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Evaluation and Management Portfolio Project

By Krista Romero

MRCP240/Ms. Norman

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Evaluation and Management Categories

The first category in the Evaluation and Management Section of our Current Procedural Terminology manual (CPT) is the Office and Other Outpatient Services with 2 subcategories for New Patient and Established patient. A new patient is one that has never been seen by the provider or anyone in their specialty group in the last three years or the established patient who has been to see this primary care provider before. These services are done in an outpatient setting such as your providers office. Example; Office Visit for Establish 27-year-old patient with stable depression and anxiety. Expanded problem focused history and exam and medical decision making was low; code 99213 established patient

Hospital Observation Service codes are used when a patient needs further observation to determine if he/she needs to be admitted for further care or the patient gets better and is discharged, this can usually be determined in 24 to 48 hours. There is 3 subcategories in this section; observation Care discharge services, Initial Observation care, Subsequent observation Care. Example; A patient presenting in the emergency room with chest pains, attending physician decides the patient needs to be monitored to further evaluate the condition, a Comprehensive history and exam were completed, and medical decision making was moderate, Code 99219 initial observation care.

Hospital Inpatient Services are used for reporting service done in an inpatient setting such as an acute care hospital. This category has 4 subcategories; Initial Hospital care is used for the first hospital encounter, subsequent hospital care is used for any changes in the patient status or condition, observation or inpatient services is used when a patient is admitted and discharged on the same day, hospital discharge services is used for the final exam and discharge of an inpatient. Example; The attending physician comes in to the patient rooms on day two to explain some test result for the EKG and explain the next plan of care. Expanded problem focus and exam was done, you would code 99232 subsequent hospital care.

Consultation services codes are used when another physician request and evaluation and management of a patient current condition or problem or a transfer of care from one physician to another. The consultation code has 2 subcategories; office or other outpatient consultation which happens in an outpatient setting such as your primary doctors office. The second is Inpatient consultation which happens in an acute care hospital or nursing home facilities. Example; A patient is admitted to hospital to get control of her diabetes and to evaluate possible gangrene in her left foot. Her physician orders an inpatient consultation with an orthopedic surgeon. The surgeon did a detailed history and exam and decision making was low; code 99253 for inpatient consultation.

Emergency Department Services codes when a patient is presenting to the emergency room with a immediate need for medical services. There is only 1 subcategory New or Established patient. There is no distinction between new or established patients in the Emergency room service codes. Example; 4-year-old patient presented to emergency

room with possible broken arm, ED physician request x-rays and performs a problem focus history and exam and medical decision making was straightforward, you would code 99281 for emergency room visit.

Critical Care Service codes are used for the direct medical care by a physician to a critically ill or injured patient. Critical illness or injury is one that impairs one or more vital organ system and without treatment would result in death. Critical care service codes are assigned by the total time spent engaged in worked directly related to the patients care. Example; Patient presented to ED in respiratory failure, ED physician provided 70 minutes of critical care service to patient, you would code 99291 for critical evaluation and management.

Nursing Facilities Services are codes used to report the evaluation and management services to patient that are admitted into long term nursing facilities, skilled nursing facilities, psychiatric facilities. There are 2 subcategories for this section New/Establish patients which is used for the initial admitting encounter, and subsequent nursing facility care which is used for reviewing medical records, going over test results, or a change in patients’ status or condition. Example; Initial evaluation and management of 75-year-old man who was admitted into the hospital with broken hip, full hip replacement done and is now going to skilled nursing facility. Physician at the skilled nursing facility does a comprehensive history and exam and medical decision making was moderate, code the initial evaluation and management for skilled nursing new patient 99327.

Domiciliary, Rest Home, or Custodial Care services codes are used for the evaluation and management services provided on a long-term basis such as Assisted living facilities. There are two subcategories in this section; New patient which means this patient has not received care from this provider in the last 3 years, and established patient is one that has received care in the last 3 years from this physician or one in the same specialty group. Example; physician provides evaluation and management to new resident of XYZ skilled nursing home. Patient is admitted with uncontrolled hypertension and diabetes. Comprehensive exam and history were performed, and medical decision making was moderate. Code 99327 for rest Home visit new patient.

Home Service Codes are used to report the evaluation and management of care to patients in there home. There are 2 subcategories in this section; New patient for the initial first encounter for a first-time patient and Establish patient visits for patient at home who have seen the provider in there home before. Example; 52-year-old established patient receives care in her home by her physician for follow up on blood pressure medication, physician completes a problem focus exam and history, you would code 99347 for establish home visit.

Prolonged Services codes are used when an unusually amount of time is spent beyond the normal Evaluation and Management service time. These codes are reported in addition to the evaluation and management service codes in an inpatient or outpatient setting. There are 4 subcategories in this section; prolonged services with direct patient

contact which means the total time spent in direct contact with the patient, Prolonged services without direct contact with the patient which means time spent reviewing an extensive record and was related to services provided during a direct patient encounter, prolonged clinical staff service with physician or other qualified health care professional supervision these codes are used when a nurse practitioner completes the evaluation and management and the teaching physician reviews it, standby services are coded when another physician request a specialty doctor to stand by in case their services are needed. Example; A physician provided level 3 office visit services for acutely ill established patient who was treated for an asthma attack with intermitted bronchial dilation and subcutaneous epinephrine. The physician provided intermittent direct service over a period of 65 minutes, report code 99213 and 99354 (AMA 2018).

Case Management Services is a process in which a physician or another qualified health care professional is responsible for the direct care of a patient, and for coordinating and managing access to, initiating, and/or supervising other health care services needed by the patient (Green 2016). There are two subcategories direct face to face contact with patient, and without direct face to face contact with the patient. Example; The physician participated in a team conference regarding the plan of care for a behavioral disturbed 35-year-old male patient, code 99367.

Care Plan Oversight Service is used when a physician is supervising a complex and extensive treatment program for patients in an inpatient setting such as a nursing home. Example; physician reviews and revises a treatment plan for chemotherapy patient totally time spent is 20 minutes 99377.

Preventative Medicine Services codes are used to report annual exams for preventive care. These codes are assigned by age of patient. There are two subcategories in this section; New patients and Established patient. Example; A new patient that is a 5-year-old boy receives preventive medicine services during his routine checkup, code 99383

Non-Face to Face service codes are used to report evaluation and management services to patients that are not in direct contact with the patient. There are 3 subcategories in this section; telephone services are used when the physician contacts patient over the phone, online medical evaluations which are used when a patient submits a survey online, interprofessional telephone/internet consultations is used when the physician request a second consultation with another qualified health care provider. Example; Physician calls established patient to review lab results and revise current medication total duration of the call was 15 minutes, code 99442.

Special Evaluation and Management Services codes are used to establish a baseline of health prior to life or disability insurance certificate being issued (AMA 2018). There are two subcategories in this section one for Basic life or a Disability evaluation Service and Work related or medical disability evaluation service. Example; A 27-year-old male is

seen after a work-related injury to determine if his injuries were work related, report code 99456 work related medical examination.

Newborn Care Services are used to report service provided to newborns during the initial evaluation right after birth until discharge of the newborn. Example; Patient was admitted after water broke which resulted in the birth of health baby boy, physician completes the initial exam to the newborn and patient and baby were discharged the next day, report code 99460

Delivery/Birthing room Attendance and Resuscitation Services code are reported with newborn care services. Example; The delivery room physician requested a pediatrician be present during delivery for stabilization of newborn, report code 99464

Inpatient Neonatal Intensive Care Services and Pediatric and Neonatal Critical Care Service codes are used to report when a service is needed for a critical ill or injured newborn (up to 28 days) or Infant (young child up to 1 year of age). Codes from this section can be used during transport of critical ill or injured infant with direct supervision of physician (meaning physician goes with infant on the ride) and with two-way radio contact during transport meaning physician is in constant contact with a two-way radio while newborn is being transported. These codes are chosen by time spent giving critical care service to the patient. Example; a critical ill newborn is being transferred to a bigger hospital, attending physician provides critical care to infant during the 55-minute ride to a children’s specialty hospital, report code 99466 for the care during transport.

Common CPT Modifiers

The CPT modifiers are 2-digit codes that are added to a five-digit CPT code. These 2 digits are called Modifiers. Modifiers are used to further clarify a service that was performed, but it does not change the meaning of the description of the CPT code. Modifiers are used to indicate that a service or procedure was altered. Modifiers are very important to the reimbursement process. These modifiers let the payer know there was a part of the procedure that may have been altered or removed. The Evaluation and Management Section has some common modifiers that I will explain the function and give an example.

Modifier -24 is used when the patient has received an E/M service for an unrelated condition during a post-operative period. This modifier has to do with the global packages. When a patient has a surgery there are services that are bundled together with the CPT surgery code, E/M services is just one of the services that are bundled into a code for the pre and post-operative period. This modifier is used when a patient is seen by the same provider during that global package period for an unrelated E/M service. For example; A patient has surgery for the removal of pins, a week after

surgery the patient is back in the providers office for a level 3 E/M services for treatment of the FLU. Report Code 99213-24

Modifier -25 is appended to the procedure code when a significantly identifiable evaluation and management service by the same provider on the same day as the procedure. For example; A patient visits his cardiologist for an appointment and is complaining of chest pains during exercise. After the physician completes the office visit, he determined that the patient needs a cardiovascular stress test that he will perform today. Report code 99214-24 for the office visit, 93015 for the cardiovascular stress.

Modifier 26 is a professional component modifier. This modifier is used when this a physician needs to remove the professional component. For example, if a patient was seen for X ray of his chest and the facilities does not have a physician to read the x-ray for a diagnosis, the facility would append a modifier 26 to let the payer know that they only completed the technical component.

Modifier 32 is a mandated Service modifier. This modifier is when a service or consultation is request by your insurance company, government agency. This modifier would be appended to the procedure or consultation code that was request. Just one little note that if a family member or patient request the consultation or procedure you would not append modifier 32. For example, A third party payer may require a second opinion before they will pay for a surgery, Orthopedist A has determined a patient needs an Arthroscopic SLAP repair (29807), before the carrier approves the surgery, it requires orthopedist N to conduct a physical examination of the patient (99243). That visit would be appended with modifier 32 (99243-32).

Modifier 33 preventative services. This code should be appended to codes representing the preventive service unless the service is inherently preventive. For example, a patient is wanted to take preventive measure you would append modifier 33 to the procedure code.

Modifier 50 Bilateral Procedure. Modifier 50 would be used when the patient is undergoing the exact same surgery but in different locations. Modifier 50 can be used for eyes, shoulders joints, or breast. A patient is having cataract surgery on one eye, but he has cataracts in both side. You would append the 50 modifiers to the procedure code to indicate that at the time of surgery 1 patient had cataracts in both eyes.

Modifier 52 Reduced Services. This code is appended when the patients surgery or procedure is canceled due unforeseen circumstance. For example; a patient is prepped and ready for surgery and the anesthesiologist has done his job and the patient blood pressure drops and is unstable for surgery. Modifier 52 would be appended to the special circumstance code to indicate that the procedure was terminated due to the drop-in blood pressure.

Modifier 55 Postoperative Management only. This code is used when 1 physician or other qualified health care professional performed the postoperative management and a 2 physician or other qualified health care professional performed the surgical procedure (AMA 2018). This modifier is indicating that the postoperative management component of this procedure was done by another qualified health care professional.

Modifier 56 Preoperative Management only is when 1 physician or other qualified health professional performed the preoperative care and evaluation, and another performed the surgical procedures (AMA 2018). What this means is that one physician will be completing your surgical procedure and then a second physician will come in and manage your preoperative care and evaluation.

3 Key Factors and 4 Contributory Factors

When looking to choose a level of service or assign an Evaluation and Management code you must first look at the 3 key factors which are History, Examination, and Medical Decision making. These are the three main part that you must investigate when you assign an E/M service Code.

The extent of history has 4 elements to consider, Chief Complaint (CC) which is what the patient tells the physician he is here for, History of Present Illness (HPI) which is a summary of when the condition started and what was going when and where it hurts, Review of System (ROS) is the questions the doctors may ask about other parts of the body, Past Social family history (PSFH) which is a summary of your past medical illness such as surgeries, anything that has to do with you past families medical history for example, dad has history of hypertension, social history is age appropriate past and current activities for example patient smokes two packs of cigarettes and drinks socially.

To determine the extent of Examination the physician will do a physical examination of the patients’ organs and body systems. When reviewing the patients chart you must decide whether a single organ examination or a general multisystem examination was completed.

To determine the complexity of Medical Decision making you must take note of the amount of data that may need to be reviewed in order to establish a diagnosis. This can be measured by the number of diagnosis, the complexity of data to be reviewed and the risk of complication or mortality.

The four Contributory factors that would be considered when selecting a level of service are counseling, coordination of care, nature of presenting problem, and time will also be considered when the focus of the encounter were one of the 4 contributory factors.

Case Study Analysis

History Case Study 1 ProblemFocused

ExpandedProblemFocused

Detailed Comprehensive

Chief Complaint□ Absentx Present

Required Required Required Required

History of Present Illnessx Locationx Duration□ ContextX Quality□ Severity□ Modifying Factors□ Timing□ Associated Signs & Symptoms

1-3 Elements

1-3 Elements

> 3 Elements > 3 Elements

Review of Systems (ROS)□ Constitutional Eyes□ ENT□ Respiratory□ Cardiovascular□ GI□ GU□ Musculoskeletal□ Skin□ Neurological□ Endocrinology□ Hematology/Lymphatic□ Immunologic/Allergy□ Psych

None 1 system 2-9 systems Minimum 10 systems

Past/Family/Social History□ Past Medical History□ Family History□ Social History

None None At least one of the three

New Patient 3/3Est. Patient 2/3

Case Study 1: The level of History is Problem-Focused




Chief Complaint□ Absent□ Present


History of Present Illness□ Location□ Duration□ Context□ Quality□ Severity□ Modifying Factors□ Timing□ Associated Signs & Symptoms

1-3 Elements

1-3 Elements


Review of Systems (ROS)□ Constitutional□ Eyes□ ENT□ Respiratory□ Cardiovascular□ GI□ GU□ Musculoskeletal□ Skin□ Neurological□ Endocrinology□ Hematology/Lymphatic□ Immunologic/Allergy□ Psych





Case Study 2 is Extended Problem Focus History




Chief Complaint□ Absent□ Present


History of Present Illness□ Location□ Duration□ Context□ Quality□ Severity□ Modifying Factors□ Timing□ Associated Signs & Symptoms

1-3 Elements

1-3 Elements


Review of Systems (ROS)□ Constitutional□ Eyes□ ENT□ Respiratory□ Cardiovascular□ GI□ GU□ Musculoskeletal□ Skin□ Neurological□ Endocrinology□ Hematology/Lymphatic□ Immunologic/Allergy□ Psych





Case Study 3 is Detailed History

Examination Component Case Study 1

ProblemFocused

Expanded ProblemFocused


Body Areas o Heado Necko Chest, breasts o Abdomeno Genit, groino Back, spineo Each extremity

Organ Systemso Const. (vitals, general

appearance)o Eyeso ENT, moutho Respiratoryo Cardiovascularo Gastrointestinalo Lymph/hem/immuno GUo Skino Integumentaryo MSo Neurologicalo Psychiatric

One or more body area or system

Two to four body systems or two to seven basic systems, including affected area

Two to Seven detailed systems, including affected area

Eight or more systems

Case Study One: Comprehensive


ProblemFocused










Case Study two is Expanded Problem Focused


ProblemFocused










Case Study 3 Detailed Exam

Medical Decision Making – Case Study 1

A B C

Level of MDM Data Review Diagnosis/Mgmt Risk

Straightforward Minimal/None (1) Minimal (1) Minimal

Low Limited (2) Limited (2) Low

Moderate Moderate (3) Multiple (3) Moderate

High Extensive (4+) Extensive (4+) High

For Case Study 1 the MDM is Moderate


A B C






Case Study two MDM is Low


A B C






References:

Green, M. A. (n.d.). 3-2-1 code it (6th ed.) Chapter 9

Current Procedural Terminology (Ser. 2018). (n.d.). American Medical Association.

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