basic cpt evaluation & management (e/m) coding ed coding irene mueller, edd, rhia montana...
TRANSCRIPT
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Basic CPT Evaluation & Management (E/M)
CodingED Coding
Irene Mueller, EdD, RHIA
Montana Hospital
Association
MT-NC Tele-Video
Spring 2008
February 20, 2008 1– 3 pm MST
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ObjectivesAssign correct CPT codes by applying
knowledge of
• Basic CPT E&M coding conventions, and
• Basic CPT coding process for ED
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2/06/08 Schedule • 1pm – 1:05
– Overview of session
• 1:05 – 1:50 pm – CPT E/M Coding
• 1:50 – 2 pm Break
• 2:00 - 2:45– CPT Coding for ED
• 2:45- 3:00 pm– Questions
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Identifiable procedures and E/M
• Any procedure id with specific CPT code performed on/subsequent to the date of initial/subsequent E/M services SHOULD BE reported separately– Performing/interpreting dx test/studies– -26 for professional component only – E/M related to procedures is part of their codes– -25 indicates that E/M services were above and
beyond those associated w/procedure (do not need different dx code)
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Most E/M Codes reflect Cognitive Services
• Provider must – Acquire information from patient, exam, tests, etc.– Use reasoning skills to process information– Interact with pt to provide feedback– Respond by creating a plan
• Do NOT include significant procedures• Do include cleaning traumatic lesions, adhesive strip
closures, applying dressings, counseling/education
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E/M “work”• Work not easy to measure, so other measures
used to establish work• Intraservice times
– F2F = office, other outpt visits• With patient/family• Valid indication of total work done before, during,
after visit– Unit/Floor = hospital, other inpt visits
• On floor and at bedside• Valid indication of total work done before, during,
after visit
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Medicine and E/M Sections• Medicine section has some codes that describe
procedures and specialty services that include E/M– Allergy testing, immunotherapy, osteopathic
manipulation, PT services, neuro/vascular testing
– General/special ophthalmologic – General/special dx and tx psychiatric
• When Medicine procedural specialty codes are assigned, do NOT also assign an E/M code
• IF significant, sep. id E/M service provided, assign E/M code with -25 modifier
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E/M Section
• Appears at beginning of code book
• 99201-99499
• Items are used by most physicians in reporting a significant portion of their services.
• E/M codes are specific to a SETTING (Place of Service (POS)
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E/M Section• Categories (by setting, etc.)
– Subcategories – Ex: Office visits subcategories of new pt, est. pt– Ex: Hospital visits – initial and subsequent
–Levels of E/M services–3-5 levels (last digit)
• Physician’s work varies by– Type of service (TOS)– Place of service (POS)– Patient’s status– Misc. services (eg prolonged, care plan oversight)
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New vs. Established Patient
• Distinguished by Professional Services– F2F services rendered by a physician and
reported via CPT codes
• New – one who has NOT received any professional services from the Dr (or another Dr of the SAME specialty who is in the SAME group practice), within the past 3 years
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New vs. Established Patient• Established – one who has received
professional services from the Dr or another Dr of the SAME specialty who belongs to the SAME group practice, within the past 3 years.
• On call/Covering physician – encounter is classified as if it would have been performed by the physician who is NOT available.
• *Decision Tree in E/M Guidelines
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Concurrent Care
• USUALLY, one E/M code reported for one day for one patient by one provider
• Provision of similar services to the same pt on the same day by more than one provider is CONCURRENT CARE
• Be sure to assign different dx codes to avoid claim denial
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Concurrent Care
• EX: Pt adm for AMI on 2/15. On 2/17, cardiologist requested consult for anxiety and depression.
• Cardiologist’s coder assigns AMI dx code(s)• Psychiatrist’s coder assigns Anxiety/depression
dx• IF both bill for AMI, 1st claim is paid, 2nd claim
denied
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Unlisted E/M services
• Only 2
• 99429
• 99499
• Requires special report to demonstrate the medical appropriateness of service
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Special Report
• Complexity of symptoms• Description of nature, extent, need for
service• Dx and Tx procedures• Follow-up care• Pt’s final dx and concurrent problems• Pertinent physical findings• Time, effort, equipment required
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Clinical Examples
• Appendix C– Examples, not descriptors
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Levels of E/M Services
• 3-5 levels within each category/subcategory• Levels NOT interchangeable between categories• Include
– Exams, Evaluations, Tx, conferences with/about pts, health supervision, other medical services
– Medical screening• Hx, exam, medical decision-making• Required to determine need/location for
appropriate care/tx• Each level may be used by all physicians
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E/M components
• Seven – Hx, Exam, Medical Decision-making (KEY)– Counseling, Coordination, Nature of
presenting problem (Contributory) – Time
• Contributory components may not be provided at every encounter
• Coordination w/out pt encounter = Case Mgt Codes
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Key Components• New Pt – All 3 components must be at a level to
justify assignment• Established Pt – 2 of 3 components to justify level
assignment
• Some E/M categories don’t distinguish between New/Est pts
• Documentation MUST support the key components used to select E/M code– (Handout)
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CMS Documentation Guidelines for E/M Services
• Guidelines and notes perceived as insufficient for consistent coding and reliable review by payers
• CMS Doc Guidelines for elements of comprehensive multisystem/single-system exams.
• 1995 – providers felt single-system exams unclear
• 1997 – providers felt confusing and burdensome (extensive counting)
• CMS policy– Providers to use whichever set of guidelines is
most advantageous for reimbursement• AMA and CMS still working on developing an
acceptable approach
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Documentation and Coding
• Provider does NOT have to re-document Hx, ROS during a previous encounter IF review and location of the information is documented in current note.
• Provider then should update information that is no older than one to two years.
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E/M Coding Process
• ID Category/Subcategory of service (POS)
• ID TOS provided
• ID if pt new/established if necessary
• Review Reporting Instructions
• Review Level of E/M Services provided– Key components – Counseling/coordination of care different
• Apply CMS Documentations Guidelines
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Office or Other Outpt Services• When a Dr provides two E/M services for the same
pt on the same day for the same problem, report just ONE E/M code (highest level)– Critical Care Services is an exception to this
• When a Dr provides multiple E/M services in this setting to same pt on the same day for DIFFERENT problems, report multiple E/M codes– Be sure to link different dx to relevant E/M codes– Add -25 to 2nd and subsequent E/M codes
• When pt receives Office E/M services and is admitted as inpt the SAME day by the SAME Dr, report the initial hospital care E/M code ONLY
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Office or Other Outpt Services
• When pt receives Office E/M services and is admitted as inpt the SAME day by the SAME Dr, report the initial hospital care E/M code ONLY
• When Dr performs comprehensive exam in office and on a later day the pt is admitted to hospital as a PLANNED admission, report a lower-level-of-service initial hospital care E/M code
• When pt’s admission is UNPLANNED on a later day, report the appropriate E/M codes for each episode of care
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99211
• “Nurse visit”• Code can be reported by any other provider
– NP, PA, Physician
• CMS guidelines – “incident to”– Physician must be PHYSICALLY PRESENT in
offices when service provided
• Documentation – CC and service description– Hx and Exam documentation NOT required
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Nursing Facility Services• Provided AT an NF, SNF, intermediate care
facility/mentally retarded (ICF), LTCF, or psychiatric residential tx facility
• NFs provide convalescent, rehab, or LT care for pts • Comprehensive assessment must be completed on
each pt– Medical, nursing, mental, psychological needs– Pt’s functional capacity, ID of potential problems,
nursing plan– Required on admission/readmission/substantial
change
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NF Services
• When a pt is discharged from hospital or observation and admitted to a NF, SNF, ICF, or LTCF on the SAME day, code for both types of E/M services
• Do NOT code ED or office E/M with initial NF care when provided on SAME day for SAME pt by SAME physician.
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NF services
• Do NOT code NF care and initial hospital care on the same date for the same pt by the same physician, code ONLY the initial hospital care.
• Code subsequent NF care when – evaluation of pt’s assessment plan is NOT
required– pt has not had a major/permanent change of
health status
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NF Services
• NF discharge – 99315 or 99316
• Pronouncement of death, completion of death summary, and discussion with family – 99315 or 99316– Provider MUST personally visit pt and
document pronouncement of death BEFORE midnight on date of death
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Misc.1. Application of casts and strapping
If sole procedure and not to treat a fracture; use appropriate E/M code and 99070 for supplies.If to treat fracture without reduction; assign code that states "closed treatment without manipulation".
2. Closure of wounds with adhesive strips is included in E/M code. p.
3. Maternity care/deliveryIf physician does NOT perform delivery, but
proved some antepartum/postpartum care, use E/M codes ONLY.
4. Vaginal foreign bodyIf removal is done WITHOUT anesthesia, use E/M codes ONLY.
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Examples• Dr. Smith provided a level 3 E/M service to new pt
in office for anxiety. The pt returns 4 hours later with anxiety problem, and Dr. Smith provides a level 2 E/M service.– Code(s)?
• Dr. Jones provides level 3 services to an est. pt. for HTN. The pt returns 5 hours later for level 4 E/M services related to hip pain caused by a fall at home.– Code(s)?
• Dr. Green provides level 4 E/M services in office. Pt is later admitted to hospital, where Dr. Green performs level 3 initial hospital care E/M services.– Code(s)?
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Examples
• Based on standing orders, Office nurse administers monthly B12 injection after taking and recording vital signs.
• Based on standing orders, Office nurse administers testosterone injection. Physician provided level 3 E/M services last week.
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Examples
• 10/14 – 97 y/o female pt transferred from hospital to NF in stable condition. Attending provided hospital discharge day mgt services and provided a level 2 initial NF service.
• 11/14 – Physician provided level l subsequent NF care.
• 11/30 – Pt expired. Physician was not in attendance.
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Break Time
Fluid Exchanges
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ED Coding
• E/M exam documentation guidelines can be the 1995 or the 1997 guidelines, whichever is preferable to the provider.
• Evaluation and Management Services Guide (2007)
• “prepared as a tool to assist providers” “is a general summary…, but is not a legal document”
• “does not replace content found in ’95/’97 guidelines”
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ED Services• Provided in a hospital• Open 24 hrs/day• Unscheduled episodic service to pts needing
immediate medical attention
• Emergency – the sudden and unexpected onset of medical
condition or – the acute exacerbation of a chronic condition
that is threatening to life, limb, or sight and that requires immediate medical treatment
– or that manifests painful symptomology requiring immediate palliative effort to relieve suffering.
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ED Services
• Any physician who provides services to a pt REGISTERED in the ED may report the ED services codes.
• The physician does NOT have to be assigned to the ED
• If services provided in the ED are determined NOT to be actual emergency, ED services codes are STILL reportable IF ED services were provided.
• Typically, the hospital will report lower level ED services code for non-emergency conditions.
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ED Services• When emergency services are provided in
the office, DO NOT assign ED E/M codes.
• If PCP meets pt in ED and the pt is NOT registered in ED, then report an Office or Other Outpt E/M code
• When ED services are provided the same day by the same physician as a comprehensive nursing facility assessment, do NOT report ED E/M code.
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E/M Components in ED
• Time is NOT a component for the ED levels
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Hospital E/M Coding for ED
• Since the MC hospital outpt PPS (HOPPS) began in 2000, hospitals have been coding clinic/ED visits using CPT
• E/M codes often do NOT fit the type of services provided by hospitals
• CMS requires hospitals to develop a methodology with internal guidelines for code assignment that maps to E/M levels of effort that refer to facility resources consumed by staff
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Hospital E/M coding for ED
• CMS requirements – Services must be documented– Medically necessary– Reasonably reflect intensity of resources– Based on resource consumption that is NOT
separately payable (x-rays, labs, etc)
• Lack of standardization– Poor data for APC reimbursement– Possible violation of HIPAA code set requirements– Coder confusion– Less effective compliance programs
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ED and Clinic E/M coding Model
• See Handouts
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Hospital Established Pt
• If a patient has a medical record that was created within the past 3 years, the patient is considered an established patient to the hospital.
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CMS Requirements for Hospital OPPS
• 2008 Hospital Clinic Visits– Continue using E/M outpatient visit codes– Continue differentiating between new, est. pts– Type of service is not differentiated
– Consultation E/M codes will not be recognized– Use new/est visit code
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CMS Requirements for Hospital OPPS
• 2008 Hospital ED Visits– Type A ED visits – ED meets CPT definition, must be open 24/7.– Continue to use CPT ED codes– Type B ED visits – ED does not meet CPT definition, open less
than 24 hours/day– Use following codes– G0380, G0381, G0382, G0383, G0384
• Critical Care– Must provide a minimum of 30 minutes to report 99291– < 30 minutes, used clinic/ED visit code
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G0380• G0380 Level 1 hospital emergency department visit provided in a
type b emergency department; (the ED must meet at least one of the following requirements: (1) It is licensed by the state in which it is located under applicable state law as an emergency room or emergency department; (2) it is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment; or (3) during the calendar year immediately preceding the calendar year in which a determination under 42 CFR 489.24 is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one-third of all of its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment)
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CMS Guidelines Principles
• Hospitals should continue to report visits according to own internal guidelines
• CMS has 11 principles that internal guidelines should follow
• First 6 reaffirmed,• Five new ones this year
• Principles/Clarification available in • AHA Coding Clinic for HSCPS, v 7, #4, Fourth
Quarter, 2007, pp. 1-3
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Hospital E/M Coding for ED
• Example - Handout
http://adam.about.com/encyclopedia/Sewing-a-wound-closed-series.htm
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Resources• AMA CPT Web Site
– www.ama-assn/org/go/cpt (early releases)
• CPT 2008 Professional Edition. AMA
• Green, Michelle. (2007). 3-2-1 Code It! Thomson Delmar Learning. ISBN 1-4180-1255-6
• Hospital E/M Coding Panel. Recommendation for Standardized Hospital Evaluation and Management Coding of ED and Clinic Services. AHIMA. June 2003.
• Peters, R. and Wiedemann, L. Applying Facility E/M Codes in the Hospital Emergency Department. Journal of AHIMA, 78, no. 5 (May 2007): 68-69.
• Pitotti, Margaret. Coding the Emergency Room visit. ADVANCE for Health Information Professionals, 10/22/07
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Resources
• OPPS Visit Codes Frequently Asked Questions http://www.cms.hhs.gov/HospitalOutpatientPPS/downloads/OPPS_Q&A.pdf
• CMS- 1506-P Proposed rule Section IX Proposed Hospital Coding and Payments for Visits (Clinic, Ed, Critical Care) http://www.cum.hhs.gov/HospitalOutpatientPPS/downloads/CMS1506.P.pdf
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Resources
Evaluation and Management Services Guide (2007)
http://www.cms.hhs.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf
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? From previous workshops
• Not coding DM if that wasn’t what brought the patient in – This is a case of dueling guidelines– As pointed out by Helen Ovitt (relaying a
question from a coder in her facility)– 2008 Coders’ Desk Reference – Diagnoses –
it states “diabetes is a systemic disease and, as such, should be coded even in the absence of documented, active intervention during a patient encounter”.
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Questions fromPrevious Workshops
• A Glycosolated Hemoglobin test is not for anemia and has nothing to do with it. It is to check the blood sugar control over a three month period in diabetics. A Glycosolated Hemoglobin of 7.9 would indicate the blood sugars were not in very good control. A regular hemoglobin of 7.9 would require intervention of some kind, possibly a transfusion.
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HGB vs HbA1c
• The confusion is occurring because the wrong test name and normal values were used on the lab report.
• You noticed the Dr. referred to the test as glycosylated hemoglobin and I noticed the name on the lab test was HGB with normal values from 13.8-17.2.
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• The lab report is for blood hemoglobin because of the name and the normal ranges. For HGB the result for the blood hemoglobin is very low and needs intervention.
• The correct name for the glycosylated hemoglobin test on a lab report would be HbA1c and the normal range for this test that indicates the average blood glucose level for the last 3 months is 4.5 – 6, with anything over 8 being considered significant.