1

General E/M

Regan Tyler, CPC, CPC-H, CPMA, CEMC

Defining “Time” Within CPT®

On page xii of 2013 Professional Edition CPT®”

“Time is the face-to-face time with the patient” (unless otherwise specified)

“A unit of time is attained when the mid-point is passed”

Page xii2013 CPT

When a distinct procedure is performed during the time-based service (eg. CPR during critical care), the time spent performing the distinct procedure “should not be included in the time used for reporting the time-based service.”

“For continuous services that last beyond midnight, use the date the service began and report the total units of time”

For E&M services, time in the outpatient setting is defined as “face-to-face” opposed to “unit/floor time” in the inpatient setting (Pages 7-8 of 2013 CPT)

What Defines The Level of Evaluation and Management (E/M) Code?

History

Exam

Medical Decision Making

“KEY” Components

Page 5-102013 CPT

g

Nature of Presenting Problem

Counseling

Coordination of Care

Time

Contributory Factors

CPT clearly demonstrates number of “key components” required

2

History- Subjective

• Chief complaint – clear, concise statement detailing the reason the patient is presenting today, usually in the patient’s own words

− According to CMS, the CC may be combined with the HPI

• HPI (history of present illness)• ROS (review of system)• PFSH (past family social history)

History of Present Illness-HPI

• Location – where is it.  (pain in LLQ abdomen)

• Quality – how does is feel –(diffuse‐achy, tingling, numb etc.)

• Context ‐ what happen to cause it (fell while playing basketball twisting his knee)

• Modifying factors ‐ what did the 

• Severity – how bad is it  (0 – 10 for pain‐adults, 0‐3 kids)

• Duration – how long  (3 days)

• Timing – when does the symptom occur (worse after meals)

patient do in an attempt to alleviate their symptoms, and the result.  (took otc)

• Associated signs and symptoms –what else is bothering the patient.  (diarrhea & vomiting)

3

Brief HPI

Mr. Jones complains of a worsening sore throat for which he has been taking SudafedSudafed.

Mr. Jones complains of a worsening QUALITY sore throat LOCATION for which he has been taking Sudafed MODIFYING FACTORS

Brief HPI

Sally continues to show improvement over the past 2 months with her cholesterol on the current regiment of Lipitorthe current regiment of Lipitor.

Sally continues to show improvement QUALITY over the past 2 months DURATIONwith her cholesterol on the current regiment of Lipitor MODIFYING FACTORS

Extended HPI

Arnold returns today with worsening low backpain. He has been taking Advil every 4 hours, and the pain is rated a 7 out of 10.p

Arnold returns today with worsening QUALITYlow back LOCATION pain. He has been taking Advil MODIFYING FACTORS every 4 hours, and the pain is rated a 7 out of 10 SEVERITY.

4

Extended HPI

Patient returns with stable diabetes that he has had for the past 10 years for which he takes Glucophage. He finds that his sugar is most unstable just before bedtime

Patient returns with stable QUALITY diabetes that he has had for the past 10 years DURATION for which he takes Glucophage MODIFYING FACTORS. He finds that his sugar is most unstable just before bedtime TIMING.

Review of Systems-(ROS)• An inventory of the body systems of the patient to determine if the

patient is experiencing additional signs and/or symptoms

• Expand on remarkable symptoms

• A complete ROS (10+ systems) – Positive or pertinent negative responses must be individually documented with a statement that captures the remainder of the required review (e.g., remainder of 10 systems ROS are reviewed and negative”). In the absence of such a notation, at least ten systems must be individually documented.

Review of Systems

• Constitutional

• Eyes

• Ears, Nose, Mouth, Throat

• Musculoskeletal

• Integumentary

• Neurological

P hi iThroat

• Cardiovascular

• Respiratory

• Gastrointestinal

• Genitourinary

• Psychiatric

• Endocrine

• Hematologic/Lymphatic

• Allergic/Immunologic

5

Review of Systems - ROS• Complete – inquires about the system(s) directly

related to the problem(s) identified in the HPI plus all additional body systems.

DG: At least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented.

**For the remaining systems, a notation indicating all other systems are negative is permissible (or something to this effect suggesting 10+ total). In the absence of such a notation, at least ten systems must be individually documented.

Past, Family, Social History

• Past− Current medications− Past surgeries− Past illnesses/injuries

• Family − Review of medical events in the patient’s

family, including diseases which may be hereditary or place the patient at risk

• Social − Age appropriate review of past and current

activities

Past, Family, SocialHistory (PFSH)

• Complete PFSH – is of a review of two or all three of the PFSH history areas, depending on E&M category

PFSH = 3/3 PFSH = 2/3

•Office – new patient

•Initial Inpatient

•Initial outpatient

•Domiciliary – new

•Home care – new

•Office established patient

•Inpatient subsequent

•Emergency Department

•Domiciliary – established

•Home care – established

6

History Auditing Reminders

• CC, ROS and PFSH may be listed as separate elements of history or included in documentation of the HPI

• Provider can use and get credit for history elements (not HPI) obtained at another visit as long as it is relevant and referenced− “Remainder of ROS and PFSH unchanged since 11/26/2012”f g

• ROS and/or PFSH may be recorded by ancillary staff or patient as long as the provider documents confirmation of the information

• TIP:− If unable to obtain a history from the patient or other source,

document the patient’s condition that precludes getting it and you can be credited for a comprehensive level of history.

1995 & 1997 Documentation Guidelines

The documentation of each patient encounter should include:

• Reason for the encounter and relevant history, physical examination findings and prior diagnostic physical examination findings and prior diagnostic test results;

• Assessment, clinical impression or diagnosis;

• Plan of care; and

• Date and legible identity of the observer.

7

Examinations- Objective

• 1995 guidelines− Count the number of systems/areas− Single system exams are not well-

defined…

• 1997 guidelines− Count the number of “elements” or

“bullets” performed− Single system exams are defined− Harder to meet without

templates/macros

Examination Documentation Reminders• A notation of “abnormal” without elaboration is insufficient

documentation.

• Unlike history, portions of examination can not be ‘deferred’

• A brief statement/notation indicating negative or normal findings is sufficient .

Pages 92013 CPT

• Normal or negative findings must be listed by body area or organ system.

• Page 9 of 2013 CPT states the only difference between an Expanded Problem Focused examination and a Detailed examination is that one is “limited” and the other is “extended”− You will need to determine which guidelines suit your providers

best and consider local carrier instruction

Problem

E d d

1995 - Body Areas 1997 -Elements

1 1 - 5

2 7 6 11

Multi - Sys Single - Sys

1 - 5

6 - 11

Determining Level of Physical Examination

Body Areas / Organ Systems

Expanded

Detailed

Comprehensive

2 - 7

2– 7 *with 1 detailed

8 + organ systems

6 - 11

12 - 17

18 / 9

6 - 11

12 +

All Shaded +1 Unshaded

Eye/Psych = 9

8

Let’s Apply 1995 Concepts

PHYSICAL EXAMINATION:

VITAL SIGNS: Stable, afebrile.GENERAL: Awake alert and oriented x3GENERAL: Awake, alert and oriented x3.CARDIOVASCULAR: Regular rate and rhythm.LUNGS: Clear to auscultation.ABDOMEN: Soft, minimal amount of tenderness right upper quadrant, no guarding, no rebound, no acute abdomen, stool in vault, no hepatosplenomegaly.

PHYSICAL EXAMINATION:VITAL SIGNS: Blood pressure 170/75, pulse 96, respirations 16, O2 saturation 97% on room air. Afebrile.GENERAL: Patient is alert and oriented to person, place and time. Is resting comfortably in bed in no acute distress.HEENT: Atraumatic, normocephalic. Pupils equal, round and reactive to light and accommodation. Extraocular movements are intact. Oropharynx is clear and moist. No exudate present.NECK: Supple. No lymphadenopathy.CARDIOVASCULAR: Regular rate and rhythm. Grade 2/6 systolic CARDIOVASCULAR: Regular rate and rhythm. Grade 2/6 systolic murmur. No rubs or gallops.LUNGS: Clear to auscultation bilaterally. No wheezes, crackles or rhonchi.ABDOMEN: Positive bowel sounds. Appropriately tender to palpation in right upper quadrant. Nondistended.GENITOURINARY: External genitalia with normal appearance. Bimanual exam is within normal limits with no palpable masses.EXTREMITIES: No erythema, no edema. No calf tenderness.

PHYSICAL EXAMINATION:GENERAL: Resting comfortably in no apparent distress.VITAL SIGNS: Temperature 99.2, pulse 190, respirations 65, blood pressure 124/76, weight 6.043 kilograms.HEENT: Normocephalic, atraumatic, pupils equal, round, reactive to light, extraocular muscles intact. Mucous membranes moist and pink.NECK: Is supple with no adenopathy. Trachea is midline.CARDIOVASCULAR: Regular rate and rhythm No murmursCARDIOVASCULAR: Regular rate and rhythm. No murmurs.LUNGS: Are clear to auscultation bilaterally.ABDOMEN: Soft, nontender, nondistended. Bowel sounds present.EXTREMITIES: Left lower extremity with erythema from the dorsum of the foot up to just above the left knee with edema and increased temperature. It does appear to be painful to touch. No obvious deformities. Range of motion is intact. There does seem to be pain with motion

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PHYSICAL EXAMINATION: This was a young male who was currently intubated and sedated on the vent.VITAL SIGNS: At time of examination, showed a pulse of 110, respiratory rate of 22, blood pressure 195/102.HEENT: The patient has a craniotomy scar on the left side.CARDIOVASCULAR: S1, S2, regular normal intensity, no rubs or murmur appreciated.RESPIRATORY: The patient has moderate rhonchi and creps anteriorly, no wheeze auscultated.GASTROINTESTINAL: Nondistended, bowel sounds positive.NEUROLOGIC: The patient was sedated.EXTREMITIES: SCDs. (Sequential compression device)

PHYSICAL EXAMINATION:VITAL SIGNS: Blood pressure is 130/80, heart rate is 82, respiratory rate 16, temperature 98. Saturating 98% on two liter of oxygen.GENERAL: Patient is alert, oriented x3, in no acute distress. He appears somewhat drowsy. He is laying down in 30 degree head-up position in no respiratory distress.HEENT: Positive PERRLA. Sclerae nonicteric. Conjunctiva pink. Oral mucosa moist and I could not evaluate the JVD due to patient's thick neck and large body habitus. No carotid bruits could be appreciated. Thyroid within normal limits.NECK: Supple.CARDIOVASCULAR: Regular rate and rhythm, normal S1-S2. No murmur or gallops could be appreciated.LUNGS: Clear to auscultation bilaterally. No crackles, wheezings, rhonchi was appreciated.ABDOMEN: Normoactive bowel sounds, nondistended, nontender. No organomegaly.EXTREMITIES: Less than 1+ pitting edema in both lower extremities. No clubbing or cyanosis. Has good distal pulses in all four extremities.INTEGUMENTARY: Intact, no rash.NEUROLOGIC: Grossly intact with no focal, sensory, or motor deficits.

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Key Components

• Medical Decision Making− Number of diagnosis or management

A t d/ l it f d t− Amount and/or complexity of data− Risk of complication

MEDICAL DECISION MAKINGBOX A: Number Of Diagnosis or Management Options (N x P = R)Problems Number Points ResultsSelf-limited or minor (stable, improved or worsening) Max = 2 1Est. problem: stable or improved 1p pEst problem: worsening, failing to change 2New problem: no additional work-up planned Max = 1 3New problem: additional work-up planned 4Bring to line A in Final Result for MDM Total

Number of Diagnosis / Problems

Impression:

Shortness of breath

Hypertension

Patient is scheduled for pulmonary consult and started on fast acting albuterol inhaler. F/U after consult.

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MEDICAL DECISION MAKINGBOX B: Amount and/or Complexity of Data to be reviewed PointsReview and/or order of clinical lab test 1Review and/or order of tests in the radiology section of CPT 1Review and/or order of tests in the medicine section of CPT 1Discussion of test results with performing physician 1Decision to obtain old records and/or obtaining history from someone other than patient 1someone other than patientReview and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider 2Independent visualization, tracing or specimen itself (not simply review of report) 2

Bring to line B in Final Result for MDM Total

In order to get credit, the provider must document review & summaryYou do not get 2 points if billing the professional component (-26)

Amount of Data

Chest Pain

Diabetes

Chest X-Ray in the office today was normal. Patient scheduled for 24-hour Holter monitor. Also ordered fasting A1C as patient is overdue.

BOX C: Risk of Complication and/or Morbidity or MortalityPresenting Problems Diagnostic Procedures ordered Management Options Selected

Mini

mal • 1 self-limited or minor problem

(eg. Cold, insect bite, tinea corporis

• Lab tests requiring venipuncture• EKG/EEG• Urinalysis• Ultrasound, X-RAYS• KOH prep

• Rest• Gargles• Elastic bandages• Superficial dressings

Low

• 2 or more self-limited or minor problems

• 1 stable chronic illness • Acute uncomplicated illness or

injury

• Physiologic test not under stress• Non-cardiovascular imaging• Superficial needle biopsies• Clinical lab test requiring arterial puncture• Skin biopsies

• Over-the-counter drugs• Minor surgery w/ no identified risk

factors• Physical therapy• Occupational therapy• IV fluids without additives

ate

• 1 or more chronic illnesses w/mild exacerbation, progression or side effects of treatment

• 2 or more stable chronic illnesses

• Physiologic test under stress• Diagnostic endoscopies w/no identified risk

factors• Deep needle or incisional biopsy

• Minor surgery with identified risk factors

• Elective major surgery w/o risk (open, percutaneous, or

Mode

ra

• Undiagnosed new problem w/ uncertain prognosis

• Acute illness with systemic symptoms

• Acute complicated injury

p p y• Cardiovascular imaging studies w/contrast,

no identified risk factors• Obtain fluid from body cavity

( p , p ,endoscopic)

• Prescription drug management• Therapeutic nuclear medicine• IV fluids with additives• Closed treatment of fracture or

dislocation w/o manipulation

High

• 1 or more chronic illnesses w/ severe exacerbation, progression, side effects of treatment

• Acute or chronic illnesses or injuries that pose a threat to life or bodily function

• Abrupt change in neurologic status

• Cardiovascular imaging studies w/contrast w/ identified risk factors

• Cardiac eletrophysiological tests• Diagnostic endoscopies w/indentified risk

factors• Discography

• Elective major surgery (open, percutaneous or endoscopic) w/risk

• Emergency major surgery (open, percutaneous or endoscopic)

• Parenteral controlled substances• Drug therapy requiring intensive

monitoring for toxicity• Decision not to resuscitate or to de-

escalate care because of poor prognosis

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Risk

Patient presents today with hypertension, diabetes and hyperthyroidism. Patient appears stable on current regimen and no appears stable on current regimen and no changes are required at this time.

MEDICAL DECISION MAKINGBOX D: Final Result for Complexity of Medical Decision Making: 2 of 3 requiredA Number of diagnoses or

management options≤ 1

Minimal2

Limited3

Multiple≥ 4

Extensive

B Amount and complexity ofdata to be reviewed

≤ 1Minimal

2Limited

3Multiple

≥ 4Extensive

C Risk of complications and/orC Risk of complications and/ormorbidity or mortality Minimal Low Moderate High

TYPE OF DECISION MAKING StraightForward

LowComplexity

ModerateComplexity

HighComplexity

Medical Decision Making

Inguinal Hernia

New Problem, no work up

Diabetes

N t dd dNot addressed

Hypertension

Not addressed

Robert presented today with acute abdominal pain. The ultrasound reveals a rather large inguinal hernia that will need surgical intervention. We will

schedule him with a general surgeon first thing in the morning.

Review/order ultrasound

Major surgery without complications

13

Medical Decision Making

Sore throat

Established Problem, worsening

Cough

N P bl k l dNew Problem, no work up planned

Patient returns with continued sore throat. Rapid Strep test done in the office is negative. New productive cough complicating sore throat. Patient given prescription for Tusslon pearls 250mg, every 4 hours for the next 24. Will call if symptoms do not improve.

Order/review lab test

Prescription Drug Management

Chief Complaint must be documented.

ProblemFocused

Exp. ProblemFocused Detailed Comprehensive Comprehensive

HPI 1-3 1-3 4+ 4+ 4+

ROS None 1 2-910+ or

“All others negative”

10+ or“All others negative”

PFSH None None 1 3 3

Examination

1 2-7 2-7w/ 1 in Detail

8+Organ

Systems

8+Organ

SystemsDetail SystemsOnly

SystemsOnly

MDMStraightForward

Straight Forward

Low Moderate High

992019924199251

992029924299252

9920399243992539922199234

99204 99244992549922299235

99205 99245992559922399236

Established Patient– Office or OutpatientOnly need 2 out of 3 Key elements in a column to support the code at the bottom.

HPI 1-3 1-3 4+ 4+

ROS None 1 2-9 10+ or“All others negative”

PFSH None None 1 2

E i ti 1 2 7 2 7 8+Examination 1Area or

Organ system

2-7Areas &/or

Organ systems

2-7Areas &/or

Organ Systems1- Detail

8+Organ

SystemsOnly

Medical Decision Making:

StraightForward

Low Moderate High

Office Est. pt. 99212 99213 99214 99215

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New Versus Established Patients

A new patient is one who has not received any face to face professional service from the physician/qualified healthcare professional

oranother physician/qualified healthcare professional of the exact same specialty/subspecialty who belongs to the same group practice within the past three years (Check

Pages 4-52013 CPT

same group practice within the past three years (Check taxonomy codes if unsure)

Medicare regulation states: "Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician."

Refer to the CPT “Decision Tree” on page 5 of 2013 CPT Professional

Important E&M Terminology• Concurrent Care

− The provision of similar services (e.g., hospital visits) to the same patient by multiple providers on the same date

• Transfer of Care− The process whereby a provider managing a patient “relinquishes” the

ibilit t th id d th t id li itl t

Page 52013 CPT

responsibility to another provider and that provider explicitly agrees to accept responsibility

• Consultation− A “request” by one provider for another provider to offer an opinion

and/or advice regarding the management of the patient… “The 3 R’s”

• Time− Inpatient- Unit/floor time− Outpatient- Face-to-face time

Office and Other Outpatient Services

• 99201-99205

− New patient visits− Require all 3 “key” components− Remember new patients have not received

professional services within previous three (3) years

99211 99215

Pages 11-132013 CPT

• 99211-99215

− Established patient visits− Require 2 of the 3 “key” components

• 99211 is a level of E&M service that typically does not require the presence of a physician

• Tip: Highlight the time frames and number of “key” components required for each of the codes in this section

15

CPT Code 99211

Typical nurse visits include, patient education, injections, infusions, problem focused evaluations and specimen collection.

Per CPT, “Usually, the presenting problem(s) are minimal. Typically,

five minutes are spent performing or supervising these services.”

G l R i t

Page 122013 CPT

General Requirements ◦ Non – Physician must be: ◦ Employee or contractor for physician

Follow physician orders resulting from his/her evaluation of the patient Be supervised by a physician

• “Because medical necessity is required, vital signs and blood pressure

checks may not be routinely performed at the time of another coded

service in order to bill for a 99211 visit” (e.g., injections, INRs, etc.)

Observation ServicesCPT® Codes 99217-99220 & 99224-99226

• Reserved for patients designated/admitted as “observation status” in the hospital− Observation is a “status”, not a physical location

• There are three “levels” for initial observation− 99218-99220

• New in 2012: Times are now associated with these codes (30min/50min/70min thresholds)

Pages 13-152013 CPT

• Use “unit/floor time” concept

• There are three NEW “levels” for subsequent observation− #99224-99226 (resequenced)

− 30min/50min/70min thresholds

• There is one code to report observation discharge− 99217

Hospital Inpatient Services• 99221-99223 for initial hospital care (“admits”)

− Defined as the “first hospital inpatient encounter by the admitting physician”

• 99231-99233 for inpatient rounds− “Clustering” levels of E/M for subsequent hospital visits can be an audit target

(CMS 10/00)

Pages 15-172013 CPT

• 99238, 99239 for inpatient discharges− You MUST document “>30 minutes” to support 99239

• 99234-99236 for same day admit/discharge− Same codes as observation but require POS 21

16

Consultation Services99241-99255§15506 MEDICARE MANUAL (CMS PUB 14-3)

• The request for consultation must be in writing

• Therapeutic or diagnostic services may be provided during the course of a consultation

• A written report to the requesting physician must be provided (outpatient setting only-‘ h d d ’)

Pages 18-212013 CPT

‘shared records’)

• The requesting physician’s NPI goes in box 17b of the CMS 1500 claim form

• Referrals are NOT to be coded as consultations

• CMS placed moratorium on consultation services (1-1-2010)

• The 3 R’s (Request, Render, Respond)

Emergency Department Services99281-99285

• Only covered for patients registered in the ED of a hospital-based facility (POS 23).

• Any physician that provides services in the ED– Do not report ED code if called in to “consult”

• Not required to be an emergency service

Pages 21-222013 CPT

Not required to be an emergency service

• No distinction between new or established patients

• Includes History, Exam, and Decision Making (all 3 required)

• No typical time associated with these codes

Critical Care Services99291-99292

Critical care: The direct delivery by a physician(s) of medical care for a critically ill or critically injured patient.

– A critical illness or injury is defined in 2013 CPT® Professional (page 23) as one that “acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration

Pages 23-25 2013 CPT

probability of imminent or life threatening deterioration in the patient’s condition”– i.e. CNS failure, circulatory failure, shock, renal failure,

etc.

– Time must be documented (suggested to use clock time)

– Time does not need to continuous (may be cumulative per day)

– For inpatients 0 days through 5yrs, refer to per diem codes 99468-99476 (Neonatal versus Pediatric)

17

Critical Care Services99291-99292

• Critical care may be provided on multiple days even without a change in treatment as long as the patient’s condition continues to require a high complexity decision making.

• For any given period of time spent providing critical care services, the physician must devote his or her full attention to the patient, and therefore, cannot provide services to any other patient during the same period of time.

• See guidelines on pages 23-24 of CPT 2013 Professional

− Same specialty providers are not permitted to report critical care on same date

− Distinct providers (and diagnoses) are permitted to report critical care

− When one MD reports “per diem” code, others must refer to 99291-25

Incident to

• Follow established patient’s on plan of care already established by physician

• Cannot see new patients and bill incident to (report under own ID)

• Cannot see established patients for a NEW problem (report under own ID)

Split / Shared Visits

• Patient is seen by both NPP and MD possibly at different times

• Each provider documents their encounter

• Physician can use NPP’s documentation towards their total encounter level

18

Split / Shared Visits

EXAMPLES OF SHARED VISITS

• 1. If the NPP sees a hospital inpatient in the morning and the physician follows with a later face-to-face visit with the patient on the same day, the physician or the NPP may report the on the same day, the physician or the NPP may report the service.

• 2. In an office setting the NPP performs a portion of an E/M encounter and the physician completes the E/M service. If the "incident to" requirements are met, the physician reports the service. If the “incident to” requirements are not met, the service must be reported using the NPP’s UPIN/PIN.

PATH Guidelines

• Resident documentation

• Attending documentation− Attestation statement examples− Time based codes (only attending time)− Surgical procedures

• Modifier 82 when resident not available/qualified

Facts Related to Modifier -25

The following statements are false:− I can always use this modifier for a new patient. − I can always use this modifier when I did not plan the

procedure. − I can always use this modifier when the diagnoses are

different. − I can never use this modifier when the diagnoses are the same.

Appropriate Usage:• “Modifier 25 indicates that on the day of a procedure, the

patient's condition required a significant, separately identifiable E/M service, above and beyond the usual pre and post-operative care associated with the procedure or service performed”

Source: WPS Medicare

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E/M Modifiers

Modifier 24: Unrelated E/M during global

Modifier 25: E/M with minor procedure

Modifier 32: Mandated Service

Modifier 57: E/M with major procedure

Regan Tyler, CPC, CPC‐H, CPMA, CEMC, ACS‐EMrtyler@drsmgmt.com