation and Management Coding of ED and Clinic Services. AHIMA. June 2003.

• Peters, R. and Wiedemann, L. Applying Facility E/M Codes in the Hospital Emergency Department. Journal of AHIMA, 78, no. 5 (May 2007): 68-69.

• Pitotti, Margaret. Coding the Emergency Room visit. ADVANCE for Health Information Professionals, 10/22/07

Resources

• OPPS Visit Codes Frequently Asked Questions http://www.cms.hhs.gov/HospitalOutpatientPPS/downloads/OPPS_Q&A.pdf

• CMS- 1506-P Proposed rule Section IX Proposed Hospital Coding and Payments for Visits (Clinic, Ed, Critical Care) http://www.cum.hhs.gov/HospitalOutpatientPPS/downloads/CMS1506.P.pdf

Resources

Evaluation and Management Services Guide (2007)

http://www.cms.hhs.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf

? From previous workshops

• Not coding DM if that wasn’t what brought the patient in – This is a case of dueling guidelines– As pointed out by Helen Ovitt (relaying a

question from a coder in her facility)– 2008 Coders’ Desk Reference – Diagnoses –

it states “diabetes is a systemic disease and, as such, should be coded even in the absence of documented, active intervention during a patient encounter”.

Questions fromPrevious Workshops

• A Glycosolated Hemoglobin test is not for anemia and has nothing to do with it.  It is to check the blood sugar control over a three month period in diabetics.  A Glycosolated Hemoglobin of 7.9 would indicate the blood sugars were not in very good control. A regular hemoglobin of 7.9 would require intervention of some kind, possibly a transfusion. 

HGB vs HbA1c

• The confusion is occurring because the wrong test name and normal values were used on the lab report.

• You noticed the Dr. referred to the test as glycosylated hemoglobin and I noticed the name on the lab test was HGB with normal values from 13.8-17.2.

• The lab report is for blood hemoglobin because of the name and the normal ranges.  For HGB the result for the blood hemoglobin is very low and needs intervention.

• The correct name for the glycosylated hemoglobin test on a lab report would be HbA1c and the normal range for this test that indicates the average blood glucose level for the last 3 months is 4.5 – 6, with anything over 8 being considered significant.

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