INTRODUCTIONTO CPT

PART THREE

Chapter 7

McGraw-Hill/Irwin Copyright © 2009 by The McGraw-Hill Companies, Inc. All rights reserved.

CPT: Evaluationand Management

Codes

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LEARNING OUTCOMESAfter studying this chapter, you should be able to:

1. Describe the organization of the CPT Evaluation and Management (E/M) section of CPT

2. Discuss the use of the section guidelines as a resource for E/M coding.3. List five questions that are used to select appropriate E/M code ranges

and assign correct codes.4. State the difference between new and established patients in CPT terms.5. Discuss the three key components that determine the level of service,

listing the four levels of each.6. Describe the process used to determine the level of service for E/M

coding, including the part played by the contributing components.7. Compare and contrast consultations and new patient (referral) E/M

services.8. Discuss the factors that are important in assigning critical care codes.9. Define observation and standby services.10. Assign CPT E/M codes, correctly applying the rules and exceptions for

each category of service.

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KEY TERMScategory

Chief complaint (CC)

Consultation

Consulting physician

Contributory components

Coordination of care

Counseling

Critical care

Direct care

E/M components

Established patient

Evaluation and management

(E/M) codes

Examination

Face-to-face time

Family history

History

History of present illness

Key components

Level of service (LOS)

Medical decision making (MDM)

New patient

1995 Documentation Guidelines

1996 Documentation Guidelines

Observation

Past history

Place of service (POS)

Presenting problem

Preventive medicine

Problem-oriented

Professional services

Referral

Referring physician

Review of systems

Roll-up rule

Social history

Standby

Time

Unit/floor/time

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CODE ORGANIZATIONE/M codes break down into categories and subcategories

Categories – examples are:• Office or outpatient services• Hospital observation services• Hospital Inpatient services

Subcategories – examples are:• New patient• Established patient• Discharge servicesSee table 7.1 for the complete listing

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SELECTION PROCESS

A standard set of questions used for determining the correct E/M code category:

1. Who is the patient?

2. What is the place of service?

3. What is the patient’s status?

4. What type of service is being provided?

5. What level of service is being provided?

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WHO IS THE PATIENT?Determine whether the patient is new or established based

on CPT E/M guidelines.

A new patient:• has not received any professional services from

the physician within three years.• has not received any professional services from

another physician of the same specialty in the same group practice within three years.

• May have received professional services from another physician in the same group who is in a different specialty within three years.

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WHO IS THE PATIENT?• An established patient:

– Has received professional services from the physician within the past three years

– Has received professional services from another physician of the same specialty in the same group practice within three years.

• Age categories– Neonate (birth to twenty-eight days)– Pediatric (twenty-nine days to twenty-four months)– Adult– Age ranges required for Preventive Medicine services

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WHAT IS THE PLACE OF SERVICE?

• Physician office• Hospital• Nursing facility• Outpatient clinic• Emergency department• Observation area of hospital

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WHAT TYPE OF SERVICEWHAT TYPE OF SERVICE?

Examples are:• Initial care for a first visit• Subsequent care for follow-up visits• Prolonged care• Standby services

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WHAT IS THE PATIENT’S STATUS?

Is the patient:• Ill or injured• Critically ill or injured• To be hospitalized• Presenting for preventive services• Under the care of an outside agency

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WHAT IS THE LEVEL OF SERVICEWHAT IS THE LEVEL OF SERVICE?

• Problem-focused (PF)• Expanded problem-focused (EPF)• Detailed (DET)• Comprehensive (COMP)

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CODE SELECTION EXAMPLEA fifty-six year old male patient who has never been seen

before by the physician has an office visit for left ankle pain caused by a fall.

• Who is the patient New, adult• What is the place of service Office• What is the patient’s status Injured, in pain• Type of service New, initial

Code range will be from 99201-99205New patient - office/outpatient category

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DETERMINE THE LEVEL OF SERVICE

E/M components:• History• Examination• Medical decision making• Counseling• Coordination of care• Nature of the presenting problem• Time

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KEY COMPONENTS

• The first three components in the list are the key components for selecting the level of service of E/M codes.– History, Examination, Medical decision making

• The next four components are considered contributory components.– Counseling, Coordination of care, Nature of the

presenting problem, Time

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DETERMINE HISTORY LEVELHistory is the information patients communicate to the

physician explaining their illness, injury and/or symptoms.

• This communication is in response to the physician’s questions.

• History is considered subjective.

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LEVELS OF HISTORY

• Problem-focused requires:– Chief complaint– Brief history of the present illness or problem

• Expanded problem-focused requires:– Chief complaint– Brief history of the present illness or problem– Problem-pertinent system review

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LEVELS OF HISTORYLEVELS OF HISTORY• Detailed requires:

– Chief complaint– Extended history of present illness or problem– Extended system review (more than just problem

pertinent)– Pertinent past history, family history and/or social

history directly related to the patient’s problem.

• Comprehensive requires:– Chief complaint– Extended history of present illness or problem– Review of all body systems– Complete past, family and social history (all three)

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DETERMINE EXAMINATION LEVELExamination describes the information a physician collects

from examining the patient.

• The examination is based on factual findings.

• Examination is considered objective.

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LEVELS OF EXAMINATION• Problem-focused requires:

– Limited exam of affected body area or organ system

• Expanded problem-focused requires:– Limited exam of affected body area or organ system

and other symptomatic or related organ systems

• Detailed requires:– Extended exam of affected body area or organ

system and other symptomatic or related organ systems

• Comprehensive requires:– General multisystem exam or complete examination

of a single organ system

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DETERMINE MEDICAL DECISION MAKING LEVEL

Medical decision making (MDM) is the process of establishing a diagnosis and determining treatment or management of the condition.

• Patients present to their physicians with symptoms.

• Physicians determine the diagnosis and treatment.

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DETERMINE MEDICAL DECISION MAKING LEVEL

Example• Patient presents with a three-day history of

redness in the left eye. There is no trauma or foreign body present. The patient complains of itching and discharge for the affected eye. There are no changes in vision.

• Once a history is taken and an examination is done the physician determines the diagnosis and how to treat or manage the diagnosis.

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DETERMINE MEDICAL DECISION MAKING LEVELDETERMINE MEDICAL DECISION MAKING

LEVEL

CPT departs from the range of problem-focused through comprehensive for MDM. The MDM levels are:

• Straightforward• Low complexity• Moderate complexity• High complexity

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DETERMINE MEDICAL DECISION MAKING LEVEL

Three measurements are used for the level of MDM

1. Number of diagnoses or management options

2. Amount of and/or complexity of medical records, tests, and other information (data).

3. The risk of complications, morbidity, and/or mortality (overall risk).

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LEVELS OF MEDICAL DECISION MAKING

• Straightforward1. Minimal diagnoses or management problems

2. Minimal or no data

3. Minimal risk

• Low complexity1. Limited diagnoses or management options

2. Limited data

3. Low risk

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LEVELS OF MEDICAL DECISION MAKING

• Moderate complexity1. Multiple diagnoses or management options

2. Moderate data

3. Moderate risk

• High complexity1. Extensive diagnoses or management options

2. Extensive data

3. High risk

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SELECTING THE LEVELS OF SERVICE

1. Identify the category and subcategory

2. Review guidelines

3. Review code descriptions

4. Determine history, exam, medical decision making

5. Select level

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LEVELS OF SERVICE REQUIREMENTS

• Know which codes require all 3 key components.• Know which codes require only 2 of the 3 key

components.• The lowest key component controls the level of

service.

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CONTRIBUTORY COMPONENTS

• Counseling• Coordination of care• Nature of the presenting problem• Time

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OFFICE OR OTHER OUTPATIENT SERVICES

• 99201-99205 • New patient• Three key components

For the purposes of E/M coding selection, the AMA has defined professional services as face-to-face services

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OFFICE OR OTHER OUTPATIENT SERVICES

• 99211-99215• Established patient • Two key components

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HOSPITAL OBSERVATION SERVICES

• 99217• Observation care discharge

The observation care discharge codes include final examination of the patient, discussion of the hospital stay, instructions for continuing care, and preparation of discharge records.

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HOSPITAL OBSERVATION SERVICES

• 99218-99220

• Initial observation care

• 3 key components

Hospital observation codes represent the E/M services provided to patients who are in observation status at the hospital but who have not gone through the hospital admission process.

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ROLL-UP RULE

• Multiple E/M services provided by the physician to the same patient on the same day are reported by one E/M code in most circumstances.

• A physician who treats a patient in the physician’s office and then sends the patient to the hospital for observation will report only the observation care codes.

• The office visit rolls up into the observation care.

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HOSPITAL INPATIENT SERVICES

• 99221-99223• Initial hospital care• Three key components

The initial hospital care codes are used to report the first hospital inpatient encounter by the admitting physician. Other physicians who treat the patient during their hospital stay will use either the consultation codes or subsequent hospital care codes.

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HOSPITAL INPATIENT SERVICES

• 99231-99233• Subsequent hospital care• 2 key components

The subsequent hospital care codes are used by the admitting physician after the first day of care. Other physicians treating the patient may also use these codes for their hospital visits.

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HOSPITAL INPATIENT SERVICES

• 99234-99236• Same-day admission and discharge• Three key components

These codes represent the services provided to patients who are in observation care or have been admitted to the hospital, and are discharged on the same date they were admitted.

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HOSPITAL INPATIENT SERVICES

• 99238-99239• Hospital discharge services• Time based

Hospital discharge services can be provided by either the attending or admitting physician on the date of discharge. The codes represent the total amount of time spent by the physician for the patient’s final discharge, whether the time is continuous or not.

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CONSULTATIONS

99241-99245• Office consultation • Three key components

99251-99255• Hospital consultation• Three key componentsConsultation codes represent the services of a physician

who has been asked by another physician or other appropriate source to give an opinion or advice on a patient.

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EMERGENCY DEPARTMENT (ED) SERVICES

• 99281-99285• Three key components

CPT specifically defines an emergency department as “an organized hospital-based facility for the provision of unscheduled episodic services to patients who present for immediate medical attention. The facility must be available 24 hours a day.”

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EMERGENCY DEPARTMENT (ED) SERVICES

• 99288• Physician direction of emergency medical

systems

This code represents the services of a physician located in the hospital emergency department or in the critical care department who is in two-way voice communication with ambulance or rescue personnel who are outside the hospital. The physician directs those personnel in providing medical procedures.

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CRITICAL CARE

Critical care is the provision of medical care to a critically ill or critically injured patient. Medical care qualifies as critical care only if both the illness or injury and the treatment being provided meet the critical care requirements. Critical illness or injury impairs one or more vital organ systems, causing a high probability of imminent or life-threatening deterioration in a patient’s condition.

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CRITICAL CARE

• 99289-99290• Pediatric critical care transport

• Time based

These codes represent the services of a physician who accompanies a critically ill or critically injured pediatric patient during interfacility transport and provides face-to-face services.

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CRITICAL CARE

• 99291-99292• Critical care services• Time based

These codes represent critical care services provided to patients beyond the pediatric age criterion of 24 months who are critically ill or critically injured. These codes are also used if outpatient critical care is provided to either pediatric or neonate patients.

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CRITICAL CARE TIME

Includes:• Patient care at bedside• Review of test results on unit or floor• Discussion of patient care• Documentation of critical care including patient’s

condition• Documentation of time

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CRITICAL CARE

• 99293-99294• Inpatient pediatric critical care• Per day codes• Patient is age 29 days through 24 months

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CRITICAL CARE

• 99295-99296• Inpatient neonatal critical care• Per day codes• Patient is 28 days of age or less

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CRITICAL CARE

• 99298-99300• Continuing intensive care• Per day codes

These codes represent services provided after the date of admission to patients that are not critically ill but continue to require intensive observation, frequent interventions and other intensive services.

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NURSING FACILITY SERVICES

• 99304-99306• Initial nursing facility care• Per day• Three key componentsThese codes are an exception to the roll-up rule. The

physician who discharges a patient from the hospital or from observation and then admits that same patient to the nursing facility is allowed to report both codes.

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NURSING FACILITY SERVICES

• 99307-99310• Subsequent nursing facility care• Per day• Two key components

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NURSING FACILITY SERVICES

• 99315-99316• Nursing facility discharge services• Time-based

• 99318• Annual nursing facility assessment• Three key components

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DOMICILIARY, REST HOME, CUSTODIAL SERVICES

99324-99328• New patient• Three key components99334-99337• Established patientTwo key componentsThese codes are for patients located in a facility that

provides room, board and other personal assistance, generally on a long term basis. The facility must provide a medical component to qualify for these codes.

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DOMICILIARY, REST HOME, HOME CARE PLAN OVERSIGHT SERVICES

• 99339-99340• Services are provided within a calendar month• Not face-to-face services• Time-based• Comparable to care plan oversight codes 99374-

99380

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HOME SERVICES

99341-99345• New patient• Three key components

99347-99350• Established patient• Two key components

Format for these codes is the same as 99201-99215

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PROLONGED SERVICES

• 99354-99357• Direct care (face-to face)• Add-on codes• Office/outpatient/inpatient setting• Time-basedThese codes represent services that go beyond typical

service in the office/outpatient/inpatient setting.

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PROLONGED SERVICES

• 99358-99359• Nondirect care (non face-to-face)• Add-on codes• Office/outpatient/inpatient setting• Time-based

These codes represent services that go beyond typical service in the office/outpatient/inpatient setting but are not face-to-face services.

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PHYSICIAN STANDBY SERVICES

• 99360• Require prolonged physician attendance• Time-based (each 30 minutes)

These codes represent services provided when a physician asks another physician to stand by during treatment of a patient in order to provide additional services that may be needed.

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CASE MANAGEMENT SERVICES

Anticoagulant Management• 99363-99364• Per days of therapyMedical Team Conferences• 99366-99368• Time-based

Case Management codes represent the services of a physician or non-physician qualified health care professional who is responsible for the direct care of a patient, and for coordinating, managing access to, initiating, and/or supervising other health care services for the patient.

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CARE PLAN OVERSIGHT SERVICES

• 99374-99380• Time-based• Patient not present

These codes represent the services that physicians provide to patients who are under the care of a home health agency, hospice, or a nursing facility.

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PREVENTIVE MEDICINE

• 99381-99387• New patient initial comprehensive preventive

service• Age-based• Include counselingThese codes represent the services provided to new

patients for assessment of their general health and to prevent illness or injury. The patient’s age determines the extent of the service provided.

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PREVENTIVE MEDICINE

• 99391-99397• Established patient comprehensive preventive

service• Age-based• Include counselingThese codes represent the services provided to established

patients for assessment of their general health and to prevent illness or injury. The patient’s age determines the extent of the service provided.

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PREVENTIVE MEDICINE

Counseling Risk Factor Reduction and Behavior Change Intervention

• 99401-99412• Preventive medicine individual counseling• Behavior change individual interventions• Preventive Medicine group counselingThe preventive medicine counseling codes relate to family

problems, diet, exercise, substance abuse, sexual practices, injury prevention, dental health, etc.

The behavior change interventions are for persons whose behavior is often considered an illness itself- tobacco use and addiction, substance abuse/misuse or obesity.

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NEWBORN CARE

Two codes for initial care of newborn• 99431 for child born in the hospitalThis code includes initiation of diagnostic and treatment

programs and preparation of hospital records.

• 99432 for child born in other than hospital or birthing room.

This code includes the physical examination of the baby and conferences with the parents.

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NEWBORN CARE

99433• Subsequent hospital care of normal newbornThis code is reported each day the physician provides care

to a newborn in the hospital.

99435• History and examination of normal newborn

assessed and discharged same dayIn addition to history and examination this code includes

preparation of medical records.

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NEWBORN CARE

• 99436• Attendance at delivery

This code represents the services of a pediatrician who has been asked to attend the delivery because the delivering physician anticipates a problem and wants immediate assistance if needed.

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NON FACE-TO-FACE PHYSICIAN SERVICES

Telephone Services• 99441-99443• Provided to established patient or established

patient’s guardian only• Must be initiated by patient or patient’s guardian• Note the time constraints related to previous and

subsequent E/M services

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NON FACE-TO-FACE PHYSICIAN SERVICES

On-Line Medical Evaluation• 99444• Provided to established patient, guardian or

health care provider• Note time constraints related to previous E/M

service.

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SPECIAL EVALUATION AND MANAGEMENT SERVICES

99450 -99499• These codes represent services provided to establish

baseline information before the issuance of life or disability insurance certificates.

• They are appropriate for any outpatient setting and for either new or established patients.

• No active management of the patient’s problems occurs during the encounter.

• 99455 is for the patient’s treating physician• 99456 is for the services of different physician

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MODIFIER 25

• For a service that is significant and separately identifiable from a procedure or another E/M service provided on the same date.

• All procedures include some E/M services• To append the modifier 25, the E/M service must

go beyond the procedural E/M services.

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NEWBORN CARE

• Newborn resuscitation• 99440This codes represents the services of a pediatrician who

has not attended the delivery but is called in after the delivery to provide assistance a newborn who is not breathing well or whose heart is not pumping correctly.