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ICD-9, CPT, E&M Coding Documentation and Compliance. …or the in-service for the in-service!!. …You’ve just seen a patient in your office…. …and after the exam You want to get paid (After all, you need to pay mortgage, food, etc) Insurance will pay you if…

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ICD-9, CPT, E&M Coding Documentation and Compliance

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ICD-9, CPT, E&M Coding Documentation and Compliance

…or the in-service for the


…You’ve just seen a patient in your office…

  • …and after the exam

    • You want to get paid

      • (After all, you need to pay mortgage, food, etc)

    • Insurance will pay you if…

      • You tell the company what you did…AND…

      • You tell the company why you did it

Types of “Codes”

  • Procedure codes

    • What I did during the visit

    • Two Types

      • CPT

      • Evaluation and Management

  • ICD

    • Why I did it

    • The actual diagnosis code

  • …and these must make sense together

ICD codes


ICD Codes

  • ICD = International Statistical Classification of Diseases and Related Health Problems

  • Provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease.

  • Every health condition can be assigned to a unique category and given a code, up to six characters long.

  • Easy to understand

  • Allows for global (international) understanding of information

ICD-9 (9th version- currently one in use)

  • 001-139: Infectious and parasitic diseases

  • 140-239: Neoplasms

  • 240-279: Endocrine, nutritional, metabolic and immunity disorders

  • 280-289: Blood ad blood-forming organs

  • 290-319: Mental disorders (used by primary care and psych for research. DSM codes are used for clinical billing by psych)

  • 320-359: Nervous system

  • 360-389: Sense organs

  • 390-459: Circulatory system

  • 460-519: Respiratory system

  • 520-579: Digestive system

  • 580-629: Genitourinary system

  • 630-676: Complications of pregnancy/childbirth

  • 680-709: Skin and subcutaneous tissues

  • 710-739: Musculoskeletal system and connective tissue

  • 740-759: Congenital anomalies

  • 760-779: Certain conditions originating in the perinatal period

  • 780-799: Symptoms, signs and ill-defined conditions

  • 800-999: Injury and poisoning

  • E and V codes: External causes of injury and supplemental classification


  • Can list by disease or symptom

  • Get better reimbursement for more detail

  • Some insurances will only pay for a certain number of visits per diagnosis

    • e.g., diabetes

  • Large book with diagnostic codes or can get on line

  • http://www.icd9coding1.com/flashcode/home.jsp

ICD-9 codes

More detail the better….

Break these down further!

Diseases of the circulatory system (390-459)

  • Hypertensive disease (401-405)

  • (401) Essential Hypertension

    • (401.0) Hypertension, malignant

    • (401.1) Hypertension, benign

  • (402) Hypertensive heart disease

  • (403) Hypertensive renal disease

    • (403.91) Hypertensive renal disease, unspec., w/ renal failure

  • (404) Hypertensive heart and renal disease

    • (405.01) Hypertension, renovascular, malignant

    • (405.11) Hypertension, renovascular, benign

Endocrine, nutritional and metabolic diseases, and immunity disorders (240-279)

  • diseases of other endocrine glands (250-259)

  • Note: for 250-259, the following fifth digit can be added:

    • (250.x0) Diabetes mellitus type 2

    • (250.x1) Diabetes mellitus type 1

    • (250.x2) Diabetes mellitus type 2, uncontrolled

    • (250.x3) Diabetes mellitus type 1, uncontrolled

  • (250) Diabetes mellitus

    • (250.0) Diabetes mellitus without mention of complication

    • (250.1) Diabetes with ketoacidosis

    • (250.2) Diabetes with hyperosmolarity

    • (250.3) Diabetes with other coma

    • (250.4) Diabetes with renal manifestations

    • (250.5) Diabetes with ophthalmic manifestations

    • (250.6) Diabetes with neurological manifestations

    • (250.7) Diabetes with peripheral circulatory disorder

    • (250.8) Diabetes with other nonspecified manifestations

    • (250.9) Diabetes with unspecified complication

(780) General symptoms

(780.0) Alteration of consciousness

(780.01) Coma, nondiabetic, nonhepatic

(780.02) Mental status changes

(780.09) Semicoma, stupor

(780.1) Hallucinations

(780.2) Syncope

(780.3) Convulsions

(780.31) Seizures, convulsions, febrile

(780.39) Seizures, convulsions, other

(780.4) Dizziness/vertigo, NOS

(780.5) Sleep disturbance, unspec.

(780.53) Hypersomnia, sleep apnea

(780.53) Sleep apnea w/ hypersomnia

(780.58) Movement disorder, sleep related

(780.6) Fever, nonperinatal

(780.7) Malaise and fatigue

(780.8) Sweating, excessive

(780.9) Other general symptoms

(780.92) Crying, infant, excessive

(780.93) Memory loss

(780.94) Early satiety

780-799: Symptoms, signs and ill-defined conditions


Current Procedural Terminology


  • CPT = Current Procedural Terminology

  • Code Set accurately describes medical, surgical, and diagnostic services

  • Designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes.

  • The current version is the CPT 2008.


  • A CPT code is a five digit numeric code that is used to describe medical, surgical, radiology, laboratory, anesthesiology, and evaluation/management services of physicians, hospitals, and other health care providers. 

  • There are approximately 7,800 CPT codes ranging from 00100 through 99499. 

  • Two digit modifiers may be added when appropriate to clarify or modify the description of the procedure.

Current Procedural Terminology

  • Chapter 1: Evaluation and Management Codes (99201-99499)

  • Chapter 2: Anesthesia Codes (00100-01999)

  • Chapter 3: Surgery Codes (10040-69990)

  • Chapter 4: Radiology Codes (70010-79999)

  • Chapter 5: Pathology/Laboratory Codes (80049-89399)

  • Chapter 6: Medicine Codes (90281-99199)

  • Appendices: Modifiers, Deleted codes

V codes: Supplemental classification

  • V01 Contact with or exposure to communicable diseases

  • V02 Carrier or suspected carrier of infectious diseases

  • V09 Infection with drug-resistant microorganisms

  • V10 Personal history of malignant neoplasm (i.e. cancer)

  • V16 Family history of malignant neoplasm

  • V17 Family history of certain chronic disabling diseases

  • V20 Health supervision of infant or child

  • V21 Constitutional states in development

  • V22 Normal pregnancy

V codes, cont

  • V23 Supervision of high-risk pregnancy

  • V24 Postpartum care and examination

  • V25 Encounter for contraceptive management

  • V28 Encounter for [antenatal] screening of mother

  • V29 Observation and evaluation of newborns for suspected conditions not found

  • V30 Single liveborn

  • V31 Twin birth mate liveborn

  • V48 Problems with head neck and trunk

  • V49 Other conditions influencing health status

  • V50 Elective surgery for purposes other than remedying health states

  • V51 Aftercare involving the use of plastic surgery

V codes, cont

  • V56 Encounter for dialysis and dialysis catheter care

  • V57 Care involving use of rehabilitation procedures

  • V58 Encounter for other and unspecified procedures and aftercare

  • V60 Housing, household and economic circumstances

  • V64 Persons encountering health services for specific procedures not carried out

  • V65 Other persons seeking consultation

  • V66 Convalescence and palliative care

  • V67 Follow-up examination

  • V68 Encounters for administrative purposes

  • V69 Problems related to lifestyle

  • V70 General medical examination

  • V71 Observation and evaluation for suspected conditions not found

  • V80 Special screening for neurological eye and ear diseases

  • V81 Special screening for cardiovascular respiratory and genitourinary diseases

  • V85 Body mass index

Relationship between CPT and ICD-9

  • The critical relationship between an ICD-9 code and a CPT code is that the diagnosis supports the medical necessity of the procedure.

  • Since both ICD-9 and CPT are numeric codes, health care consulting firms, the government, and insurers have all designed software that compares the codes for a logical relationship. 

    • For example, a bill for CPT 31256, nasal/sinus endoscopy would not be supported by ICD-9 826.0, closed fracture of a phalanges of the foot.    

    • Such a claim would be quickly identified and rejected.

…trivia for boards…

  • Health Care Financing Administration (HCFA)

    • Common Procedural Coding System (HCPCS)

  • Diagnosis CodesICD – 9

    • Creates medical necessity

  • Level I CPT

    • Updated Annually

  • Level II (national)HCPCS (A-V)

    • Alphanumeric System

  • Level III (State)Local Codes (W-Z)

E & M Coding

Evaluation and Management

Most confusing for physicians

What are E&M Codes?

  • The Evaluation & Management (E&M) codes are a sub-set of the CPT codes.

  • Can be used by all privileged providers

  • Describes:

    • Complexity of care provided to a patient for non-procedural visits.

    • The place of service (inpatient or outpatient)

    • The type of service (new vs. established, consult, preventive, ER, critical care, etc)

  • Defined by 3 components

    • The patient history

    • The physical examination

    • Medical decision making

Why Code?


    • Third Party Payers/Insurance Agencies

    • Prospective Payment Systems (PPS)

  • Over coding = Fraud

  • Under coding = Lost Revenue

What Do Coders Look For?

  • Professional Coders in your office or from insurance companies have been trained to match documentation in charts to the billing information

  • It is the Content, not the volume, of documentation that determines your E&M code!

What Do Coders Look For?

  • Every patient encounter should be legible and include:

    • Date of Encounter

    • Reason for the visit (chief complaint)

    • Appropriate history of present illness

    • An exam when necessary or appropriate; i.e. a new patient (consistency and problem pertinent)

    • Review of lab, x-ray, other ancillary services when appropriate

    • Assessment

    • Plan of care/Treatment options

    • Provider signature

Why is Documentation Important?

  • The documentation must support the E&M code you select.

  • Your documentation must also support the medical necessity of the services provided.

    • The first step is to clearly document the reason for every visit – the chief complaint.

  • The use of “Follow-up” is insufficient documentation as it does not indicate medical necessity.

    • However it is acceptable to document “Follow-up for _____”.

  • “If it isn’t documented, it wasn’t done!”

Patient Type

New vs. Established


Inpatient vs. Outpatient

New vs. Established

  • New patient

    • Any patient who has not received professional services, within the previous 36 months, from a provider within the same group, of the same specialty

      • Same group practice: One Federal Tax ID number for all providers, if more than one Federal Tax ID, can consider the patient new

        • e.g., current practice seen in OLBH ER and Outreach offices

      • Professional Services: Phone call, prescription, hospital or office visit, etc.

      • Specialty Issue: Optional if one federal Tax ID is shared by practitioners of other specialties (e.g., surgeon and FP)

  • ** DO’s and MD’s of the same specialty DO NOT differ even if OMT is offered by the DO

Average and Recommended Code Distributions

The difference in the bell curves represents loss in physician income!!

Determining the Correct E&M Code

  • There are three key components to consider when selecting the appropriate E&M:

    • History

    • Exam

    • Medical Decision Making (MDM)

  • All three components must be documented for a newpatient (new to clinic or not seen within the past three years). Indicate in CC if patient is new.

  • Only two of the three components must be documented for established patients (seen within the past three years).

  • E&M selection should never be based on the allotted time on the appointment schedule!

Determining the Correct E&M Code

  • To determine the correct level E&M code, consider the complexity of your patient’s condition and your medical decision making, then support that level of complexity with your documentation of history and/or exam.

  • Remember:

    • For a new clinic patient, initial consult, initial inpatient visit or ED encounter you must document all three key components

      • history, exam and your medical decision making.

Defining Levels of E&M Services

  • 7 components

    • History

    • Examination

    • Medical Decision Making

    • Counseling

    • Coordination of care

    • Nature of Presenting Problem

    • Time

The Medical History


  • Also has several components to determine “complexity” or “type”

    • History of Present Illness (HPI)

    • Review of Systems (ROS)

    • Past Family and/or Social History (PFSH)

  • The extent of history is dependent on clinical judgment and the nature of the presenting problem.

  • The four types of History include: Problem focused, Expanded Problem Focused, Detailed and Comprehensive.

History of Present Illness

History – Chief Complaint

  • Chief Complaint Required

    • concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter.

  • The CC is usually stated in the patient’s own words.

    • For example, patient complains of upset stomach, aching joints, and fatigue

  • Cannot be the words “follow up” alone

History – History of Present Illness

  • Two types of HPI

  • Brief, which includes documentation of one to three HPI elements.

    • In the following example, three HPI elements – location, severity, and duration – are documented:

      • CC: A patient seen in the office complains of left ear pain.

      • Brief HPI: Patient complains of dull ache in left ear over the past 24 hours.

History – History of Present Illness

  • Extended, which includes documentation of at least four HPI elements or the status of at least three chronic or inactive conditions.

    • In the following example, five HPI elements – location, severity, duration, context, and modifying factors – are documented:

      • Extended HPI: Patient complains of dull ache in left ear over the past 24 hours. Patient states he went swimming two days ago. Symptoms somewhat relieved by warm compress and ibuprofen.

History Components

  • Location

    • Area of body, localized, unilateral, bilateral, fixed, migratory, radiation, referred

  • Quality

    • Specific pattern, sharp, dull, throbbing, stabbing, constant, intermittent, acute, chronic, stable, improving, worsening

      • Laceration as jagged or straight

      • Sore throat as scratchy

  • Severity

    • Pain scale, “compared to”, observation by physician (discomfort, wincing)

  • Duration

History Components

  • Timing

    • Onset of problem or symptom and progression, recurrent, comes and goes, worsens or improves

  • Context

    • Associated with activity, improves with activity, etc

  • Modifying factors

    • Steps the patient has taken to alleviate symptoms, what exacerbates symptoms, is helped by, is hindered by

  • Associated signs/symptoms

    • Clinical impressions direct physician questioning

      • Specific symptoms (weakness, headache with injury)

      • Generalized symptoms, chills, fever, “pertinent positives and negatives”

History Guidelines

  • HPI must be documented by the physician

  • ROS and/or PFSH can be recorded by ancillary staff

    • Physician must supplement or confirm the information

    • If obtained at a prior visit, do not need to re-record. Can review and update

      • Describe new information

      • Note date and location of earlier information

History Guidelines

  • If unable to obtain a history

    • Describe patient’s medical condition or circumstance which precludes obtaining a history

Review of Systems

Review of Systems

  • Definition

    • An inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced

  • The following “systems” are recognized:

    • Constitutional (fever, weight loss)- Psychiatric

    • Eyes- Endocrine

    • Ears, nose, mouth throat- Neurological

    • Cardiovascular- Allergic/Immunologic

    • Respiratory

    • Gastrointestinal

    • Musculoskeletal

    • Integumentary (skin and/or breast)

    • Hematologic/Lymphatic

Review of Systems

  • Three categories of review

    • Problem Pertinent

      • ROS inquires about the system directly related to the problem(s) identified in the HPI

        • Both positive responses and pertinent negatives should be documented

    • In the following example, one system – the ear – is reviewed:

      • CC: Earache.

      • ROS: Positive for left ear pain. Denies dizziness, tinnitus, fullness, or headache.

Review of Systems

  • Extended

    • ROS inquires about the system directly related to HPI AND a limited number of additional systems

      • 2-9 systems which are documented

    • In the following example, two systems – cardiovascular and respiratory – are reviewed:

      • CC: Follow up visit in office after cardiac catheterization. Patient states “I feel great.”

      • ROS: Patient states he feels great and denies chest pain, syncope, palpitations, and shortness of breath. Relates occasional unilateral, asymptomatic edema of left leg.

Review of Systems

  • Complete

    • ROS inquires about the system directly related to the HPI AND all other body systems

      • At least 10 body systems must be documented

      • Those systems w/pertinent +or- responses must be individually documented, however for the remaining systems, “all other systems are negative” is permissible

Review of Systems

  • In the following example, 10 signs and symptoms are reviewed:

    • CC: Patient complains of “fainting spell.”

    • ROS:

      • Constitutional: weight stable, + fatigue.

      • Eyes: + loss of peripheral vision.

      • Ear, Nose, Mouth, Throat: no complaints.

      • Cardiovascular: + palpitations; denies chest pain; denies calf pain, pressure, or edema.

      • Respiratory: + shortness of breath on exertion.

      • Gastrointestinal: appetite good, denies heartburn and indigestion.

      • + episodes of nausea. Bowel movement daily; denies constipation or loose stools.

      • Urinary: denies incontinence, frequency, urgency, nocturia, pain, or discomfort.

      • Skin: + clammy, moist skin.

      • Neurological: + fainting; denies numbness, tingling, and tremors.

      • Psychiatric: denies memory loss or depression. Mood pleasant.

Past Medical History




History - PFSH

  • Past History

    • Past experience with illnesses, operations, injuries and treatments

  • Family History

    • Review of medical events in patients family, including hereditary disease

  • Social History

    • Age appropriate review of past and current activities

History - PFSH

  • Pertinent

    • review of the history areas directly related to the problem(s) identified in the HPI.

    • Must document one item from any of the three history areas.

  • In the following example, the patient’s past surgical history is reviewed as it relates to the current HPI:

    • Patient returns to office for follow up of coronary artery bypass graft in 1992. Recent cardiac catheterization demonstrates 50 percent occlusion of vein graft to obtuse marginal artery.

History - PFSH

  • Complete

    • A review of two or all three of the areas, depending on the category of E/M service.

    • Requires a review of all three history areas for services that, by their nature, include a comprehensive assessment or reassessment of the patient.

    • A review of two history areas is sufficient for other services.

History - PFSH

  • At least one specific item from each of the history areas must be documented for the following categories of E/M services:

    • Office or other outpatient services, new patient;

    • Hospital observation services;

    • Hospital inpatient services, initial care;

    • Consultations;

    • Comprehensive Nursing Facility assessments;

    • Domiciliary care, new patient; and

    • Home care, new patient.

History - PFSH

  • Does NOT need to be re-recorded

  • Record new information only

  • “No change” PFSH can be documented

History Algorithm

Physical Examination

Physical Exam

  • Looked at either by

    • Body Areas

    • Organ Systems

Physical Exam

  • Body areas recognized:

    • Head (including face)

    • Neck

    • Chest, including breast and axillae

    • Abdomen

    • Genitalia, groin, buttocks

    • Back (including spine)

    • Each extremity (separately)

Physical Exam

  • Organ systems recognized

    • Constitutional

    • Eyes

    • ENT, Mouth

    • Cardiovascular

    • Respiratory

    • GI

    • GU

    • Musculoskeletal

    • Skin

    • Neurologic

    • Psychiatric

    • Hematologic; Lymphatic; Immunologic

  • The general multi-system exam should include findings of at least 8 of the above 12 organ systems

Documentation of Examination

  • Make sure you note specific abnormal or relevant findings of affected body areas or organ systems

  • Brief statement indicating negative or normal is sufficient for unaffected or asymptomatic systems

  • Describe abnormal or unexpected findings of asymptomatic areas or organs

Physical Examination

Physical Examination

Physical ExaminationGeneral Multi-System Examinations

Physical ExaminationGeneral Multi-System Examinations

Exam Bullets

  • Constitutional

    • 3 vital signs

    • General appearance

  • Eyes

    • Inspection of Conjunctiva and Lids

    • Examination of Pupils and Iris (PERLA)

    • Ophthalmoscopic discs and posterior segments

  • Ears, Nose, Mouth and Throat

    • External appearance of Nose and Ears

    • Otoscopic Examination

    • Assessment of Hearing

    • Inspection of Nasal Mucosa/Septum

    • Examination of oropharynx

Exam Bullets

  • Neck

    • Examination of Neck

    • Examination of Thyroid

  • Respiratory

    • Assessment of respiratory effort

    • Percussion of Chest

    • Palpation of Chest

    • Auscultation of Lungs

Exam Bullets

  • Cardiovascular

    • Palpation of PMI

    • Auscultation of the Heart

    • Assessment of Lower Extremity Edema

    • Examination of Carotid Artery

    • Examination of abdominal aorta

    • Examination of femoral pulse

    • Examination of pedal pulse

  • Chest (breasts)

    • Inspection of breasts

    • Palpation of breasts and axillae

Exam Bullets

  • Gastrointestinal (abdomen)

    • Examination with notation of masses or tenderness

    • Examination of liver and spleen

    • Examination for presence/absence of hernias

    • Examination of anus, perineum, rectum, including sphincter tone, hemorrhoids

    • Obtain stool for occult blood

  • Genitourinary (male)

    • Examination of scrotal contents

    • Examination of Penis

    • DRE prostate

Exam Bullets

  • Genitourinary (female)

    • Examination of external genetalia

    • Examination of urethra

    • Examination of bladder

    • Examination of cervix

    • Examination of uterus

    • Examination of adenexa

  • Lymphatic

    • Palpation of lymph nodes in two or more areas

    • Neck, axillae, groin, other

Exam Bullets

  • Musculoskeletal

    • Examination of gait and station

    • Examination of joints, bones and muscles of one or more of the following 6 areas

      • Head and Neck

      • Spine, ribs and Pelvis

      • Right Upper Extremity

      • Left Upper Extremity

      • Right Lower Extremity

      • Left Lower Extremity

    • Examination includes…Inspection and/or palpation with notation of any misalignment, asymmetry, crepitation, etc; range of motion with notation of pain, crepitation; assessment of stability; assessment of muscle strength

Exam Bullets

  • Skin

    • Examination of skin and subcutaneous tissue

    • Palpation of skin and subcutaneous tissue

  • Neurologic

    • Test cranial nerves with notation of deficit

    • Examination of DTR

    • Examination of sensation

  • Psychiatric

    • Description of judgment and insight

    • Brief assessment of mental status

Medical Decision Making

Determination of Medical Decision Making

  • Based upon

    • Number of diagnoses or management options

    • Amount and complexity of data

    • Overall risk

Medical Decision Making

  • (MDM) refers to the complexity of determining a diagnosis and/or the selection of a treatment option.

  • Measured by documentation of the following:

    • Number of diagnoses and/or management options that must be considered.

    • Amount and/or complexity of data to be reviewed.

    • Risk of complications, morbidity and/or mortality, and co-morbidities.

  • Four types

    • Straightforward, Low Complexity, Moderate Complexity, and High Complexity.

Documentation to Support Complexity

  • Consider the following for risk

    • Chronic illness(es)

      • Well controlled

      • Mild exacerbation

      • Severe exacerbation

    • Acute illness

      • Uncomplicated like allergic rhinitis

      • With systemic symptoms like pneumonitis

Medical Decision MakingDiagnoses/Management OptionsMax of 4 points

Documentation to Support Complexity

  • Consider the following…

    • Did you order/review labs?

    • Did you order/review X-rays, US, MRI

    • Did you order/review any other testing

    • Did you visualize image, tracing, or specimen

    • Did you review or summarize old records

      • Must document this on the record

        • …old records reviewed which noted ….

Medical Decision MakingAmount and Complexity of DataMax of 4 points

Table of Risk

Medical Decision Making

  • The HIGHEST level of ANY ONE of the three aspects of a medical decision making will determine the overall level chosen

Medical Decision MakingFinal Medical Decision Making2 of 3 rule

Defining Levels of E&M Services

  • 7 components

    • History

    • Examination

    • Medical Decision Making

    • Counseling

    • Coordination of care

    • Nature of Presenting Problem

    • Time

Counseling and Coordination of Care

  • Discussion with patient or family concerning one or more of the following:

    • Diagnostic results

    • Prognosis

    • Risk & benefits of management options

    • Instruction for management

    • Compliance

Time…as another factor

  • Appropriate in cases where counseling and/or coordination of care dominates (>50%) of the patient and/or family encounter

  • Documentation requirements

    • Total face to face time or encounter

    • Total counseling/coordination time

    • Content of counseling/coordination

Time based billing…example

  • cc: Depression

  • Hx cc: 59 y/o female w/depression and anxiety. Denies suicidal ideations. Hx ativan use in past

  • Exam: vitals (list)

  • A/P: Depression. Had long discussion w/patient and counseled him on exacerbating factors and treatment options. Rx ordered (list)

  • Total visit time 25 minutes, counseling time 15 minutes

Summing Up Your Services

Billing the Correct Code…

The Constants of Coding

  • 3 of 3 rule

    • Go to the lowest component

      • i.e., 2,3,4 = 2

      • 3,3,4 = 3

    • Used for new patient, initial consults, initial hospital care and emergency department visits

  • 2 of 3 rule

    • Go to the middle component

      • 2,3,4 = 3

      • 3,3,4 = 3

    • Used for established patient, subsequent hospital f/u, f/u consult

New vs. Established Patient

  • New Patient

    • All key components must meet or exceed the stated requirements to qualify for a particular level

  • Established Patient

    • Two key components must meet or exceed stated requirements to qualify for a particular level

Documentation RequirementsNew Patient Office Visit3 of 3 rule

Documentation RequirementsNew Patient Office Visit3 of 3 rule

Documentation RequirementsNew Patient Office Visit3 of 3 rule

Documentation RequirementsNew Patient Office Visit3 of 3 rule

Established Patient CPT E&M Guidelines2 of 3 rule

Established Patient CPT E&M Guidelines2 of 3 rule

Established Patient CPT E&M Guidelines2 of 3 rule

Inpatient Codes

  • Follow 3 of 3 rule

  • Inpatient Services and Observation

  • Inpatient Consults

  • Inpatient follow ups follow the 2 of 3 rule

Other Medical Services

General Consultant

Pre/Post Operative Consults

Definition of Consultation

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

Consultation Services

  • Documentation MUST include

    • Request for consultation documented in the medical record

    • Reason for consultation (medical necessity)

    • Report- Consultant’s opinion, advice and evaluation of the patient (this MUST be communicated back to the requesting physician)

  • Have separate initial coding

    • Follow up visits use established patient visits

Preoperative Consultation

  • Must request opinion or advice regarding a specific problem

  • Request and need for consult must be documented in the medical record

  • Any services ordered or performed must be documented

  • Consultant’s opinion, advice and evaluation of the patient must be communicated back to the requesting surgeon

Preoperative Clearance

  • ICD-9 diagnosis codes

    • V72.81 Preoperative cardiovascular examination

    • V72.82 Preoperative op respiratory examination

    • V72.83 Other specified preoperative examination

    • V72.84 Preoperative examination, unspecified

    • V72.85 Other specified examination

  • Must supplement with sigh/symptom/dx codes

  • Must also include surgical indication (eg, cataracts)

Rules for Consultation99241-99275

  • Opinion or advise regarding E&M of a specific problem is requested

  • Documented request from appropriate source is required (if patient generated for 99271-99275)

  • Written report sent to referring provider (a letter for an outpatient)

  • Initiation of care at time of consult is acceptable

  • Post-op consult by provider performing pre-op clearance should use subsequent hospital codes or established office visit codes

New outpatient and consultative CPT E&M Guidelines3 of 3 rule

Coding Examples

Documentation RequirementsEstablished Patient Office Visit

Example 99211Non-physician visit

  • Patient Calls Advice Nurse with Possible UTI

    • Patient brings and drops-off UA

    • Nurse processes UA

    • You (Doctor/PA/NP) review and find UTI

    • Nurse calls in antibiotics and documents in Chart

  • Blood Pressure Check

Example 992124y/o female with fever and ear pain

  • Established Patient: 2 of 3 required

    • History: 1-2 HPI

    • Exam: 1-5 elements

    • Medical Decision Making: 1 self limited minor problem

Example 992124y/o female with fever and ear pain

  • History

    • Fever 101

    • Left ear 3 days

  • Exam

    • Injection with redness and drainage of tympanic membrane

    • Pharynx red, no exudates

    • + anterior cervical nodes

    • Lungs clear

    • Heart rrr

  • Medical Decision Making

    • OM – Prescription Antibiotics

    • Fever control

    • Recheck in 2 weeks

Example 992134 y/o female with fever and ear pain

  • History:

    • 1-3 HPI elements …AND

    • ROS

  • Exam: 6-11 elements

  • Medical Decision Making:

    • 2 self-limited or minor problems …OR

    • 1 new problem plus low risk

Example 992134 y/o female with fever and ear pain

  • History:

    • Fever and Ear pain for 3 days

    • ROS

      • Cough/sinus congestion, sore throat, vomiting and diarrhea

    • PFSH

      • NKA/Immunization/passive smoking/any chronic meds

  • Exam

    • 3 vitals (weight, temp, BP)

    • Left TM red, pharynx red, tender nodes, neck supple, lungs clear, heart regular, abdomen non-tender

  • Medical Decision Making:

    • LOM

    • Antibiotics/Fever Control

    • Recheck in 2 weeks

    • Call if worse

Example 9921458 y/o male at 3 month check up

  • Detailed history

    • Extended HPI

    • Extended ROS

    • One element PFSH

  • Detailed exam

    • 12 exam elements from at least 2 systems

  • Moderate Complexity

    • 2 of the following: Multiple dx; Moderate amount and complexity of data; Moderate risk

Example 9921458 y/o male at 3 month check up

  • History

    • HTN; DM; DJD; vision exam UTD; (-) HA; (-) SOB; (-) CP; (-) NVDC; (-) Hematochezia; (-) Nocturia

    • PFSH

      • Unchanged from prior exam

  • Detailed exam

    • 12 exam elements from at least 2 systems

  • Medical Decision Making

    • EKG, Pulse Oximetry; UA, Rapid Strep

    • Review of CXR

    • Prescriptions written

  • Document Procedures

  • Document OMM

OMT Billing

OMT codes

  • These are nonallopathic lesions, not elsewhere classified.

  • CPT codes 98925 – 98929

  • ICD codes 739.0 – 739.9 depending on body region

  • Will be discussed at separate lecture in detail

Other Billable Services

Other Billable Services

  • Injections/Immunizations

  • Smoking Cessation

  • Visit and procedures


  • 90471 is for first administration

  • 90472 is for EACH additional administration

  • Cannot report if patient brings their own supply

  • Cannot bill 99211 (nursing service) if only injection given

    • Must provide separately identifiable service

      • e.g., get vital signs

Smoking Cessation

  • Document that you told patient to stop smoking

    • 99406 Greater than 3 minutes, up to 10 minutes

    • 99407 Greater than 10 minutes

Other Billable Services

  • Digital Rectal Exam for Prostate Cancer Screening

    • G0102

  • Visual Acuity Exam (Snellen Chart)

    • 99173

  • Needle Sticks!!

    • 96150 – e.g., when an occupational health nurse sees a patient due to a needle stick he/she can code this encounter as 99499 E/M and 96150 CPT with the applicable ICD-9 primary for the wound and a secondary ICD-9 code of the External cause.

Billing an office Visit and a Procedure

  • Procedure must be a separate service from the evaluation and management service

  • Modifier 25 should be added to the evaluation and management service to identify that it is a separate service

Other Coding Opportunities

  • Modifiers

    • 22 Unusual procedural service

    • 25 significantly, separately identifiable E&M service by the same physician on the same day of the procedure or other service

      • e.g., patient comes in with sinus infection – you do OMT “cause it will help” vs. patient coming in specifically for OMT

    • 32 Mandated by 3rd party (HMO)

    • 51 Multiple Procedures

Other Miscellany


  • If you see a patient and admit directly to a hospital, you should submit only the hospital code.

Critical Care Codes

  • Use appropriate E&M code if < 30 minutes

  • 99291

    • First 30-74 minutes of evaluation and management

  • 99292

    • Each additional 30 minutes (can round up after 15 minutes)

    • e.g., 105-134 minutes = 99291 x 1 and 99292 x 2

Prolonged Care Codes

  • Threshold time is 30 minutes over the time component allotted for the E&M code

    • Outpatient

      • 99354-99355

      • Face to face time

    • Inpatient

      • 99356-99357

    • Inpatient or outpatient office/floor/unit time without direct patient contact

      • 99358-99359

      • e.g., IV running for rehydration in your office for 1 hour

Other Coding Opportunities

For Further Information

  • Evaluation and Management Services Guide - AMA

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