E/M Documentation & Coding Lianne Beck, MD Assistant Professor Emory Family Medicine January 2011
Objectives • Review criteria for E/M coding • Optimize your coding • Understand time based coding • Know when to use modifiers • Billing for consultation and preventive health services
Coding Patterns 70 60 50 40 30 20 10 0 Figure. Average and Recommended Code Distributions. *Medicare Part B Physician/Supplier National Data, Calendar Year 2000,Evaluation and management codes.
E/M Coding • E/M = Evaluation and Management • How patient encounters are translated into 5 digit numbers to facilitate billing • Within each type of encounter there are various levels of care 99211 $28.14 99212 $45.16 99213 $65.49 99214 $91.37 99215 $112.69 36%
E/M Guidelines • Developed by AMA and CMS • First released in 1995 • Second set released in 1997 • Based on 3 “Key Components” • History • Physical • Medical Decision Making
Determining Level of Service • 3 Components • History • Physical • Medical Decision Making • New patients – must document all 3 • Established patients – must document 2 of 3
CC HPI ROS PFSH Problem Focused Expanded Problem Focused Detailed Comprehensive History
HPI • A narrative of the patient’s symptoms or illnesses since onset or since the previous encounter. • It is the only component of history that must be personally obtained and documented by the provider.
HPI • Location • Onset/Duration • Character/Quality • Aggravating/ Alleviating Factors • Associated Signs/Symptoms • Timing • Environment/Context • Severity
Constitutional Eyes Ears, Nose, Mouth, Throat CV Resp GI GU M/S Skin Neuro Psych Endocrine Heme/Lymph Allergic/Immun ROS • May be completed by staff or by having patient fill out questionnaire.
PFSH • Past Medical • Previous illnesses, surgeries, immunizations, allergies, current medications • Family History • Health status of parents/siblings/children, including relevant or hereditary diseases • Social History • Marital status, occupation, education, sexual history, tobacco, alcohol, drug abuse • May be completed by staff or by having patient fill out questionnaire.
Physical Exam http://www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf
Straightforward Low Complexity Moderate Complexity High Complexity Problems Data reviewed Risk Medical Decision Making * Need 2 out of 3 to qualify for given level of MDM
DOCUMENTATION REQUIREMENTS FOR NEW PATIENTS 99201 99202 99203 99204 99205 Required 1-3 elements 4+ elements (or 3+ chronic diseases) 1 2-9 systems 10+ systems 1 3 elements 3 elements 1-5 elements 6-11 elements 12 or more elements Comprehensive 8+ systems 1 system 2-4 systems 5-7 systems OR complete exam of single organ system Straightforward 10 minutes 20 minutes 30 minutes 45 minutes 60 minutes Three of three key
The Importance of Medical Necessity • “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of E/M service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed.”
Key Components History History Physical MDM Physical Exam MDM
Physical Problem focused Expanded problem focused Detailed Comprehensive Problem focused Expanded problem focused Detailed Comprehensive History MDM History Physical MDM Straightforward Low complexity Moderate complexity High complexity
There’s a better way! Purpose-Driven Documentation Try working backwards “Correct” Level of Care Target E/M Code “Full” E/M Code Matches the Medical Necessity and Cognitive Labor Provided 1 2 3 History Physical MDM MDM
Rational Physician Coding History Physical MDM 1. What level of care is supported by the MDM? 2. What documentation is required? 3. Is it reasonable to do what the documentation asks?
3 prob pts: - 3 estab prob - New prob - 1 estab prob, worse + 1 stable prob 3 data pts: -order and review xray, EKG, or PFT’s -order labs and review old records 99212 99213 99214 Pts sent to ED/Hosp 99215
Rational Physician Coding History Physical MDM • Determines the highest ethical level of care • Driven by medical necessity • Ensures 100% E/M compliance • Saves time by avoiding over-documentation • Increases revenue by preventing undercoding • Focuses on patient care
Time Based Billing • When you spend more than 50% of your face to face time with the patient counseling or coordinating care, time may be considered the key or controlling factor to qualify for a particular E/M service. • Physicians in training are NOT allowed to bill based on time alone.
Time Based Coding • Example: • You spend 25 minutes face to face with an established patient in the office. • More than half that time you spend: reviewing diagnostic results or recommended tests, prognosis, risk/benefits of treatment, instructions for management or follow-up, importance of compliance, or risk factor reduction/patient education. • You can use a Level 4 (99214) code even if you lack the history, exam, MDM elements. • Must document your counseling and coordination of care. • Does NOT include psychotherapy.
Modifier – 25 • Significant, separately identifiable evaluation and management service by the same provider on the same day of the procedure or other service. • Your documentation should clearly reflect the significant additional work related to the problems addressed. • Be aware that some payers will not pay for both services at the same visit and could deny or reduce the problem-oriented service.
Examples of Modifier – 25 • Well Exam: Patient in for a well woman exam and is newly diagnosed with hypertension at the time of the visit. • Bill for the WW exam (Preventive service code). Use modifier-25 and an additional E/M code listed for the additional diagnosis and services dealing with HTN. • Knee Pain: At time of visit you determine patient needs an arthrocentesis. The procedure is performed. • Bill the appropriate E/M code for the visit itself. Use modifier-25 and bill for the procedure. • Smoking Cessation: During a follow up visit for on-going chronic illnesses, you provide counseling for smoking cessation. • Bill the appropriate E/M code for the visit along with modifier-25 and 99406 (3- 10 min) and 99407 (> 10 min).
Modifier – 51 • Modifier – 51 indicates that you did more than one procedure at the same session. • Example: If you excise a benign skin lesion with an excised diameter over 4.0 cm from a patient's chest and close the defect using a layered closure • Submit code 11406 ("Excision, benign lesion including margins, except skin tag [unless listed elsewhere], trunk, arms or legs; excised diameter over 4.0 cm") • Submit code 12032 – 51 ("Layer closure of wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 2.6 cm to 7.5 cm").
Modifier – 51 • Payers, such as Medicare, typically reduce the fee for the code with modifier – 51 attached by about 50 percent • Attach it to the lesser-valued service so that you are paid in full for the more expensive procedure. • However, be sure to bill the full fee for each procedure and let the payer make the reduction consistent with its own payment policy.
Other Common Modifiers • 50 – Bilateral Procedure • 52 – Reduced Services • 53 – Discontinued Procedure • 59 – Distinct Procedural Service
Consultation Codes • Centers for Medicare and Medicaid Services (CMS) decided as of January 1, 2010 to no longer reimburse physicians for CPT consultation codes 99241-99245 or 99251-99255. • CMS instructs that any physician who sees a patient in the office or other outpatient setting will need to select either a new or established outpatient evaluation and management code (99201-99215 or 99381-99397) rather than a consultation code for Medicare claims depending on the status of the patient (new vs. established).
Consultation Codes • Use appropriate ICD-9 codes for pre-op exam: • V72.81 (pre-op cardiovascular exam) • V72.82 (pre-op respiratory exam) • V72.83 (another specified pre-op exam) • V72.84 (unspecified pre-op exam) • Include a second diagnosis code to indicate the condition for which surgery is indicated. • Also include any diagnosis that arise during your consultation.
Prolonged Services Code • CPT’s prolonged services code (99354-99359) can be used when the time you spend providing a service is beyond the usual time for that service. • Outpatient use: 99354 for the first 30-74 minutes and 99355 for each additional 30 minutes. • Example: A patient with acute asthma that you are treating with multiple nebs and does not require hospitalization.
Preventive Medicine Visit • A comprehensive history and physical examination based on patients age, gender and identified risk factors. • Anticipatory guidance, risk factor reduction interventions or counseling • The ordering of appropriate immunizations or laboratory/diagnostic procedures • Management of insignificant problems
Preventive Medicine Service Codes • Used when providing annual physicals • Well woman exam (V72.31) • Well child exam (V20.2) • Well adult exam (V70.0) • IPPE “Welcome to Medicare Exam” (G0402) • Use CPT codes (99381- 99387) for New and (99391- 99397) for Established patients. • Counseling that occurs during a preventive medicine encounter is considered to be part of the preventive medicine services codes. • When preventive counseling is the focus of a separate visit, it should be reported with the preventive counseling codes (99401-99412) and ICD-9 codes (V65.3, V65.41)
Preventive visit for Medicare • Recently, Medicare has begun to cover some preventive medicine services. • The “Welcome to Medicare” physical is available only to Medicare beneficiaries during their first 12 months of Medicare Part B coverage and is subject to the Medicare Part B deductible. • The “Annual Wellness” visit, is being covered since Jan 2011.