de-mystifying evaluation & management documentation & coding · •the three key components...

DE-MYSTIFYINGEVALUATION & MANAGEMENT DOCUMENTATION & CODING

Focus on Primary Care & Behavioral Health

DISCLAIMER

Neither the presenter nor HealthCare Management Consultants have any relevant relationships or potential conflicts of interest to disclose.

January 2018HCMC for Oregon Nurses Association

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ON THE AGENDA

The Importance of Documenting

Medical Necessity

The Algorithm of an E/M Code

Emphasis on Decision Making

for 99213 & 99214

When to Consider

Reporting 99215

Documentation Requirements

for New Patient Codes

Documenting Coding Based

on Time

Behavioral Health Coding

Psychotherapy Documentation

EHR: The Frenemy


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KNOWLEDGE CHECK• The three key components of E/M coding are history, exam, and medical

decision making. Which of the three is most important to determining the code level?

• An E/M level can be determined either based on key components, or under some circumstances based on time. If I spend 20 minutes reviewing the patient’s records prior to the appointment, can I include that time towards time coding?

• What is the difference between the 1995 and 1997 exam guidelines?

• For behavioral health, can I bill a time-based E/M code in addition to psychotherapy for medication management?


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MEDICAL NECESSITYPer Medicare:"Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code.

It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted.

The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported.“

“Furthermore, all services must be sufficiently documented so the medical necessity is clearly evident. Medicare cannot pay for services for which the documentation does not establish the medical necessity.”


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ALGORITHM OF AN E/M CODEKey

ComponentsHistory Exam Medical Decision

Making1995 Guidelines 1997 Guidelines

Chief Complaint Body Areas/Organ Systems

Bullet Points Diagnosis/TxOptions

History of Present Illness

Data Complexity

Review of Systems Level of RiskPast, Family, & Social History


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CODING TIP FOR ESTABLISHED PATIENTS


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First determine your level of medical decision making,

1Support it with your history documentation,

2Perform & document the level of exam necessary based on the clinical need of the patient

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CODING TOOLS


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• Coding Tool: New Patient• Coding Tool: Established Patient• Exam Guidelines: 1995• Exam Guidelines: 1997 Multi-System• Exam Guidelines: 1997 Single System Psychiatric• Established Patient Coding Quick Reference

FOCUS ON DECISION MAKING: ESTABLISHED PATIENT CODES

Level History Exam Medical Decision Making

99211 May not require the presence of a physician (i.e., nurse only encounter)99212 Problem Focused History Problem Focused Exam Straightforward99213 Expanded Problem

Focused HistoryExpanded Problem Focused Exam

Low Complexity

99214 Detailed History Detailed Exam Moderate Complexity

99215 Comprehensive History Comprehensive Exam High Complexity

The level of service for an established patient is based on the level of medical decision making supported by the history and/or exam documentation


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EXAMPLES OF LEVELS OF DECISION MAKING

Code Level of Decision Making

Scenario

99212 Straightforward • New minimal or self limited problem• Follow-up singular stable or improved problem

99213 Low Complexity • New acute uncomplicated problem• Follow-up singular problem exacerbated or not improved• Follow-up of 2 stable or improved problems

99214 Moderate Complexity • New acute complicated problem• Follow-up 2 problems, at least 1 exacerbated• Follow-up at least 3 problems

99215 High Complexity • Initial treatment acute or chronic condition posing threat to life or bodily function

• Follow-up minimum 2 problems, both severely exacerbated• Follow-up minimum 3 problems, at least 1 severely

exacerbated January 2018HCMC for Oregon Nurses Association

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99213 & 99214: PRIMARY CARE99213

Low Complexity Decision MakingNew Acute Uncomplicated Problem

Follow-up 2 Stable/Improved ProblemsFollow-up Singular Exacerbated Problem

Expanded Problem Focused History:• Chief Complaint• 1-3 HPI• 1 ROSExpanded Problem Focused Exam:(1995) 2-4 body areas/organ systems(1997) 6-11 bullet points

99214Moderate Complexity Decision Making

New Acute Complicated ProblemFollow-up 3 Stable/Improved Problems

Follow-up 2 Problems; 1 Stable + 1 ExacerbatedDetailed History:• Chief Complaint• >4 HPI or status 3 chronic conditions• 2-9 ROS• 1 PFSHDetailed Exam:(1995) 5-7 body areas/organ systems(1997) 12-17 bullet points


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99213 & 99214: BEHAVIORAL HEALTH99213

Low Complexity Decision MakingMedical Management of:

New Acute Uncomplicated ProblemFollow-up 2 Stable/Improved Problems

Follow-up Singular Exacerbated ProblemExpanded Problem Focused History:• Chief Complaint• 1-3 HPI• 1 ROSExpanded Problem Focused Exam:(1995) 2-4 body areas/organ systems(1997) 6-8 bullet points

99214Moderate Complexity Decision Making

Medical Management of:New Acute Complicated Problem

Follow-up 3 Stable/Improved ProblemsFollow-up 2 Problems; 1 Stable + 1 Exacerbated

Detailed History:• Chief Complaint• >4 HPI or status 3 chronic conditions• 2-9 ROS• 1 PFSHDetailed Exam:(1995) 5-7 body areas/organ systems(1997) Minimum 9 bullet points January 2018HCMC for Oregon Nurses Association

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EXAM OPTIONSLevel 1995 Exam

Guidelines1997 Multi-System Exam 1997 Single System

Psychiatric ExamProblem Focused(99212)

1 body area/ organ system

1-5 bullet points 1-5 bullet points

Expanded Problem Focused(99213)

2-4 body areas/ organ systems

6-11 bullet points 6-8 bullet points

Detailed(99214)

5-7 body areas/ organ systems

12-17 bullet points Minimum 9 bullet points

Comprehensive(99215)

8 organ systems Minimum 9 systems w at least 2 bullet points in each of 9 systems

All required bullet points


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WHEN DO YOU REPORT 99215?In order to report 99215 based on key components, high complexity decision making is required. This must be supported by either a comprehensive history or exam.

In most cases requiring high complexity decision making, it may not be medically necessary or feasible to obtain a comprehensive history or exam at the time. If that is the case, the encounter will support a lower code.

If more than 40 minutes are spent face to face with the patient, and more than half of that time is spent in counseling, it may be appropriate to report 99215 based on time.


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E/M CODING BASED ON TIME:Important Distinction:

E/M coding based on time is applicable to primary care and to behavioral health when only E/M codes are reported

E/M codes reported during the same encounter as psychotherapy cannot be reported based on time


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CPT DEFINITION OF COUNSELING:In the office, when more than half of the face to face encounter with the billing provider in spent in counseling, then the encounter can be coded based on time.Counseling, defined by CPT is a discussion with the patient/family/caregiver, etc. regarding • Diagnostic results, impressions, and/or recommended diagnostic studies• Prognosis• Risks and benefits of management (treatment) options• Instructions for management (treatment) and/or follow-up• Importance of compliance with chosen management (treatment) options• Risk factor reduction• Patient and/or family education


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E/M CODING BASED ON TIME:

Code Typical Time Code Typical Time99201 10 minutes 99211 5 minutes (if

applicable)99202 20 minutes 99212 10 minutes99203 30 minutes 99213 15 minutes99204 45 minutes 99214 25 minutes99205 60 minutes 99215 40 minutes


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TIME CODING DOCUMENTATION REQUIREMENTS

• Clinical documentation as appropriate to support the medical necessity of the encounter

• In the office, the total length of time spent by the billing provider face to face with the patient

• In the hospital, the total length of time spent by the billing provider on the unit in the patient’s behalf

• The fact that more than 50% of that time is spent in counseling or in coordination of care, or in a combination of both

• If counseling is the reason for time coding, the nature of the counseling must be documented

• If coordination of care is the reason for time coding, the nature of the coordination of care must be documented

• If both counseling and coordination of care are the reason for time coding, then the nature of both the counseling and the coordination of care must be documented


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TIME CODING EXAMPLE STATEMENT

“I spent 25 minutes face to face with the patient. More than half of that time was spent counseling the patient on his new diagnosis of afib, potential treatment options and reviewing the instructions for taking Pradaxa”


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TIME CODING DOCUMENTATION TIP

Per Medicare: “While some CPT codes allow the LOS to be time based, it is not acceptable to simply state ‘35 minutes spent with patient discussing treatment.’ When counseling and/or coordination of care is the key factor is determining LOS, documentation needs to support the amount of time spent in discussion anddetail the context of the conversation and any decisions made or actions that will result based on this counseling.”

Each patient and each encounter is unique. Do not attempt to develop a “one size fits all” generic time coding statement to explain the nature of the counseling.


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NEW PATIENT CODING:PRIMARY CARE

A new patient is a patient who has not received professional services by a provider in the same specialty within the group practice for at least three years.

“Group practice” is defined by tax ID number. If the practice has multiple locations, a patient who has been seen by a PCP in one location is an “established patient” to all PCPs in all of the group’s practice locations.

If a provider joins a group, patients transferring from the provider’s previous practice to the new group are considered “established patients”.


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NEW PATIENT CODING:99201 99202 99203 99204 99205

History Chief Complaint1-3 HPI

Chief Complaint1-3 HPI1 ROS

Chief Complaint>4 HPI or status of 3 chronic conditions2-9 ROS1 element of past or family or social history

Chief Complaint>4 HPI or status of 3 chronic conditionsMinimum 10 ROS1 element each: past, family, & social history

Exam: Problem Focused Expanded Problem Focused

Detailed Comprehensive

Medical Decision Making

Straightforward Low Complexity

Moderate Complexity

High Complexity

All three key components must support the codeJanuary 2018HCMC for Oregon Nurses Association

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OPTION FOR BEHAVIORAL HEALTH


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Code Description90791 Psychiatric diagnostic evaluation90792 Psychiatric diagnostic evaluation with medical services

OPTION FOR BEHAVIORAL HEALTH


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Code 90791 reports a psychiatric diagnostic interview exam including a complete medical and psychiatric history, a mental status exam, ordering of laboratory and other diagnostic studies with interpretation, and communication with other sources or informants. The psychiatrist then establishes a tentative diagnosis and determines the patient's capacity to benefit from psychotherapy treatment.

The patient's condition will determine the extent of the mental status exam needed during the diagnostic interview. In determining mental status, the doctor looks for symptoms of psychopathology in appearance, attitude, behavior, speech, stream of talk, emotional reactions, mood, and content of thoughts, perceptions, and sometimes cognition.

The diagnostic interview exam is done when the provider first sees a patient, but may also be utilized again for a new episode of illness, or for re-admission as an inpatient due to underlying complications.

When a psychiatric diagnostic evaluation is performed alone, report code 90791. When medical services are provided in conjunction with the psychiatric diagnostic evaluation, report code 90792.

DIAGNOSTIC EVALUATION DOCUMENTATION REQUIREMENTS


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Per the APA, the following is required:• Date of service• Chief complaint• History of present illness• Review of systems• Family & psychosocial history• Complete mental status exam• Assessment/plan• Identified goals of treatment• Plan for follow-up• Legible documentation and authentication by the provider

OTHER BEHAVIORAL HEALTH CODING GUIDELINES


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• E/M levels of service cannot be reported on the same day as 90791 or 90792• Psychiatric Diagnostic Evaluation codes are reported based on their

occurrence, not on time spent in the evaluation• Interactive complexity (90785) can be reported in addition to 90791 and

90792 but it cannot be added to E/M codes• The codes 90839-40 (Psychotherapy for crisis) can be added to E/M codes,

but cannot be reported with Psychiatric Diagnostic Evaluation codes• Psychotherapy codes can be added to E/M codes if psychotherapy is

provided at the initial encounter, but they cannot be added to the Psychiatric Diagnostic Evaluation codes

PSYCHOTHERAPY CODES


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Code Description Time Requirement90832 Psychotherapy, 30 minutes with patient 16-37 minutes90833 Psychotherapy, 30 minutes with patient when

performed with an evaluation and management service

16-37 minutes

90834 Psychotherapy, 45 minutes with patient 38-52 minutes90836 Psychotherapy, 45 minutes with patient when


38-52 minutes

90837 Psychotherapy, 60 minutes with patient 53 minutes or more90838 Psychotherapy, 60 minutes with patient when


53 minutes or more

DOCUMENTATION• Date of Service• Participants• Time spent in psychotherapy• Type of therapeutic intervention (i.e., insight oriented, supportive, etc.)• Documentation of therapist’s intervention• Target symptoms• Diagnoses• Progress toward treatment goals• Status of the patient’s condition(s)• Legible signature & authentication


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PSYCHOTHERAPY & E/M CODINGE/M codes are typically added to psychotherapy coding when a) either additional medical conditions are addressed; or b) the provider furnishes medication management related to the patient’s

behavioral health conditions.

Documentation must support the level of E/M service reported


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EHR: THE FRENEMY

PerksDocumentation EfficiencyDocumentation PromptsLegibilityInformation Repository

Pitfalls• Cloning• Automatic “pull through” documentation• “Click” statements or sections• Contradictory statements• Unreviewed/incomplete notes/garbled

statements (VRS errors)• Poor documentation• “Padded” notes• Lack of authentication • Medical necessity not supported


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YOUR EHR CAN BE YOUR BEST FRIEND OR YOUR WORST ENEMY

Depending on how you use it

January 2018HCMC for Oregon Nurses Association 31

DID THEY REALLY SAY THAT?• She has insomnia-she takes her temazepam at HS-she is gestating at least 5 hours at

night• On the second day the knee was better and on the third day it had completely

disappeared• The patient was in his usual state of good health until his airplane ran out of gas and

crashed• The patient was to have a bowel resection. However, he took a job as stockbroker

instead• Discharge status: Alive but without permission• The patient will need disposition, and therefore we will get Dr. Jones to dispose of

him• The patient expired on the floor uneventfully


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KNOWLEDGE CHECK:1 MORE TIME

• The three key components of E/M coding are history, exam, and medical decision making. Which of the three is most important to determining the code level?

• An E/M level can be determined either based on key components, or under some circumstances based on time. If I spend 20 minutes reviewing the patient’s records prior to the appointment, can I include that time towards time coding?

• What is the difference between the 1995 and 1997 exam guidelines?

• For behavioral health, can I bill a time-based E/M code in addition to psychotherapy for medication management?


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QUESTIONS


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REFERENCESCPTICD-10-CMCMS Claims Payment Manual 100-4CMS Evaluation & Management Documentation GuidelinesNoridian MedicareProcedure Coding Handbook for Psychiatrists, 4th EditionAPAAACAPCodeCorrect.comFindACode.comOptum


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THANK YOU FOR PARTICIPATING!Carol Wintermute, ACS-EM

HealthCare Management Consultants7070 SW 169th Ave

Beaverton OR 97007

Phone: 503-591-7264Fax: 503-848-4664

[email protected]


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