Evaluation & Management

Which element of HPI are met in this statement? Patient complains of headache and blurry vision for the past 3 days.

Location, quality and duration

A physician admits a pt to the hospital . They are there for 5 days & the physician sees them each day in the hospital. What subcategory of codes would be used for days two, three, and four?

Subsequent hospital care.

If the pain is sharp stabbing or dull, what is the component of the HPI?

Quality

Where are clinical examples for evaluation and management codes found in the CPT?

Appendix C

A pt presents to a cardiologist for an initial visit at the request of his pcp to treat CHF and to take over care. The cardiologist exams the pt and discusses treatment options and schedule the pt for a stress test. he provides a detailed report to the patients pcp. An E/M code would be selected from what subcategory?

New pt office visit.

According to the CPT guidelines, what is the first step in selecting an E/M code?

Determining the category or subcategory

What category of codes should be used to report an E/M service provided to a pt in a psychiatric residential treatment center ?

Nursing facility services.

A pt is fishing and gets light headed and dizzy. He goes to the local hospital ED and evaluated by the ED physician. This is the fist time he has been to this hospital. What subsection would be used to report the ED visit?

Emergency department services.

A pt is seen by Dr. B, who is covering on call services for Dr. A. The pt is an established pt with Dr. A, but has never been seen by Dr. B before. What is the appropriate E/M subcategory to report for services by Dr. B?

Established pt office visit .

What modifier would be used to report an E/M service mandated by a court order.

Modifier 32

When tissue glue is used to close a wound involving the epidermis layer how is it reported?

As thought it was a simple closure.

P1

A normal heathy patient

P2

A patient with mild systemic disease.

P3

A patient with a severe systemic disease.

P4

A patient with a severe systemic disease that is a constant threat to life.

P5

A moribund patient that is not expected to survive without the operation.

P6

A declared brain dead patient whose organs are being removed for donor purposes.

Palpation

Refers to examination of the body by touch.

Auscultation

Listening to body sounds.

Percussion

Creating sounds from tapping on body areas to examine body organs and cavities. the vibrations of the sounds help identify abnormalities. (lungs sound hollow when percussed.)

Stethoscope

May be used to listen to the heart and lungs for sounds.

BP

Blood pressure

CC

chief complaint

HEENT

Head, eyes, ears, nose and throat

h/o

history of

HPI

history of present illness

Hx

history

NAD

no apparent distress

NKDA

no known drug allergies

PE

physical examination

PERLA

Pupils equal and reactive to light and accommodation. (in other words, normal)

PMH

past medical history

pt

patient

R/O

rule out

ROS

review of systems

WNL

Within normal limits

E/M services are used to…what

Used to "evaluate and manage" all symptoms, illnesses, and diseases.

The primary diagnosis for E/M is …

the reason the visit was initiated. It can be a symptom ( such as a cough or disease), or for preventative care (V code needed).

Is diagnosis for acute, chronic or an acute phase of a chronic condition?

When the condition is an acute phase of a chronic condition and there is a code to describe each of the phases, list the acute code first and the chronic second. Be aware of combination codes, such as "acute and chronic cholecystitis" 575.12, where a single code is reported for both conditions.

Signs and symptoms

Typically coded from Ch 16. Symptoms should be used as a diagnosis only if no definitive diagnosis is provided. Signs and symptoms routinely associated with a disease process should not be coded separately from the definitive diagnosis. Signs and symptoms not associated with a disease process routinely should be coded separately. EX; patient comes in with fever cough and elbow pain. Physician diagnoses fever and cough as part of pneumonia. Report pneumonia and elbow pain separately.

When a patient with multiple conditions is seen..

..only those conditions affecting care, or requiring provider care or management, are coded.

E/M codes describe ….

a provider’s service to a patient including evaluating the patient’s condition(s) and determining the management of care required to treat the patient.

What are the 7 components making up E/M service

History, Exam, Medical Decision Making (MDM), Counseling, Coordination of Care, Nature of Presenting Problem, and Time. Three of these components – History, Exam, and MDM – are considered key components to determining the overall level of an E/M service.

What are the 3 key components of E/M

History, Exam, and MDM ( medical decision making)

The Evaluation and Management Services Guidelines in CPT® outline six steps to determine the level of an E/M service:

1. Select the category or subcategory of service and review the guidelines; 2. Review the level of E/M service descriptors and examples; 3. Determine the level of history; 4. Determine the level of exam; 5. Determine the level of medical decision making; and 6. Select the appropriate level of E/M service. Steps three through six are referred to as "leveling" an E/M service, or determining the level of service that was provided.

What is medical necessity

It is what is necessary to treat the patient for a given condition/complaint.

The first step to determine level of E/M service is to determine the category or subcategory of service. How do you do that

E/M codes are divided into categories representing the type of service, such as office visits, emergency department visits, nursing facility care, etc. Some categories are divided further into subcategories to indicate specific details reflecting the status of the patients as new or established, or inpatient or outpatient. Subcategories are divided into levels, which are assigned a five-digit code. Individual code descriptors provide specific details such as place and or type of service; content of the service provided; nature of the presenting problem; and the time generally required to provide the service. For example, the first E/M category is Office or Other Outpatient Services. The Subcategory is New Patient. The level 1 code is 99201. In the descriptor it shows this level of visit requires three key components, which are a problem-focused history, a problem focused exam, and a straightforward medical decision-making. It also shows the typical amount of face-to-face time the provider will have with the patient. In this case, it is 10 minutes.

What is a new patient

A patient is new if he or she has not received any face-to-face professional services from the physician/qualified health care professional, or a physician/qualified health care professional of the exact same specialty and subspecialty within the group practice, within the last three years.

What is an established patient

Patient has been seen in the last three years by the same physician/qualified health care professional, or another physician/qualified health care professional of the exact same specialty and subspecialty within the same group practice.

Is there a distinction between new and established patient in the emergency department?

No distinction is made between a new and established patient in the ED.

What is a chief complaint (CC)

It is a concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the REASON FOR THE ENCOUNTER, usually stated in patients words.

concurrent care

the provision of similar services (eg, hospital visits) to the same patient by more than one physician or othe qualified health care professional on the same day. when concurrent care is provided, no special reporting is required.

Transfer of care

The process whereby a physician or other qualified health care professional who is providing management for some or all of a patient’s problems, relinquishes this responsibility to another physician or qualified health care professional who explicitly agrees to accept this responsibility and who, from the encounter, is not providing consultative services.

What is observation status

When a patient has a condition needing to be monitored to determine a course of action. EX: a patient presents to the ED with concussion, the provider can admit patient to observation status. After period of monitoring, patient may be discharged or if condition worsens, may be admitted to hospital as inpatient. There is not a specific "place" for observation. There is no distinction between new and established patient for observation. When the patient is seen at another site of service, all E/M services provided by the admitting physician are considered to be part of initial observation care and not reported sep.

Hospital Observation includes what 3 types of service

Observation care discharge services, Observation Care and Subsequent Observation Care. The initial observation care should reported only by the physician admitting the patient to observation status.

Within each E/M category and subcategory, code discriptors define the specific details of the service to include:

place and type of service; content of service; content of the service provided; nature of presenting problem; and time generally required to provide the service.

What drives the level of service for E/M?

Most E/M service are provided at varying levels of intensity. The extent of the patient’s illness or injury will determine the amount of physicians work and skill required to evaluate and treat the patient. The physicians effort ( when documented appropriately and supported by medical necessity) drives the level of the service.

medical necessity

what is necessary to treat the patient for the given condition/complaint.

Levels of E/M codes

Referred to as level 1, level II, level III, etc, depending on the last number of the code referred to in the category. Each level has a unique description and requirement for its category or subcategory. Each of the key components, Level of history, Level of exam and Level of medical decision making (MDM), are further broken down into further divisions. HISTORY: chief complaint; history of present illness (HPI); review of systems (ROS); and past, family, social history (PFSH). EXAM: Constitutional; Eyes; Ears, Nose and Throat; Cardiovascular; Respiratory; Gastrointestinal; Genitourinary; Musculoskeltal; Skin; Neurological; Psychiatric; Hematologic/lymphatic/immunologic MEDICAL DECISION MAKING: Number of diagnosis and management options; Amount and complexity of data to be reviewed; Level of risk The level of each key component is used to determine the overall level of E/M service.

What are the divisions and subdivisions of E/M codes

HISTORY: chief complaint; history of present illness (HPI); review of systems (ROS); and past, family, social history (PFSH). EXAM: Constitutional; Eyes; Ears, Nose and Throat; Cardiovascular; Respiratory; Gastrointestinal; Genitourinary; Musculoskeltal; Skin; Neurological; Psychiatric; Hematologic/lymphatic/immunologic MEDICAL DECISION MAKING: Number of diagnosis and management options; Amount and complexity of data to be reviewed; Level of risk

1995 and 1997 E/M Documentation Guidelines website on CMS website

www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html

What is the difference between 1995 and 1997 guidelines

Main difference between them is leveling of Exam component.

Which set of guidelines should be used

The set that is most beneficial to the provider should be used unless the insurance carrier or company policy dictates which should be used.

What is "chief complaint"

It is the medically necessary reason for patient to meet with physician. It is part of the history component. It is often stated in the patient’s own words, ex, " I have a sore throat." or " I am having pain in my back."

What if there is no chief complaint

The service would be considered preventative and a dedicated preventative service code is reported.

What if it is a "follow up"

This is not sufficient for a "chief complaint". It is necessary for the provider to document the condition being followed up on. A more concise statement would be, " follow up of ankle pain" or " follow up of diabetes"

How to determine Level Of History

This is used to troubleshoot the chief complaint based on the interview with the patient. It is divided into following components; History of Present illness (HPI) Review of Systems (ROS) Past, Family, Social History (PFSH) Some categories only require an interval history

Is a complete level of history necessary for every category of service?

No, some only require an interval history, such as subsequent hospital care, follow-up inpatient consultations and subsequent nursing facility care.

What is an interval history

It is the history during the time period since the physician last performed an assessment on the patient. The PFSH is not required for interval history.

What are the components of History of Personal Illness (8)

1. Location: the anatomical place, position, or site of the chief complaint (back pain, sore elbow, cut on leg, etc) 2. Quality: a problem’s characteristics, such as how it looks or feels ( yellow discharge, popping knee) 3. Severity: A degree of measurement of how bad it is. (improved, unbearable pain, blood sugar 205) 4. Duration: How long the complaint has been occurring, or when it first occurred. ( since childhood, first noticed month ago, on and off for a couple of weeks) 5. Timing: A measurement of when, or at what frequency, they notice the problem. (intermittent, constant, only in the evening) 6. Context: What the patient was doing, environmental factors, and/or circumstances surrounding the complaint. (while standing, during exercise, after a fall) 7. Modifying factors: Anything that makes the problem better or worse ( improves with aspirin, worse with sitting, better with lying down) 8. Associated signs and symptoms: Additional complaints that may be related.

What is the difference between brief and extended HPI

Brief will document 1-3 elements of HPI while an extended will document 4 or more elements.

Chronic conditions and HPI

1997 documentations guidelines allow credit for patients who are seen for chronic conditions as reasons for a visit. It is not sufficient for just a chronic problem: The status of at least 3 chronic (or inactive) conditions must be documented to meet requirements of an extended HPI. This is only available for an extended HPI. If the status of fewer than 3 have been documented without documentation of any of the eight HPI elements, then the documentations guidelines for a brief or extended HPI have not been satisfied.

What does the Review of Systems (ROS ) consist of?

It consists of questions to inventory the body systems to assist in identifying signs or symptoms the patient has experienced or is currently experiencing. NOTE: The ROS is NOT a hand-on exam! It is only verbal.

What are the 14 systems recognized for the ROS

Some symptoms can fall into one or more body systems of review, but each statement in a mdeical record can only be used once. They include: 1. Constitutional symptoms: General symptoms such as fever, weight loss, fatigue, energy level, etc. 2. Eyes: Questions surrounding patient’s vision. (blurriness, wear glasses ) 3. Ears, nose, mouth and throat (ENMT): May ask about hearing loss, nose bleeds, runny nose, dizziness, dental disease, sore throat, etc 4. Cardiovascular (CV): Symptoms in the cardiovascular system may include asking about shest pain, high blood pressure, palpitations, tachypnea, varicous viens, etc. This component will focus on the heart, veins, and arteries. 5. Respiratory: Shortness of breath, chest pain, asthma, and cough, etc. anything to do with the respiratory system. 6. Gastrointestinal(GI): Nausea, diarrhea, trouble swallowing, jaundice, heartburn, indigestion etc. 7. Gentiourinary system (GU): Reviews incontinence, pain or burning during urination and difficulty with flow. The Reproductive system might cover dysmenorrhea, menopause, contraception, pain during intercourse for the female. For the male, hernias, testicular pain, or impotence. 8. Musculoskeletal (MS): The muscles and joints work together for body movement. A review will include joint pain, stiffness, arthritis, limitation of movement, etc 9. Integumentary: This covers both the skin and the breasts. Symptoms sought can include rashes, dryness, nipple discharge, tenderness, or may include information about self-breast exams. 10. Neurological: Focused on the central and peripheral nervous system, such as paralysis, weakness, clumsiness, or loss of balance. 11. Psychiatric: Look for questions regarding insomnia, mood, nervousness, or depression. 12. Endocrine: Endocrine system consists of glands and secretions of hormones to keep our bodies in balance. Provider may ask about effects of gland not functioning properly, such as thyroid trouble, heat or cold intolerance, excessive sweating, thirst, or urination. 13. Hematologic/ lymphatic: Asks about bruising, anemia, frequent infections, fatigue and swollen lymph nodes. 14. Allergic/ immunologic: Reviews body’s ability to fight infection or response to environmental factors. Reviews include allergies to food, environmental allergens, urticaria, hives, etc.

What are the 3 types of ROS and how are they counted

1. Problem Pertinent: Review of systems addresses only the body system directly related to the problem. 2. Extended: The system directly affected and related systems are reviewed. Provider will inquire about 2-9 systems. 3. Complete: A provider reviews 10 or more body systems. May be documented by either individually documenting 10 or more systems, or by documenting the positive or pertinent negative responses individually and adding a notation that all other systems were reviewed and are negative. NOTE: Some systems can fall into one or more body systems of the review. Ex: Chest pain could be indication of cardiac problems, respiratory illness, psychiatric illness, musculoskeletal problems, or gastrointestinal distress. When using chest pain as an element of review, it can only be used for one review of systems. If counted as cardiac, it cannot be used for respiratory. Each statement can only be used once.

Medical necessity determines the extent of the ROS. (explain)

It may be necessary to obtain complete ROS when a new patient presents, but not necessary to repeat on every follow-up visit. For most payers, if there is separate documentation of at least one pertinent positive or negative ROS, and the provider states the remaining systems are reviewed and negative, credit should be given for a complete ROS. Ex: The ROS for a new patient visiting a cardiologist may read, " Denies additional cardiac complaints; the remaining systems were reviewed and otherwise negative."

What does the PFSH ( past, family, social history) describe

It describes occurrences with illness, surgeries, and treatments the patient and the patient;s family have incurred, as well as social factors influencing the patient’s health. Past history focuses on patient’s prior medical treatments and can include: Prior major illnesses and injuries Prior operations Prior hospitalizations Current medications Allergies Age appropriate immunization status Age appropriate feeding/dietary status Family history describes occurrences in the patient’s family and typically includes a list of diseases or hereditary conditions that may place patient at risk. Also may include the age of death or living status of immediate family. Social history identifies current and past activities, such as: Social status and living arrangements Employment status Occupational history Drug, tobacco, alcohol use ( if child, exposure to second hand smoke) Educational level Sexual history Any social event/occurrence impacting patient’s condition

What are the 2 types of PFSH

Pertinent and complete. Pertinent requires one review directly related to CC and complete requires more than one but the number needed depends on the category of E/M service.

What is a pertinent PFSH

Pertinent is a review of history directly related to the chief complaint. Only one history component must be documented

What is a complete PFSH

It is more than one but the number depends on the category of E/M service. For the following categories, 2 of 3 history areas must be documented: Office or other outpatient services, established patient Emergency Department Domiciliary care, established patient Home care, established patient For other categories, at least one from each history area (3 of 3) must be documented: Office or other out patient services, new patieent Hospital observation services Hospital inpatient services, initial care Consultations Comprehensive Nursing Facility assessments Domiciliary care, new patient Home care, new patient.

Totaling the Level of History

When the level for each element of history has been determined, the levels are combined to determine overall level of history. The four levels are defined in E/M guidelines (pgs 6-8)and a grid (easiest method) is on page 3> -Problem Focused -Expanded Problem Focused -Detailed -Comprehensive All 3 history elements must support the work level to meet overall history level requirement. The lowest element within the history component always determines the overall history level. Ex: If the HPI and the ROS both support detailed but PFSH supports only expanded problem focused, the history level will stay at the expanded problem focused level. The level of history required for each level of service is stated in the description of the CPT code.

The 1995 and 1997 Documentation Guidelines for E/M Services regarding Exam

They define differently the specific elements determining the exam level. The primary weakness for 1995 is the inability to acknowledge the more specific work and documentation provided by a specialist. The primary weakness of the 1997 is it requires too many specific documentation elements. Consider your specialty’s nature, and the typical documentation the physician generates, to determine which guidelines to use. Both recognize the same body areas and same organs systems. Both also requires provider to elaborate on abnormal findings and describe unexpected findings. Both also allow a brief note of "negative" or "normal" to document normal findings or unaffected systems. NOTE: Most carriers require you to work with either the body areas or organ systems, not both.

ROS vs Physical Exam Elements

The ROS and exam elements are not interchangeable and most payers want you to count a single element toward either the ROS or the Exam. ROS is written or verbal. Often garnered information from intake form or verbally asking questions before the physical part occurs. The Exam is physical and observed through contact. When reading notes, ask yourself if the notation is something a patient said or something a provider saw, heard, or measured.

Determining the Level of Exam

See graph in CPT pg 3 This is the physician’s physical examination of the body. There are 4 levels (based on 1995): Problem focused: A limited exam of the affected body area or organ system. (one part only) Expanded problem focused: Limited exam of the affected body area or organ system and other symptomatic or related organ system (limited exam of two) Detailed: Extended exam of the affected body area(s) and other symptomatic or related organ system(s). (extended exam of two areas or organ systems) Comprehensive: General multi-system exam or complete single-organ system examination (medical record for a general multi-system examination should include findings about 8 or more of the 12 organ systems)

Pulse sites of the body

Determining overall MDM level

Most important of the 3 primary components of E/M code selection. Also the most subjective….. You chose an overall MDM based on 3 factors: The number of diagnoses or management options; The amount and/or complexity of data to be reviewed; and The risk of complications and morbidity or mortality.

Diagnoses or management options point system

Based on the relative difficulty level in making a diagnosis, and the status of the problem. Typically determined using a point system. Points are assigned according to how sick the patient is , and the amount of physician work involved. -Minor problems, such as those resolving regardless if patient had sought medical attention, are worth 1 point. A patient may have 4 minor, documented problems. For coding purposes, a max of two such problems can be counted. -Established , stable, or improved conditions are worth 1 point each. -Established, worsening conditions are worth 2 points each. -A new problem (new to patient or new to provider) without any additional workup is worth 3 points. You may only count once per encounter, even if multiple occurrences in the encounter. -A new problem with additional workup is counted as 4 points.

Workup

Defined as anything the physician does after making the diagnosis the patient left with. Ex; Physician suspects a particular diagnosis and sends patient on for a diagnostic test to confirm suspicion, the test counts as workup.

Data Amount and Complexity

the amount and complexity of data for review is measured by the need to order and review tests, and the need to gather information and data. Planning, scheduling, and performing labs and tests are indications of complexity, as is the need to request old records, or obtain additional history from someone other than the patient. Documented discusssions with the performing physician about unusual or unexpected patient results may also result in credit. Ex; Physician makes independent visualization and interpretation with MRI or Gram stain, and does not bill separately for the service, it would be credited in this component of code selection.

Point system for Complexity of data

Clinical labs ordered – 1 point Any test reviewed/ordered from med sect of CPT- 1 point Any procedures reviewed/ordered from Rad sect of CPT- 1 point. (Regardless of number of tests, only one point allowed) Discussing patient’s results with the performing or consulting physician- 1 point if captured in documentation Decisions to obtain old records or additional history for someone other than patient – 1 point Review and summary of data from old records or additional history gathered from someone other than patient- 2 points Independent or second interpretation of an image tracing or specimen- 2 points. (not just review, but also actual film image or tracing)

Levels of Risk

Risk is measured based on the physician’s determination of the patient’s probability of becoming ill or diseased, having complications, or dying between this encounter and the next planned encounter. Risk indications include the nature of the presenting problem, the urgency of the visit, co-morbid conditions, and the need for diagnostic tests or surgery.

Counseling

May be included during the visit of a patient and reflect conversations with the patient and/or family regarding risk reduction, treatment options, benefits and risk associated with differing treatment options and other education given to the patient and/or family. Often occurs when a patient has a complicated illness or injury with different treatment options to consider. Also common when a patient is newly diagnosed with an acute or chronic illness posing a threat to life.

What is Nature of Presenting Problem

It is the reason for the visit: the signs, symptoms, illness, or disease being treated.

What are the 5 types of Presenting problems

Minimal: A problem that doesn’t require the presence of a physician; however, services provided are under the physician’s supervision. Problems presenting are usually for services not billed for an office visit. Ex: removal of sutures, supervised drug screen, medical release for work or school. Self-limited or Minor: does not permanently alter health status and with good management and compliance has an outcome of "good". These usually heal on their own without physician intervention. Ex: poison ivy/oak exposure, sore throat, patient with resolved tonsillitis after a completed round of antibiotics. Low Severity: Risk of morbidity/mortality without treatment is low and full recovery with no functional impairment is expected. Ex: management of hypertensive patient on medication, established patient for follow up of osteoporosis, and a patient with a painful bunion. Moderate severity: Risk of morbidity/mortality without treatment is moderate, uncertain prognosis or increased probability of prolonged functional impairment. Ex: diabetic with complications, a status-post MI patient who is not doing well on his medication, or possibly a patient with new onset of right lower quadrant abdominal pain. High Severity: Risk of morbidity/mortality without treatment is highly probable; uncertain prognosis or high probability of severe prolonged functional impairment. Ex: status post transplant patient developing new symptom or a cancer patient with signs of paralysis.

Reporting Time (counseling and coordination of care)

It may be considered the controlling factor to qualify for a particular E/M service level, " When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter..,". The category must include a time reference separate from the time spent taking the patient’s history or performing an examination. Time may include face-to-face time in the office or other outpatient setting, or floor/unit time in the hospital or nursing facility, and includes time spent with parties who have assumed responsibility for the care of the patient or decision making whether or not they are family members. BY CONTRAST: ED services 99281-99285 do not include a stated time component; these may not be reported with time as the deciding component.

Counseling and coordination of care should include:

Needs to include (documented) discussion about one or more of: -diagnostic results -impressions and/or recommended diagnostic studies -prognosis -risks and benefits of treatment options -instructions for treatment and/or follow-up -importance of compliance with chosen treatment options -risk-factor reduction -patient/family education Provider’s documentation should support the content and extent of the patient’s counseling.

Common modifiers used for E/M

Modifier 24- "Unrelated evaluation and management service by the same physician or other qualified healthcare professional during a postoperative period." To be used when a patient is seen by the same physician, another physician, or other qualified healthcare professional of the same specialty who belongs to the same group practice during a postoperative period for an unrelated evaluation and management service. This occurs when a patient develops a symptom unrelated to the surgery. Some payers will allow Mod 24 on an E/M service when it is for a complication related to the surgery. Modifier 25- "Significantly, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service." Commonly used to indicate a significant and separately indentifiable service was provided on same day as E/M service. Medicare states the procedure/service and the office visit do not require different diagnosis codes. The best way to determine if the documentation supports an E/M service with a Mod 25 in addition to a procedure/service is to separate the note into separate notes. (Break into 2 pieces of documentation) Modifier 32- "Mandated Services" Used to show a service was mandated by a 3rd party payer (workman’s comp) or government, or that the service is a legislative or regulatory requirement. Modifier 57- "Decision for surgery" Used when decision for surgery is made during an E/M service on the day of, or the day before a surgery. Payers will have different guidelines for use of this modifier, check… For Medicare, Mod 57 should only be used for major surgeries. If the decision to perform a minor surgery ( global days 0-10) is made during a visit, Mod 25 would be appended to appropriate E/M service code. To know which procedures are major surgery and which are minor, refer to global days in the Medicare Physician Fee Schedule.

Fred is fishing at the local area lake while on vacation. He gets lightheaded and dizzy and goes to the local hospital Emergency Department. He’s evaluated by the ED physician. This is the first time he has been to this hospital. What subsection should be used to report the ED visit?

Correctb. Emergency Department Services Response Feedback: Rationale: No distinction is made between a new and or an established patient in the emergency department. An Evaluation and Management service provided in an Emergency Department is reported with codes from the Emergency Department Services Subsection 99281-99285.

Which elements of HPI are met in this statement? Patient complains of headache and blurry vision for the past 3 days.

. Location, quality and duration Response Feedback: Rationale: Location (headache), quality (blurry), duration (past three days).

According to CPT® guidelines, what is the first step in selecting an evaluation and management code?

Correctc. Determine the category or subcategory Response Feedback: Rationale: According to the CPT® guidelines, the first step to determining a level of evaluation and management visit is to determine the category or subcategory of service.

What modifier is used to report an evaluation and management service mandated by a court order?

Correctb. 32 Response Feedback: Rationale: Modifier 32 is used for services related to mandated consultation and/or related services by a third party payer, governmental, legislative, or regulatory requirements.

Where are clinical examples for evaluation and management codes found in CPT®

d. Appendix C Response Feedback: Rationale: Appendix C of CPT® contains clinical examples of evaluation and management codes. It may be used in addition to the code descriptors.

Dr. Jones documents Mrs. Smith’s condition has improved during his third visit to her hospital room. Upon entering the room, he finds her sitting up in bed, watching television and eating breakfast. Dr. Jones performs a problem focused exam and a low medical decision making. What CPT® code should be reported?

Correctb. 99231 Response Feedback: Rationale: This is a subsequent hospital care visit. Subsequent hospital care codes are 99231-99233. Codes in this section require 2 of 3 key components be met. A problem focused exam and low medical decision making supports a 99231. Question 7

The attending physician at the hospital spent 25 minutes with the patient in morning and another 15 in the afternoon examining the patient, writing discharge orders, and giving discharge instructions to the patient. What CPT® code should be reported for the discharge?

ationale: In the CPT® Index, look for Hospital Services/Inpatient Services/Discharge Services and you are directed to code ranges 99238-99239 and 1110F-1111F. Codes 1110F-1111F are Category II supplemental codes used for performance measurement. They may not be used as a substitute for Category I codes. Codes 99238-99239 are based on time. All of the time spent by the discharge physician on the discharge date is included in the time. The physician spent a total of 40 minutes with the patient on the discharge date. 99239 is the correct code choice.

32 year old patient sees Dr. Smith for a consult at the request of his PCP, Dr. Long, for an ongoing problem with allergies. The patient has failed Claritin and Alavert and feels his symptoms continue to worsen. Dr. Smith performs an expanded problem focused history and exam and discusses options with the patient on allergy management. The MDM is straightforward. The patient agrees he would like to be tested to possibly gain better control of his allergies. Dr. Smith sends a report to Dr. Long thanking him for the referral and includes the date the patient is scheduled for allergy testing. Dr. Smith also includes his findings from the encounter. What E/M code is reported?

Rationale: The three R’s of consultation are documented (request, render, reply). The consultation code range is 99241-99245, and applies to new or established patients. Consultations require three key components. The documentation states the history and exam were expanded problem focused and the MDM is straightforward. These three key elements meet the requirement for 99242.

The EMS brought a 31-year-old motor vehicle accident patient to the Emergency Department. After a comprehensive history, a comprehensive exam, and medical decision making of high complexity, the provider determines the patient has multiple internal injuries and needs immediate surgery. What level ED code is reported?

Rationale: In the CPT® Index look for Evaluation and Management/Emergency Department. The code range is 99281-99288. All three key components must be met in order to reach the level of visit. A comprehensive history, comprehensive exam and medical decision making of high complexity supports a level 5 ED visit, 99285.

A soccer player hits his head during an indoor game and is admitted to observation to watch for head trauma.
Admit date/time: 01/21/20XX 8:12 PM
Detailed History, Detailed Exam, Low MDM

Discharge date/time: 01/22/20XX 8:15 AM
Discharge time: 20 minutes

What CPT® code(s) is/are reported for the admission and discharge to Observation Care?

Rationale: Although the patient was in observation for less than 24 hours, the service covered two dates of service. The Observation care discharge day management code – 99217 – says this code is to be utilized to report all services provided to a patient on discharge from ‘observation status if the discharge is on other than the initial date of ‘observation status." Initial Observation care is reported with code range 99218-99220. The level of history, exam and medical decision making support level 99218. Code 99217 is reported for Observation care discharge.

A physician makes a home care visit to a 63-year-old hemiplegic patient who has been experiencing insomnia for the last two weeks. The patient has been home-bound for the last year. The last visit from this physician was four months ago to manage his DM. The physician performs an expanded problem focused examination and low MDM. The physician speaks with the spouse about the possibility of placing the patient in a nursing facility. What CPT® code is reported?

Rationale: According to CPT® E/M guidelines, Home Services codes (99341-99353) are used to report evaluation and management services provided in a private residence. This is an established patient to the physician. Established patient home care codes require two of three key components. The physician performed an expanded problem focused exam and low MDM resulting is code 99348

25 year-old male is brought by EMS to the Emergency Department for nausea and vomiting. Patient has elevated blood sugars and the ED physician is unable to get a history due to patient’s altered mental status. An eight organ system exam is performed and the MDM is high. The patient was stabilized and transferred to ICU. The ED physician documents total critical care time 25 minutes. What CPT® code should be reported?

Rationale: According to CPT® guidelines: "99291 is used to report the first 30-74 minutes of critical care on a given date. Critical care of less than 30 minutes of total duration on a given date should be reported with the appropriate E/M code. "For this encounter the physician is short 5 minutes of 30 minutes needed to bill the critical care code. The encounter takes place in the emergency department. In the CPT® Index, look for Evaluation and Management/Emergency Department. You are referred to 99281-99285. For emergency room services, three out of three key components are required. In this case, the provider is unable to obtain a history due to the patient’s condition. According to the CMS Documentation Guidelines, the provider must indicate the reason they could not obtain a history. The level is determined by the exam and MDM. The exam is comprehensive (eight organ systems) and MDM is moderate (new problem to the examiner, 0 data points and high level of risk). The proper code is 99285. There is also a statement in the description of 99285 that states, "within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status".

3-year-old critically ill child is admitted to the PICU from the ER with respiratory failure due to an exacerbation of asthma not manageable in the ER. The physician starts continuous bronchodilator therapy and pharmacologic support along with cardiovascular monitoring and possible mechanical ventilation support. The physician documents a comprehensive history and exam and orders are written after treatment is initiated. What is the CPT ® code for this encounter?

Rationale: This visit meets the criteria for Inpatient Neonatal and Pediatric Critical Care. Codes 99471 – 99476 are used to report the direction of the inpatient care of a critically ill infant or young child from 29 days through less than 6 years. Codes are further divided by initial and subsequent care. This is the initial care of a critically ill 3-year-old. Services provided in the ER by the admitting provider may not be coded. When a neonate, infant, or child requires initial critical care services on the same day the patient has already received hospital care or intensive care services by the same provider, only the initial critical care service code (99468, 99471, 99475) is reported. Code 99475 is the correct code for this service.

75-year-old established patient sees his regular primary care provider for a physical screening prior to joining a group home. He has no new complaints. The patient has an established diagnosis of Cerebral Palsy and Type II Diabetes and is currently on his meds. A comprehensive history and examination is performed. The provider counsels the patient on the importance of taking his medication and gives him a prescription for refills. Blood work was ordered. PPD was done and flu vaccine given. Patient already had had a vision exam. No abnormal historical facts or finding are noted. What CPT® code is reported?

Rationale: According to CPT® guidelines, Preventive Medicine Services codes provide a means to report a routine or periodic history and physical examination in asymptomatic individuals. They include only those evaluation and management services related to the age specific history and examination provided by the physician. The patient is here for a preventive service. He did not have any complaints and the doctor did not identify any new problems. In the CPT® Index, look for Preventive Medicine/Established Patient. You are referred to 99382-99397. The code selection is based on age. Code 99397 is the correct code for a patient who is older than 65 years.

10 year old girl is scheduled for her yearly physical with her pediatrician. At the time of the visit, the patient complains of watery eyes, scratchy throat, and stuffy nose for the past two days. The physician performs a complete physical and evaluates and treats the patient for a URI. What CPT® code(s) is/are reported for this visit?

Rationale: The physical exam code is selected from the Preventive Medicine Services and selected based on whether the patient is new or established and by age. The pediatrician also evaluates and treats the URI. The additional work for the URI allows us to report an established patient office visit. Modifier 25 is appended to the office visit to show it is a significant and separately identifiable service from the preventive visit.

An established patient presents to the office with a recurrence of bursitis in both shoulders. Examination is only limited to the shoulders in which range of motion is good and full, but he has tenderness in the subdeltoid bursa. Both shoulders were injected in the deltoid bursa with 120mg Depo-Medrol. What CPT® code(s) is/are reported for this visit?

Rationale: For this encounter, no additional work in evaluating the patient has been performed to support an E/M service that is significant and separately identifiable from the procedure. Only the procedure should be billed. To perform an arthrocentesis, the physician inserts a needle through the skin and into a joint or bursa. A fluid sample may be removed from the joint or fluid may be injected for lavage or drug therapy. In the CPT® Index, look for Shoulder/Arthrocentesis. You are referred to code 20610. Review the code description to verify accuracy. Modifier 50 Bilateral Procedure is attached since both shoulders are injected.

New patient History & Physical

CHIEF COMPLAINT: Right inguinal hernia.

HISTORY OF PRESENT ILLNESS: This 44-year-old athletic man has been aware of a bulge and a pain in his right groin for over a year. He is very active, both aerobically and anaerobically. He has a weight routine which he has modified because of this bulge in his right groin. Usually, he can complete his entire workout. He can swim and work without problems. Several weeks ago in the shower he noticed there was a bulge in the groin and he was able to push on it and make it go away. He has never had a groin operation on either side. The pain is minimal, but it is uncomfortable and it limits his ability to participate in his physical activity routine. In addition, he likes to do a lot of exercise in the back country and his personal physician, Dr. X told him it would be dangerous to have this become incarcerated in the back country.

PAST MEDICAL HISTORY: Serious illnesses: Reactive airway disease for which he takes Advair. He is not on steroids and has no other pulmonary complaints. Operations: None.

MEDICATIONS: Advair.

ALLERGIES: None.

REVIEW OF SYSTEMS: He has no weight gain or weight loss. He has excellent exercise tolerance. He denies headaches, back pain, abdominal discomfort, or constipation.

PHYSICAL EXAMINATION:
VITAL SIGNS: Weight 82 kg, temperature 36.8, pulse 48 and regular, blood pressure 121/69.
GENERAL APPEARANCE: He is a very muscular well-built man in no distress.
SKIN: Normal.
LYMPH NODES: None.
HEAD AND NECK: Sclerae are clear. External occular eye movements are full. Trachea is midline. Thyroid is not felt.
CHEST: Clear to auscultation.
HEART: Regular rhythm with no murmur.
ABDOMEN: Soft. Liver and spleen not felt. He has no abnormality in the left groin. In the right groin I can feel a silk purse sign, but I could not feel an actual mass. I am quite sure he has by history and by physical examination a rather small indirect inguinal hernia. His cord and testicles are normal.

IMPRESSION: Right indirect inguinal hernia.

PLAN: We discussed observation and repair. He is motivated toward repair and I described the operation in detail. I gave him the scheduling number and he will call and arrange the operation.

Rationale: This is a new patient office visit which is coded from range 99201-99205. For a new patient office visit, all three key components must be met in order to support the level of visit. We have a detailed history (Extended HPI + Extended ROS + Pertinent History), Comprehensive exam (Const, Skin, Lymphatic, Eyes, Respiratory, Cardiovascular, Gastrointestinal, Genitourinary) and moderate MDM (New problem, no additional work up, no tests, elective surgery). The level of visit is 99203. In the ICD-9-CM Index to Diseases (Alphabetic Index), look for Hernia/inguinal. Indirect is a nonessential modifier listed for Hernia/inguinal. You are directed to 550.9 which requires a 5th digit. This is unilateral so 5th digit 0 would be used.

An established patient presents to the clinic today for a follow-up of his pneumonia. He was hospitalized for 6 days, on IV antibiotics. He was placed back on Singulair and has been doing well with his breathing since then. An expanded problem focused exam was performed. Records were obtained from the hospital and the physician reviewed the labs and X-rays. The patient was told to continue antibiotics for another two weeks to 20 days, and the prescription Keteck was replaced with Zithromax. Patient is to return to the clinic in two weeks for recheck of his breathing and re-X-ray then. What CPT® code should be reported?

Rationale: The patient was seen in the clinic, which is an outpatient service. The physician performed a problem focused history (brief HPI, no ROS, and pertinent PFSH) + expanded problem focused exam + moderate MDM (new problem to examiner, three data points, and acute illness with systemic symptoms and prescription drug management). Established patient office visits require two of three components be met. Code 99213 is the appropriate code for this visit.

37-year-old female is seen in the clinic for follow-up of lower extremity swelling.
HPI: Patient is here today for follow-up of bilateral lower extremity swelling. The swelling responded to hydrochlorothiazide.

DATA REVIEW: I reviewed her lab and echocardiogram. The patient does have moderate pulmonary hypertension.

Exam: Patient is in no acute distress.
ASSESSMENT:
1. Bilateral lower extremity swelling. This has resolved with diuretics, it may be secondary to problem #2.
2. Pulmonary hypertension: Etiology is not clear at this time, will work up and possibly refer to a pulmonologist.

PLAN: Will evaluate the pulmonary hypertension. Patient will be scheduled for a sleep study.

Rationale: This is a follow up visit indicating an established patient seen in the clinic. In the CPT® Index, look for Established Patient/Office Visit. The code range to select from is 99211-99215. For this code range, two of three key components must be met. History – PF (HPI-Brief, ROS-None, PFSH-Pert), Exam – Problem Focused, MDM – Moderate (Mgmt options – 1 stable problem, one new problem with workup; Data reviewed – lab and EKG; Level of Risk Moderate with unknown cause of pulmonary HTN). 99212 is the level of visit supported.

Dr. Inez discharges Mr. Blancos from the pulmonary service after a bout of pneumococcal pneumonia. She spends 45 minutes at the bedside explaining to Mr. Blancos and his wife the medications and IPPB therapy she ordered. Mr. Blancos is a resident of the Shady Valley Nursing Home due to his advanced Alzheimer’s disease and will return to the nursing home after discharge. On the same day Dr. Inez re-admits Mr. Blancos to the nursing facility. She obtains a detailed interval history, does comprehensive examination and the medical decision making is moderate complexity. What is/are the appropriate evaluation and management code(s) for this visit?

Rationale: Hospital discharge is a time-based code. The documentation states that the physician spent 45 minutes discharging the patient. In the CPT® Index, look for Hospital Services/Discharge Services. Code 99239 is for 30 minutes or more. Upon discharge the patient was readmitted to a skilled nursing facility (SNF), where he is a resident. CPT® guidelines preceding the Nursing Facility Services codes state when a patient is discharged from the hospital on the same day and readmitted to a nursing facility both the discharge and readmission should be reported. Initial nursing facility care codes require the three key components to meet or exceed the requirements. Documentation tells us the physician provided a detailed history, comprehensive exam, and medical decision making was of moderate complexity. Code 99304 states the history and exam can be detailed or comprehensive. Our documentation shows it to be of moderate complexity, which meets the requirements. Because our history is only detailed, the requirements are not met for 99305.

ICU – CC: Multi-system organ failure
INTERVAL HISTORY: Patient remains intubated and sedated. Overnight events reviewed. Tolerating tube feeds. Systolic pressures have been running in the low 90s on LEVOPHED. Cultures remain negative. Kidney function has worsened, but patient remains non-oliguric.

PHYSICAL EXAM: 96/60, 112, 100.8. Lungs have anterior rhonchi. Heart RRR with no MRGs. Abdomen is soft with positive bowel sounds. Extremities show moderate edema.
LABS: BUN 89, creatinine 2.6, HGB 10.2, WBC 22,000. ABG: 7.34/100/42 on 50% FiO2. CXR shows RLL infiltrate.

IMPRESSION
Hypoxic respiratory failure
Community acquired pneumonia
Septic shock
Non-oliguric acute renal failure

PLAN: Continue NS at 75 cc/hr. Decrease ZOSYN to 2.25 grams IV Q 6H
Follow cultures. Continue tube feeds. Titrate LEVOPHED to maintain SBP > 90
Usual labs ordered for tomorrow.
Critical care time: 35 minutes

What CPT® code(s) is/are reported?

Rationale: This patient meets the definition of a critically ill patient as defined by the E/M Guidelines for Critical Care services. A critical illness is one acutely impairing one or more vital organ system with a high probability of imminent or life threatening deterioration in the patient’s condition. The physician documents 35 minutes of critical care time. Critical care for 35 minutes is reported with 99291.

Patient comes in today at four months of age for a checkup. She is growing and developing well. Her mother is concerned because she seems to cry a lot when lying down but when she is picked up she is fine. She is on breast milk but her mother has returned to work and is using a breast pump, but hasn’t seemed to produce enough milk.

PHYSICAL EXAM: Weight 12 lbs 11 oz, Height 25in., OFC 41.5 cm. HEENT: Eye: Red reflex normal. Right eardrum is minimally pink, left eardrum is normal. Nose: slight mucous Throat with slight thrush on the inside of the cheeks and on the tongue. LUNGS: clear. HEART: w/o murmur. ABDOMEN: soft. Hip exam normal. GENITALIA normal although her mother says there was a diaper rash earlier in the week.

ASSESSMENT
Four month old well check
Cold
Mild thrush
Diaper rash
PLAN:
Okay to advance to baby foods
Okay to supplement with Similac
Nystatin suspension for the thrush and creams for the diaper rash if it recurs
Mother will bring child back after the cold symptoms resolve for her DPT, HIB and polio

What E/M code(s) is/are reported?

Rationale: Documentation states the encounter is for a "checkup," which is a Preventive Medicine Service. In the CPT® Index, see Preventive Medicine/Established Patient. Preventive Medicine Service codes are age specific. Although the child has a cold and thrush, additional history and exam elements beyond what is performed in the preventative exam are not documented. It would be inappropriate to bill for an additional E/M service with the modifier 25. See Appendix A description of modifier 25.

33 year-old male was admitted to the hospital on 12/17/XX from the ER, following a motor vehicle accident. His spleen was severely damaged and a splenectomy was performed. The patient is being discharged from the hospital on 12/20/XX. During his hospitalization the patient experienced pain and shortness of breath, but with an antibiotic regimen of Levaquin, he improved. The attending physician performed a final examination and reviewed the chest X-ray revealing possible infiltrates and a CT of the abdomen ruled out any abscess. He was given a prescription of Zosyn. The patient was told to follow up with his PCP or return to the ER for any pain or bleeding. The physician spent 20 minutes on the date of discharge. What CPT® code is reported for the 12/20 visit?

Feedback: Rationale: The patient is being discharged from the hospital. Hospital discharge codes are determined based on the time documented the physician spent providing services to discharge the patient. The provider documented 20 minutes, which is reported with 99238.

90-year-old female was admitted this morning from observation status for chest pain to r/o angina. A cardiologist performs a comprehensive history and comprehensive exam. Her chest pain has been relieved with the nitroglycerin drip given before admission and she would like to go home. Doctor has written prescriptions to add to her regimen. He had given her Isosorbide, and she is tolerating it well. He will go ahead and send her home. We will follow up with her in a week. Patient was admitted and discharged on the same date of service. What CPT® code is reported?

Rationale: This patient was admitted and discharged on the same date of service from observation status. According to CPT® guidelines for Observation or Inpatient Care Services (Including Admission and Discharge Services), services for a patient admitted and discharged on the same date of service should be reported by one code. For a patient admitted and discharged from observation or inpatient status on the same date, codes 99234-99236 should be reported as appropriate." The provider performed a comprehensive history, comprehensive exam and moderate MDM (New problem to the examiner, 0 data points and moderate risk). The correct code is 99235.

Dr. X asks Dr. Y to look at a 65-year-old male who is in a nursing facility for decubitus ulceration. Dr. Y is unable to obtain history due to current mental status. He obtains a detailed history from Dr. X since the patient is unable to provide a history. A detailed exam along with low MDM is performed. Dr Y. recommends to Dr. X that the patient needs to go to the surgical suite for debridement of the ulcerations. Since the patient is unstable at the moment due to elevated blood pressure and a UTI, they decide to delay surgery and to keep monitoring the patient until he stabilizes. Written report is documented. What CPT® code is reported?

Rationale: Dr. X asks Dr. Y to perform a consultation on a patient residing in a nursing facility. According to CPT® guidelines: "The initial inpatient consultation codes (99251-99255), are to be used only once by the reporting physician for an individual hospital or nursing facility patient for a particular admission. These codes are to be reported for consultations provided to hospital inpatients, residents of nursing facilities, or patients in a partial hospital setting." 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. The consulting physician performs the consultation, documents his or her opinion in the patient’s medical record, and communicates findings/recommendations by written report to the requesting physician or other appropriate source. Consultations require the documentation of three of three key components. The provider performed a detailed history, detailed exam and moderate MDM. The correct code is 99253.

A physician admits Mrs. Smith to the hospital. She is there for five days. The physician sees her each day she’s in the hospital. What subcategory of codes would be used for days two, three and four?

ationale: Codes from the Subsequent Hospital Care subcategory would be used for days two, three and four. The code for the first day would be from the Initial Hospital Care subcategory. Day five could be reported with either subsequent hospital care, or hospital care discharge depending on the role of the physician.

A patient is seen by Dr. B who is covering on call services for Dr. A. The patient is an established patient with Dr. A. but she has not been seen by Dr. B. before. Which E/M subcategory is appropriate to report the services provided by Dr. B?

Rationale: According to the E/M Guideline for New and Established Patient, when a provider is on call or covering for another provider, the patient’s encounter will be classified as it would have been by the provider who is not available. In this instance, Dr. B would report an established patient office visit.

A patient presents to a cardiologist for an initial visit at the request of his PCP to treat congestive heart failure. After the cardiologist examines the patient and discusses the treatment options, he schedules the patient for a stress test. The cardiologist provides a detailed report to the patient’s PCP and will be taking over the care. An E/M code would be selected from what subcategory for the cardiologist?

Rationale: The PCP sent the patient to the cardiologist to treat the congestive heart failure. This is a new patient to the cardiologist. Even though the cardiologist provided a letter back to the PCP, the cardiologist will be taking over the care of the patient. A code would be selected from the new patient office visit subcategory.

When tissue glue is used to close a wound involving the epidermis layer how is it reported?

Rationale: The Guidelines for Repair (Closure) include tissue adhesive along with sutures and staples, either singly or in combination with each other can be reported with the repair codes. In this case the tissue glue (adhesive) is a one layer closure and can be reported with a simple repair code. Wound closure utilizing adhesive strips as the sole repair material should be coded using the appropriate E/M code.

75-year-old established patient sees his regular primary care provider for a physical screening prior to joining a group home. He has no new complaints. The patient has an established diagnosis of Cerebral Palsy and Type II Diabetes and is currently on his meds. A comprehensive history and examination is performed. The provider counsels the patient on the importance of taking his medication and gives him a prescription for refills. Blood work was ordered. PPD was done and flu vaccine given. Patient already had had a vision exam. No abnormal historical facts or finding are noted. What CPT® code is reported?

Rationale: According to CPT® guidelines, Preventive Medicine Services codes provide a means to report a routine or periodic history and physical examination in asymptomatic individuals. They include only those evaluation and management services related to the age specific history and examination provided by the physician. The patient is here for a preventive service. He did not have any complaints and the doctor did not identify any new problems. In the CPT® Index, look for Preventive Medicine/Established Patient. You are referred to 99382-99397. The code selection is based on age. Code 99397 is the correct code for a patient who is older than 65 years.

25 year-old male is brought by EMS to the Emergency Department for nausea and vomiting. Patient has elevated blood sugars and the ED physician is unable to get a history due to patient’s altered mental status. An eight organ system exam is performed and the MDM is high. The patient was stabilized and transferred to ICU. The ED physician documents total critical care time 25 minutes. What CPT® code should be reported?

Rationale: According to CPT® guidelines: "99291 is used to report the first 30-74 minutes of critical care on a given date. Critical care of less than 30 minutes of total duration on a given date should be reported with the appropriate E/M code. "For this encounter the physician is short 5 minutes of 30 minutes needed to bill the critical care code. The encounter takes place in the emergency department. In the CPT® Index, look for Evaluation and Management/Emergency Department. You are referred to 99281-99285. For emergency room services, three out of three key components are required. In this case, the provider is unable to obtain a history due to the patient’s condition. According to the CMS Documentation Guidelines, the provider must indicate the reason they could not obtain a history. The level is determined by the exam and MDM. The exam is comprehensive (eight organ systems) and MDM is moderate (new problem to the examiner, 0 data points and high level of risk). The proper code is 99285. There is also a statement in the description of 99285 that states, "within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status".

A pediatrician is asked to be in the room during the delivery of a baby at risk for complications. The pediatrician is in the room for 45 minutes. The baby is born and is completely healthy, not requiring the services of the pediatrician. What CPT® code(s) is/are reported by the pediatrician?

Rationale: The physician provider standby services. In the CPT® Index, look for Standby Services and you are directed to 99360. 99360 is reported based on time. Each 30 minutes is reported if only the entire 30 minutes is met. 99360 with 1 unit is the correct code choice.

Mr. Flintstone is seen by his oncologist just two days after undergoing extensive testing for a sudden onset of petechiae, night sweats, swollen glands and weakness. After a brief review of history, Dr. B. Marrow re-examines Mr. Flintstone. The exam is documented as expanded problem focused and the medical decision making of moderate complexity. The oncologist spends an additional 45 minutes discussing Mr. Flintstone’s new diagnosis of Hodgkin’s lymphoma, treatment options and prognosis.
What is/are the appropriate procedure code(s) for this visit?

Rationale: This is an established patient. Two of the three key elements are required for an established patient. An expanded problem focused exam and moderate MDM meet or exceed the requirement for code 99213. The physician spent an additional 45 minutes with the patient discussing the patient’s new diagnosis. Prolonged Service codes 99354-99357 are used when physician or other qualified heath care professional provides prolonged service involving direct patient contact that is provided beyond the usual service. The codes reported based on the place of service and total time. Codes 99213 and add-on code 99354 are used to report the services.

A new patient visits the internal medicine clinic today for diabetes, chronic constipation, arthritis and a history of cardiac disease. The physician performs a detailed history, comprehensive exam and a medical decision making of moderate complexity. What CPT® code should be reported?

Rationale: In the CPT® Index, look for Office and/or Other Outpatient Services/Office Visit/New Patient and you are directed to codes 99201-99205. For New Patient visits, all three key components must be met. This service supports a level 3 new patient visit, 99203.

The attending physician at the hospital spent 25 minutes with the patient in morning and another 15 in the afternoon examining the patient, writing discharge orders, and giving discharge instructions to the patient. What CPT® code should be reported for the discharge?

Rationale: In the CPT® Index, look for Hospital Services/Inpatient Services/Discharge Services and you are directed to code ranges 99238-99239 and 1110F-1111F. Codes 1110F-1111F are Category II supplemental codes used for performance measurement. They may not be used as a substitute for Category I codes. Codes 99238-99239 are based on time. All of the time spent by the discharge physician on the discharge date is included in the time. The physician spent a total of 40 minutes with the patient on the discharge date. 99239 is the correct code choice.

Dr. Inez discharges Mr. Blancos from the pulmonary service after a bout of pneumococcal pneumonia. She spends 45 minutes at the bedside explaining to Mr. Blancos and his wife the medications and IPPB therapy she ordered. Mr. Blancos is a resident of the Shady Valley Nursing Home due to his advanced Alzheimer’s disease and will return to the nursing home after discharge. On the same day Dr. Inez re-admits Mr. Blancos to the nursing facility. She obtains a detailed interval history, does comprehensive examination and the medical decision making is moderate complexity. What is/are the appropriate evaluation and management code(s) for this visit?

Rationale: Hospital discharge is a time-based code. The documentation states that the physician spent 45 minutes discharging the patient. In the CPT® Index, look for Hospital Services/Discharge Services. Code 99239 is for 30 minutes or more. Upon discharge the patient was readmitted to a skilled nursing facility (SNF), where he is a resident. CPT® guidelines preceding the Nursing Facility Services codes state when a patient is discharged from the hospital on the same day and readmitted to a nursing facility both the discharge and readmission should be reported. Initial nursing facility care codes require the three key components to meet or exceed the requirements. Documentation tells us the physician provided a detailed history, comprehensive exam, and medical decision making was of moderate complexity. Code 99304 states the history and exam can be detailed or comprehensive. Our documentation shows it to be of moderate complexity, which meets the requirements. Because our history is only detailed, the requirements are not met for 99305.

45-year-old established, female patient is seen today at her doctor’s office. She is complaining of severe dizziness and feels like the room is spinning. She has had palpitations on and off for the past 12 months. For the ROS, she reports chest tightness and dyspnea but denies nausea, edema, or arm pain. She drinks two cups of coffee per day. Her sister has WPW (Wolff-Parkinson-White) syndrome. An extended exam of five organ systems are performed. This is a new problem. An EKG is ordered and labs are drawn, and the physician documents a moderate complexity MDM. What CPT® code should be reported for this visit?

Rationale: This is a follow up visit indicating an established patient seen in the clinic. In the CPT® Index, look for Established Patient/Office Visit. The code range to select from is 99211-99215. For this code range, two of three key components must be met. History Detailed (HPI-Extended; ROS-Extended, PFSH-Complete), Exam – Detailed, MDM Moderate. 99214 is the level of visit supported.

An established 47-year-old patient presents to the physician’s office after falling last night at her home when she slipped in water on the kitchen floor. She is complaining of back pain and no tingling or numbness. Physician documents that she has full range motion of the spine, with discomfort. Her gait is within normal limits. Straight leg raising is negative. She requested no medication. It is recommended to use heat, such as a hot water bottle. Doctor’s Assessment: Back Strain. What E/M and ICD-9-CM codes are reported for this service?

Rationale. The patient is an established patient. In the CPT® Index, look for Established Patient/Office and/or Other Outpatient/Office Visit. You are referred to 99211-99215. An established patient visit requires 2 of 3 key components. The physician documents an Expanded Problem Focused History (brief HPI, pertinent ROS, and no PFSH), a Problem Focused Exam (1 affected organ system, musculoskeletal) and Low MDM (New Problem to examiner, ,no additional work-up, 0 data points, and acute complicated injury, e.g, simple sprain). Review codes to choose the appropriate level of service. Code 99213 is the correct code. Back strain was the doctor’s diagnosis. In the ICD-9-CM Index to Diseases, look for Sprain, strain/back. You are referred to 847.9. Review the code in the tabular section to verify accuracy. In the ICD-9-CM Index to Diseases, go to Section 3, Alphabetic Index to External Causes of Injury and Poisoning (E code). Look for Slipping/surface/wet. You are referred to E885.X. A fourth digit is needed to complete code. Review the code in the Tabular List to verify accuracy. E885.9 is the most accurate code. In the ICD-9-CM Index to Diseases, go to Section 3, Alphabetic Index to External Causes of Injury and Poisoning (E code). Look for Accident/occurring/home. You are referred to E849.0. Review the code in Tabular List to verify accuracy.

60-year-old woman is seeking help to quit smoking. She makes an appointment to see Dr. Lung for an initial visit. The patient has a constant cough due to smoking and some shortness of breath. No night sweats, weight loss, night fever, CP, headache, or dizziness. She has tried patches and nicotine gum, which has not helped. Patient has been smoking for 40 years and smokes 2 packs per day. She has a family history of emphysema. A limited three system exam was performed. Dr Lung discussed in detail the pros and cons of medications used to quit smoking. Counseling and education was done for 20 minutes of the 30 minute visit. Prescriptions for Chantrix and Tetracylcine were given. The patient to follow up in 1 month. A chest X-ray and cardiac work up was ordered. Select the appropriate CPT code(s) for this visit.

Rationale: Patient is coming to the doctor’s office for help to quit smoking. The patient is new. The physician documents that 20 minutes of the 30 minute visit was spent counseling the patient. E/M Guidelines identify when time is considered the key or controlling factor to qualify for a E/M service. When counseling and/or coordination of care is more than 50% face to face time in the office or other outpatient setting, time may be used to determine the level of E/M. The correct code is 99203 based on the total time of the visit which is 30 minutes.

28-year-old female patient is returning to her physician’s office with complaints of RLQ pain and heartburn with a temperature of 100.2. The physician performs a detailed history, detailed exam and determines the patient has mild appendicitis. The physician prescribes antibiotics to treat the appendicitis in hopes of avoiding an appendectomy. What are the correct CPT® and ICD-9-CM codes for this encounter?

Rationale: This is an established patient E/M level of service due to the indication she returning to her physician for the visit. Code 99214 is appropriate when two of the three key components are met for an established patient. According to the ICD-9-CM Official Coding Guidelines Section I.B.6-8, a definitive diagnosis is reported when it has been established; appendicitis is reported with code 541. Look in the ICD-9-CM Index to Diseases for Appendicitis 541. Any signs or symptoms that would be an integral part of that definitive diagnosis/disease process would not be separately reported. Heartburn is not a symptom commonly seen with appendicitis so we can report this as an additional code. Look in the Index to Diseases for Heartburn 787.1. Verification in the Tabular List confirms code selection.

An established patient presents to the clinic today for a follow-up of his pneumonia. He was hospitalized for 6 days, on IV antibiotics. He was placed back on Singulair and has been doing well with his breathing since then. An expanded problem focused exam was performed. Records were obtained from the hospital and the physician reviewed the labs and X-rays. The patient was told to continue antibiotics for another two weeks to 20 days, and the prescription Keteck was replaced with Zithromax. Patient is to return to the clinic in two weeks for recheck of his breathing and re-X-ray then. What CPT® code should be reported?

Rationale: The patient was seen in the clinic, which is an outpatient service. The physician performed a problem focused history (brief HPI, no ROS, and pertinent PFSH) + expanded problem focused exam + moderate MDM (new problem to examiner, three data points, and acute illness with systemic symptoms and prescription drug management). Established patient office visits require two of three components be met. Code 99213 is the appropriate code for this visit.

Subsequent Hospital Visit
CHIEF COMPLAINT: CHF

INTERVAL HISTORY: CHF symptoms worsened since yesterday.
Now has some resting dyspnea. HTN remains poorly controlled with
systolic pressure running in the 160s. Also, I’m concerned about his
CKD, which has worsened, most likely due to cardio-renal syndrome.

REVIEW OF SYSTEMS: Positive for orthopnea and one episode of
PND. Negative for flank pain, obstructive symptoms or documented
exposure to nephrotoxins.

PHYSICAL EXAMINATION:
GENERAL: Mild respiratory distress at rest
VITAL SIGNS: BP 168/84, HR 58, temperature 98.1.
LUNGS: Worsening bibasilar crackles
CARDIOVASCULAR: RRR, no MRGs.
EXTREMITIES: Show worsening lower extremity edema.

LABS: BUN 56, creatinine 2.1, K 5.2, HGB 12.

IMPRESSION:
1. Severe exacerbation of CHF
2. Poorly controlled HTN
3. Worsening ARF due to cardio-renal syndrome
PLAN:
1. Increase BUMEX to 2 mg IV Q6.
2. Give 500 mg IV DIURIL times one.
3. Re-check usual labs in a.m.
Total time: 20minutes.

What CPT® code should be reported?

Rationale: This is a subsequent hospital visit which is reported with code range 99231-99233. In the CPT® Index, look for Hospital Services/Subsequent Hospital Care. 2 of the 3 key components must be met to support a level of visit. Detailed history (Extended HPI + Extended ROS + 0 PFSH), EPF Exam (using 1995 documentation guidelines of a limited exam of 2-7 of affected BA/OS and other related OS), Medical Decision Making (MDM) high complexity (extensive diagnoses and management and high- risk to the patient for complications). According to the documentation guidelines for E/M services, for the subsequent care category, CPT® requires only an "interval" history. It is not necessary to record information about the PFSH. The diagnoses are CHF, HTN and ARF due to cardio-renal syndrome. Code 99233 is the appropriate code.