webcast session i an introduction to evaluation and management (em) coding accurate coding for...
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Webcast Session IAn Introduction to Evaluation and Management (EM) Coding
Accurate Coding for Evaluation and Management (EM) Services
A webcast designed for headache and migraine specialists
PresentersStuart B. Black, MD
American Headache Society (AHS)Sheila J. Madhani, MA, MPH, CCS-P
MARC Associates
October 9, 2007
Goals• Introduction to CPT EM codes
• Review of CPT coding guidelines and practices
• Application of CPT coding guidelines and practices to clinical scenarios relevant to headache specialists
What Will We Discuss?• Importance of accurate coding• CPT codes vs. ICD codes• Components of EM codes• Types of EM codes• How to properly select and report EM
codes/services• Use of modifiers• Clinical examples• Coding resources
Importance of Accurate Coding• Full and fair description of services
provided
• Avoid over-coding (fraud and abuse) and under-coding (not reporting all the services you have provided)
• Improve quality of patient care
CPT codes vs. ICD codes
CPT codes vs. ICD codes• CPT codes
– CPT is an acronym for Current Procedural Terminology
– CPT codes are published by the American Medical Association and are used by CMS and many private insurers to report physician services
– A CPT code is a five digit numeric code that is used to describe
medical, surgical, radiology, laboratory, anesthesiology, and evaluation/management services
– There are approximately 7,800 CPT codes ranging from 00100 through 99602
– Two digit modifiers may be appended when appropriate to clarify or modify the description of the procedure
CPT codes vs. ICD codes
• ICD– ICD stands for International Classification of
Diseases
– It is a coding system used to code signs, symptoms, injuries, diseases, and conditions
CPT codes vs. ICD codes• Relationship between CPT and ICD
– Both types of codes must be reported on claims to Medicare and many private insurers
– CPT code• Describes medical procedure or service
– ICD code• Describes clinical condition of patient to support
the medical necessity of the procedure or service
CPT codes vs. ICD codes• ICD-9-CM
– Diagnosis coding classification system used in the delivery of patient care
• ICD-10– Used to track mortality data
• ICD-10-CM– Currently under development
Components of EM codes
Components of EM codes• All EM services follow a similar format
– Unique code number– Place and/or type of service– Content of service– Nature of the presenting problem– Time typically associated with service
Components of EM codes• Ex. 99213, Office or other outpatient visit, est. patient
Unique code number 99213
Place and/or type of service
Office or other outpatient visit¹
Content of service •Expanded problem focused history•Expanded problem focused examination•Medical decision making of low complexity
Nature of the presenting problem
Usually, the presenting problem(s) are of low to moderate severity
Time typically associated with the procedure
Physicians typically spend 15 minutes face-to-face with the patient and/or family
¹ Includes hospital outpatient
Categories of EM codes
Categories of EM codes• Physicians use EM codes to report
professional services
• Documentation in the medical record must support the EM code and ICD-9 code(s) submitted
• Submitting a code that is not supported by documentation may be considered fraud
Categories of EM codesOffice or other Outpatient Services,
New Patient99201-99205
Office or other Outpatient Services, Established Patient
99211-99215
Hospital Inpatient Services,
Initial Hospital Care
99221-99223
Hospital Inpatient Services, Subsequent Hospital Care
99231-99233
Office or Other Outpatient Consultations,
New or Established Patient
99241-99245
Inpatient Consultations,
New or Established Patient
99241-99255
Categories of EM codes• Levels of service
– Within each category there are various codes representing the different levels of service
– Increased levels of service reflect the increased levels of time, intensity, and complexity of the service
– Ex. Office or other outpatient visit, new patient• 99201 – Level 1• 99202 – Level 2• 99203 – Level 3• 99204 – Level 4• 99205 – Level 5
How to properly select and report EM codes/services
5 Steps to Selecting Appropriate EM codes/services
• Step 1.- Type of Service: What type of service is the patient receiving? (office visit, consultation etc.)
• Step 2.- New or Established: If this is an office visit, is this a new or established patient?
• Step 3.- Key Components: What level of the key components (history, examination, medical decision making) have been met or exceeded
• Step 4.- Time: Will time determine the level of E/M service?
• Step 5.- Documentation: Document! Document! Document!
Step 1: Type of Service• What type of service is the patient
receiving (office visit, consultation etc.)?– Common EM services performed by
headache specialists• Office/Outpatient Services
– 99214» 2005 Medicare utilization by neurologists: 1,768,059
• Consultation Services– 99244
» 2005 Medicare utilization by neurologists: 519,888
Step 1: Type of Service• When is a consultation a consultation?
– Consultation• A type of service provided by a physician whose
opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source
– Not a Consultation• Ongoing management of the patient by the
consultant physician
Step 1: Type of Service• When is a consultation a consultation?
– CMS Transmittal 788 – effective 1/17/06– To bill for a consultation, there must be
documentation of the request– If there is no request, an outpatient/office visit (new or
established) should be reported• “…a consultation request may be verbal however the
verbal interaction identifying the request and reason for a consult shall be documented in the patient’s medical record by the requesting physician or qualified NPP, and also by the consultant physician or qualified NPP in the patient’s medical record.” (CMS Transmittal 788)
Step 1: Type of Service• When is a consultation an office visit?
– Transfer of care • A transfer of care occurs when a physician
requests another doctor to assume the care of the patient for a specific condition
• Once a transfer occurs consultations can no longer be reported
• Established patient EM codes must be reported
Step 2: New or Established Patient?
• CPT differentiates between new and established patients (office/outpatient)
• New patients– More physician work– Greater documentation requirements– Higher reimbursement
Step 2: New or Established Patient?• Is this a new or established patient?
– New patient: one who has not been seen by the physician or another physician of the same specialty who belongs to the same group within the past 3 years
– Established patient: one who has been seen by the physician or another physician of the same specialty who belongs to the same group within the past 3 years
Step 3: Key Components• There are six components that are used to
define the level of an E/M service– History– Examination– Medical Decision Making– Counseling– Coordination of Care– Nature of Presenting Problem– Time
Step 3: Key Components• The three key components must be
considered and supported by documentation in the medical record before selecting a code – History– Examination– Medical decision making
Step 3: Key Components History
• Elements– Chief complaint– History of the present illness (HPI)– Review of symptoms– Past medical, family, and social history (PFSH)
• Levels– Problem focused– Expanded problem focused– Detailed– Comprehensive
Step 3: Key Components History
• Chief complaint– “A chief complaint is a concise statement
describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter, usually stated.”
American Medical Association. Current Procedural Terminology CPT 2007. Chicago, Ill: AMA press;2007
Step 3: Key Components History
• History of Present Illness (HPI) – Must be performed by physician
HPI Elements
LevelsProblem Focused
Expanded Problem Focused
Detailed Comprehensive
•Location•Quality•Severity•Duration•Timing•Context•Modifying factors•Associated signs or symptoms
Brief
(1-3 elements)
Brief
(1-3 elements)
Extended
(4 or more elements)
Extended
(4 or more elements)
Step 3: Key Components History
• Review of Systems (ROS) – Can be performed by medical extender
ROSLevels
Problem Focused
Expanded Problem Focused
Detailed Comprehensive
•Constitutional (wt loss etc)•Eyes•ENT, Mouth•Respiratory•Cardiovascular•GI•GU•MS•Neuro
•Integumentary•Endocrine•Hem/lymph•Allergy/Immun•Psychiatric•All others negative
None Problem specific (1 system)
Extended
(2-9 systems)
Complete
(Greater than 10
systems or some with all
others negative)
Step 3: Key Components History
• Past Medical, Family, and Social History (PFSH)– Can be performed by medical extender
PFSH Levels
Problem Focused
Expanded Problem Focused
Detailed Comprehensive
Pertinent
At least 1 item from at least 1 history.
Complete
Specifics of at least 2
history areas documented. All 3 for new
patient.
None None Pertinent Complete
Step 3: Key Components History• Summary
Elements Problem Focused
Expanded Problem Focused
Detailed Comprehensive
HPIHistory of Present Illness
Brief
(1-3 elements)
Brief
(1-3 elements)
Extended
(4 or more elements)
Extended
(4 or more elements)
ROSReview of Systems
None Problem Specific Extended Complete
PFSHPast Medical, Family and Social History
None None Pertinent Complete
Step 3: Key Components Physical Examination
• The level of exam is determined by the number of body areas or organ systems documented
• Levels – Problem focused– Expanded Problem Focused– Detailed– Comprehensive
Step 3: Key Components Physical Examination
CPT Descriptors For Four Levels of Physical Examination
Problem focused - A limited examination of the affected body area or organ system(s)
Expanded problem focused - A limited examination of the affected body area or organ system and other symptomatic or related organ system(s)
Detailed - An extended examination of the affected body area or organ system and other symptomatic or related organ system(s)
ComprehensiveA general multi-system examination or a complete examination of a single organ system
American Medical Association. Current Procedural Terminology CPT 2007. Chicago, Ill: AMA press;2007
Step 3: Key ComponentsPhysical Examination
• Documentation guidelines for physical examination– 1995 Guidelines (general exams)– 1997 Guidelines (specialty exams)
– Single system (specialty) examination» Neurological – recommended for headache
specialists– General multisystem examination
Step 3: Key ComponentsPhysical Examination
Constitutional
EyesCardiovascular
Neurological
Measurement of any 3 of 7 vital signs General appearance of the patient Ophthalmoscopic examination Examination of carotid arteries Auscultation of heart Examination of peripheral vascular system Higher cortical functions Cranial nerves Sensation Muscle strength Muscle tone Deep tendon reflexes Coordination Gait and station
• 1997 Guidelines – Neurological
Step 3: Key ComponentsPhysical Examination
• SummaryLevel of Exam 1997 Single Organ System
Problem focused 1-5 elements
Expanded Problem Focused At least 6 elements
Detailed At least 12 elements
Comprehensive Perform all elements
Document all elements in•Constitutional•Eyes•Musculoskeletal•Neurological
Document 1 element in•Cardiovascular
Step 3: Key Components Medical Decision Making (MDM)
• What is medical decision making (MDM)?– MDM refers to the complexity of establishing a
diagnosis and/or selecting a management option
• Of the three key components of EM, MDM is the most challenging to meet and document
Step 3: Key Components Medical Decision Making (MDM)
• How is MDM measured?– Number of diagnoses or management options
• Number of possible diagnoses• Number of options that must be considered
– Amount and/or complexity of data to be reviewed• Amount and/or complexity of medical records, diagnostic tests
and/or other information that must be obtained, reviewed and analyzed
– Risk of complications and/or morbidity or mortality• The risk of significant complications, morbidity and/or mortality
associated with the patient’s presenting problem• The risk of comorbidities associated with the patient’s presenting
problem• The risk of the diagnostic procedure(s) and/or the possible
management options
Step 3: Key Components Medical Decision Making (MDM)
• What are the different levels of MDM?– Straightforward– Low complexity– Moderate complexity– High complexity
Step 3: Key Components Medical Decision Making (MDM)
• SummaryNumber of
diagnoses or management
options
Amount and/or complexity of data
to be reviewed
Risk of complications
and/or morbidity or mortality
Type of decision making
(Level of MDM)
Minimal Minimal or None
Minimal Straightforward
Limited Limited Low Low Complexity
Multiple Moderate Moderate Moderate Complexity
Extensive Extensive High High Complexity
Step 3: Key Components• Choosing an appropriate level of EM
service based on key components– New patient, office/outpatient and office
consultations• You must meet or exceed ALL of the requirements
to qualify for a particular level of an EM service
– Established patient, office/outpatient• You must meet or exceed 2 out of the 3
requirements to qualify for a particular level of an EM service
Step 3: Key Components Summary
• New Patient – Office/OP (3 out of 3)Code History Exam Medical Decision
Making
99201 Problem focused Problem focused Straightforward
99202 Extended problem focused
Extended problem focused
Straightforward
99203 Detailed Detailed Low complexity
99204 Comprehensive Comprehensive Moderate Complexity
99205 Comprehensive Comprehensive High Complexity
Step 3: Key Components Summary
• Office or other Outpatient Consultation (3 out of 3)
Code History Exam Medical Decision Making
99241 Problem focused Problem focused Straightforward
99242 Extended problem focused
Extended problem focused
Straightforward
99243 Detailed Detailed Low complexity
99244 Comprehensive Comprehensive Moderate Complexity
99245 Comprehensive Comprehensive High Complexity
Step 3: Key Components Summary
• Established Patient – Office/OP (2 out of 3)Code History Exam Medical Decision
Making
99211 Minimum services; Physician not required
99212 Problem focused Problem focused Straightforward
99213 Extended Problem Focused
Extended Problem Focused
Low complexity
99214 Detailed Detailed Moderate Complexity
99215 Comprehensive Comprehensive High Complexity
Step 4: Time• Time is included in the definition of levels
of EM services– Ex. “99213 Office or other outpatient visit…
physicians typically spend 15 minutes face-to-face with the patient and/or family.”
• This time is considered average time that may be higher or lower depending on specific circumstances
Step 4: Time
In certain circumstances the three key
components (history, physical examination and MDM) are not
the controlling factor
in determining the level of an EM service
Step 4: Time
In certain circumstances
TIME
is the controlling factor
in determining the level of an EM service
Step 4: Time• Time determines the level of E/M service
when counseling and/or coordination of care dominate (> 50%) the encounter– Counseling and coordination is separate from the
history, physical exam and medical decision making
– More common scenario for headache specialists
– The extent of counseling and/or coordination of care must be documented in the medical record independent of the three key components
Step 4: Time• Counseling patient and/or family
– 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 education– Patient and family education
American Medical Association. Current Procedural Terminology CPT 2007. Chicago, Ill: AMA press;2007
Step 5: Documentation• General Principles of Medical Record Documentation¹
– Medical record complete and legible
– The documentation of each patient encounter includes:• Reasons for the encounter and relevant history, physical
examination findings and prior diagnostic test results;• Assessment, clinical impression or diagnosis;• Plan for care; and• Date and legible identity of the provider
– If not documented, the rationale for ordering diagnostic and other ancillary services easily inferred
¹ 1997 EM Guidelines, Centers for Medicare and Medicaid Services (CMS)
Step 5: Documentation• General Principles of Medical Record
Documentation¹– Past and present diagnoses accessible
– Appropriate health risk factors identified
– Patients progress and response to changes in treatment included
– CPT and ICD-9 codes supported by documentation¹ 1997 EM Guidelines, 1997 EM Guidelines, Centers for Medicare and Medicaid Services (CMS)
Use of modifiers
Use of Modifiers• What is a modifier?
– Modifiers indicate that a service was altered in some way from the stated CPT descriptor without changing the definition
• Why use modifiers?– When you need to communicate something unusual
about the service to Medicare
• What is the impact of modifiers?– Modifiers can maintain, reduce or increase
reimbursement levels for a service
Use of Modifiers• Common modifiers for EM services
– -21: Prolonged evaluation and management services• Only can be used with the highest level EM service
– -25: Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service
• Appropriate documentation for the need of the EM service should be recorded in the patient’s medical record
– -52: Reduced services• Should not be used if there is a code at a lower level that
describes the service provided
Clinical examples
Case #1 – History (HPI, ROS, PFSH)
32 year old woman with PMH of “TTH”. Onset of H/A age 14. H/A associated with vomiting, photophobia & dysfunction. 8 year history of chronic daily headaches. Taking Vicodan daily (4-6/D) for 5 years; was taking Butalbital before Vicodan. Disability for 2 years. New onset: “visual blurring” OD; Numbness in RUE; Transient Confusion
Case #1Level of Care 99241?; 99242?; 99243?; 99244?; 99245?
99201?; 99202?; 99203?; 99204?; 99205?
Physical Exam Exam: 23 Bullets
BP 210/105; Pulse 72 Irreg.; RR 15; General Exam: Otherwise WNL
Neurological Exam
Higher Cortical Function; Cranial Nerves; Motor; Coordination; Gait; Reflexes
Sensation; All WNL
Diagnosis 1. Migraine with aura; 2. Chronic Daily H/A; 3.Medication Overuse Headache; 4. Hypertension; 5. R/O Cardiac Arrthymia; 6. R/O CNS Mass Lesion; 7. R/O Cerebral Vascular Disease (TIA, Cerebral Emboli, Infarct)
Complexity of Data Reviewed
Reviewed
22 pages of prior records; Head Ct without contrast (2004); CT cervical spine (2004)
Ordered
MRI Head with contrast; Lab; EKG; Cardiology Consult; Hospital Care?
Risk Risk of Presenting Problem:
Minimal?; Self Limited or Minor?; Low severity?; Moderate severity?
High severity?
Risk of Management Options?; Risk of Diagnostic Procedures?
Case #1Pre-service
– Reviewed the medical history form completed by the patient and vital signs obtained by clinical staff
Intra-service– A comprehensive History– A comprehensive neurological exam > 23 Bullets
Medical Decision Making– Number of Diagnoses or Treatment Options >4– Amount / Complexity of Data Reviewed > 4– Using Table of Risk:
• “One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment”
• “An abrupt change in neurologic status, e.g. seizure, TIA, weakness, sensory loss”
• “Drug therapy requiring intensive monitoring for toxicity”
Case #1
Post-service– Complete the medical record documentation – Provide necessary post evaluation care and
coordination of care
The Level of Care would be 99205 because History and Exam were Comprehensive and MDM was High Complexity. This would not be a Consultation or 99245 because the referral requires a transfer of care for further E /M.
Case #2 – History (HPI, ROS, PFSH)
29 year old woman with PMH of MH without aura. Established Pt. Hospitalized 2 years ago due to medication overuse headache; took Fiorocet daily for 3 years; now on Topamax; limits abortive triptan to 2 days per week. Is Bipolar; Has insomnia; Had “Syncopal Spell” one day ago with loss of bladder control; struck head . New onset vertigo.
Case #2Level of Care Office Visit: 99212?; 99213?; 99214?; 99215?
Physical Exam Exam: 23 Bullets
BP 130/80; Pulse 72 regular RR 16; Bruise on R frontal area from trauma when fell; General Exam: Otherwise WNL
Neurological Exam
Awake, alert, coherent. Memory/intellect intact No aphasia or dysarthria CN’s: WNL; Motor exam wnl Coordination intact; Gait; no ataxia; Reflexes: wnl; Sensation: intact
Diagnosis 1.Migraine with aura; 2. Medication overuse headache by history; 3. Bipolar disorder; 4. Sleep disorder; 5.Syncope; 6. Head trauma due to #5; 6. R/O vasovagal syncopy; 7. R/O seizure; 8. New onset Vertigo
Complexity of Data Reviewed
Reviewed
1.Current chart; 2. Hospital records; 3. All current meds
Ordered
1.Lab; 2.Repeat MRI of head; 3.EEG; 4.EKG
Risk Risk of Presenting Problem:
Minimal?; Self Limited or Minor?; Low severity?; Moderate severity?
High severity?
Risk of Management Options?; Risk of Diagnostic Procedures?
Case #2Pre-service
– Reviewed the medical history form completed from the patient, vital signs obtained by the clinical staff
Intra-service– Obtained a comprehensive history including a review of all medications for possible drug
interactions. Compared status to last visit. Performed comprehensive neuro exam. Considered relevant data, options, and risks; formulated a diagnosis; developed a treatment plan. Discussed diagnosis, treatment options and risks with patient and family. Ordered and arranged diagnostic testing.
Medical Decision Making– Number of Diagnoses or Treatment Options list 5 established Dx. & 2 R/O Dx .– Amount / Complexity of Data Reviewed >4– Using the Table of Risk:
• “One or more chronic illness with severe exacerbation, progression, or side effects of treatment”
• “An abrupt change in neurologic status, e.g.. seizure, TIA, weakness, sensory loss”“Drug therapy requiring intensive monitoring for toxicity”
Case #2Post-service– Complete medical record documentation. Provide
necessary communication and coordination of care. Respond to testing results and revise treatment plan.
The level of care would meet the criteria for 99215 because not only 2 out of 3 but 3 out of 3 requirements were met; a comprehensive History, Exam and High Complexity MDM
Case #3 – History (HPI, ROS, PFSH)
33 year old woman; 10 year history of MH without aura. Established pt. Hospitalized at another clinic 5 years ago because of MOH. Did well until 4 mo ago; recurrent daily “migraine” with 7 days a week of OTC use & triptans bid 4 days a week. On Inderal for headache and BP control. New onset stress; crying; not sleeping. C/O difficulty “Coping”.
Case #3Level of Care Office Visit: 99212?; 99213?; 99214?; 99215?
Physical Exam Exam: 12 Bullets
BP 160/90; Pulse; 90 Regular; RR 17; Pt appeared depressed; crying
Neurological Exam
MS. Awake, alert, coherent; affect flat; judgment impaired; intellect and memory intact; no dysarthria/aphasia; CN disc flat OU, 3,6,7,12 intact: Motor: Coordination: Gait: intact
Diagnosis 1.Migraine without aura; 2. New Onset Chronic Daily Headache; 3.Medication Overuse Headache (OTC, Triptans); 4. Hypertension; 5. New Onset Depression; 6. R/O acute CNS lesion
Complexity of Data Reviewed
1.Records including prior medication history reviewed; 2. Patient has had no recent lab; studies ordered to include CBC, SMA, Sed rate, Thyroid profile; 3. Repeat MRI? ; 4. Will Discuss meds, clinical change, with PCP
(Time spent with patient: 35 minutes)
Risk Greater than 50% of the time was spent in coordination of care
1.Discussed prognosis if not treated; 2. Discussed Risk of Medication Overuse; 3. Discussed Risk and benefits of treatment options; 4. Discussed Risk of non-compliance; 5. Discussed tests ordered and future tests if need; 6. Discussed instructions for treatment and follow-up.
Case #3Pre-service
– Reviewed the medical history form completed by the patient and vital signs obtained by the clinical staff. Discussed new symptoms with the NP.
Intra-service– An extended problem focused history including current meds for headache
control and antihypertensive meds. Discussed new onset daily headaches and depression. Discussed risk of using triptans with hypertension and use of Inderal in depression
– Performed an extended problem focused examination including mental status
Medical Decision Making– Number of Diagnoses or Treatment Options > 4– Amount / Complexity of Data Reviewed > 2– Using the Table of Risk:
• “One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment”
• “Prescription drug management”
Case #3
Post-service– Complete medical record documentation– Provide coordination of care and review with PCP; consider Psych
consult
The H & P are Extended Problem Focused. The CPT level of care would be 99213. However, since greater than 50% of time was spent in Counseling and Coordination of Care, if that criteria were used, the level of care would be coded as 99214.
The counseling and discussion included prognoses, risks andbenefits of treatment options, instructions for treatment and follow up, importance of compliance, risk factors of current course, and risk factor reduction with proper management.
Coding resources
Coding resources• American Headache Society (AHS)
– AHS’s Headache Coding Corner• http://www.americanheadachesociety.org/professionalresources/AHSsHead
acheCodingCorner.asp
• American Medical Association– CPT-related resources
• http://www.ama-assn.org/ama/pub/category/3113.html
• Centers for Medicare and Medicaid Service (CMS)– Evaluation and Management Services Guide
• http://www.cms.hhs.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf
– 1997 Documentation Guidelines for Evaluation and Management Services
• http://www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp
Next AHS Coding Webcast
Don’t forget to register for our next Webcast: Understanding Medical Decision Making (MDM) on October 16.
To register please go directly to: https://americanheadachesociety.webex.com/americanheadachesociety/onstage/g.php?p=0&t=m
Thank You
The American Headache Society thanks you for your participation.
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Please contact American Headache Society (AHS) headquarters for further information: [email protected] or 856-423-0043.