INPATIENT SERVICES Physician Training Presented by La Verne

INPATIENT SERVICES Physician Training Presented by: La Verne Jones 1

The Coding Network (TCN) Quality and Affordability THE CODING NETWORK is committed to provide cost effective state-of-the-industry procedural and diagnostic coding support to medical groups, academic practice plans, hospitals, ambulatory surgery centers, and billing companies throughout the United States. 2 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

TCN provides physician & hospital coding, compliance reviews and training l l l l Avoid costly mistakes and unnecessary audits. Maximize your revenue. Reduce fixed expenses. Maintain continuity of coverage. Safeguard OIG and CMS compliance. Eliminate coding backlogs. Add new specialists with confidence. 3 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

TCN is the nation’s leading remote coding service l l Each specialty is managed by a national coding expert, with years of coding experience in his specialty. Our staff of certified coders understand the subtle differences that exist in each specialty. All coders have years of experience coding exclusively for their specialty. Since our 1995 establishment, not a single physician has ever paid a penny for recoupments, fines or penalties for a case coded by TCN. 4 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

TCN’s areas of expertise PHYSICIAN CODING l Ambulatory Surgery Centers l Anesthesiology l Cardiac Catheterization l Colorectal Surgery l Emergency Medicine l Evaluation and Management Services l Gastroenterology l General Surgery l Gynecology and Gynecologic Oncology l Interventionional Radiology l Neurosurgery l Ophthalmology l Orthopedics l Otolaryngology – Head and Neck Surgery l Pain Management 1/15/2009 l l l l l Pathology – Surgical and Anatomic Pediatric Surgery Plastic and Reconstructive Surgery Radiology Surgical Oncology Transplant Surgery Trauma and Burn Urology Vascular Surgery FACILITY CODING l Ambulatory Surgical Centers l Emergency Medicine l Radiology l Inpatient Records l Outpatient Ambulatory Coding www. codingnetwork. com © 2006 The Coding Network, LLC 5

When TCN codes for you l l l l Provide coverage for absent coders due to illness, vacation or family leave. Eliminate backlogs and/or bottlenecks. Reduce exposure to denials, recoupments and audits. Optimize revenue. Stay on top of coding changes. Comply with all laws and regulations. Receive coding "helpline" access. Receive documentation training. Access to certified experienced coders. Cut overhead by eliminating salaries and benefits. Curtail fixed expenses. Errors and omissions insured. Receive prompt turnaround. 6 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

Coding compliance reviews l l l The OIG recommends periodic independent reviews to evaluate your coding for accuracy. TCN’s coding specialist examines a sample of your coded medical records to validate the procedural and diagnostic coding. Proper modifier usage and other compliance issues are evaluated and reported. 7 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

Physician and staff training l l l Physician and staff training on site at your facility. Extensive physician-specific training to assist in the proper documentation of patient care. All courses are specialty specific and include a syllabus for each participant. 8 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

LA VERNE JONES CCP, CPC l l 30 years of experience in practice management settings 13 years as facilitator of procedural and diagnostic coding 13 years experience as practice management consultant of HCFA policies 7 years experience as Compliance Officer 9 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

Course Agenda l Components of E&M Services History l Examination l Medical Decision-Making l Time l l l Inpatient Categories of Service and Documentation Requirements Teaching Physician Guidelines 10 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

Let’s get started! l l How to use the course workbooks. Lecture – please follow along with the overheads. Resources & Follow-Up Questions – Please ask me! 11 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

INPATIENT SERVICES 12 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

EVALUATION AND MANAGEMENT SERVICES 13 1/15/2009 www. codingnetwork. com © 2006 The Coding Network,

l KEY COMPONENTS FOR SELECTION OF LEVEL OF SERVICE Three (3) key components: l l l History l l Examination Physician Training l Presented by: La Verne Jones l l l Medical Decision-Making Key components drive the decision for level of service unless a visit consists predominantly of counseling or coordination of care. 1/15/2009 14 www. codingnetwork. com © 2006 The Coding Network, LLC

KEY COMPONENT #1: HISTORY l l The extent of history of present illness, review of systems and past family and/or social history obtained and documented is dependent upon clinical judgment and the nature of presenting problem(s). Physician Training History is comprised of some or all of the following Presented by: La Verne Jones elements: l l Chief Complaint (CC) l l History of Present Illness (HPI) l l Review of Systems (ROS) l l Past, Family and/or Social History (PFSH) 1/15/2009 l www. codingnetwork. com © 2006 The Coding Network, LLC 15

There are four (4) types of history: Problem Focused, Expanded Problem Focused, Detailed and Comprehensive. To qualify for a given type of history, all three (3) criteria of HPI, ROS and PFSH must be met or exceeded. TYPES OF HISTORY HPI ROS PFSH PROBLEM FOCUSED Brief N/A Problem N/A 1 -3 EXPANDED PROBLEM FOCUSED 1 -3 DETAILED 1 Extended 4+ 2 -9 COMPREHENSIVE Brief Pertinent Extended 4+ Complete 1 2 -3 10 16

DOCUMENTATION GUIDELINES FOR HISTORY: REVIEW OF SYSTEMS AND PAST FAMILY SOCIAL HISTORY A Review of Systems and/or Past, Family and/or Social History obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his own record, or in an institutional setting, or group practice where many physicians share a common record. The review and/or update may be documented by describing any new ROS/PFSH information or noting there has been no change in the information. The date and location of earlier ROS/PFSH should be noted. Documentation of Review of Systems and/or Past, Family Social History by University Hospital System or Christus Santa Rosa staff cannot be counted toward the provider’s E&M level. 17 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

DOCUMENTATION GUIDELINES FOR HISTORY: REVIEW OF SYSTEMS AND PAST FAMILY SOCIAL HISTORY If the physician is unable to obtain a history from the patient or other source, the record should describe the patient’s condition/ circumstances which precludes obtaining history, i. e. , patient unconscious, patient intubated. Physicians cannot use “all other systems are negative” as a completion statement for Review of Systems. Medical students can document in the record but attendings can only count their documentation of ROS and PFSH. The faculty attending must re-perform or re-document any other work that the medical student has performed. 18 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

KEY COMPONTENT #2: EXAMINATION There are four (4) types of examinations. Problem Focused Exam – 1 body area or organ system Expanded Problem Focused Exam – Limited exam of affected area + 2 -7 body areas or organ systems – Ex: AA 0 X 3, CTAB, Abdomen ND/NT Detailed Exam – Document 3 or more elements of exam of affected area + 2 -7 body areas or organ systems – Ex: AA 0 X 3, CTAB, Abdomen ND/NT, +BS, no HSM Comprehensive Exam – 8 or more organ systems 19 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

1995 EXAMINATION DOCUMENTATION GUIDELINES Body Areas: l l l l Head, including the face Neck Chest, including the breasts and axillae Abdomen Genitalia, groin, buttocks Back Each extremity 20 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

Organ Systems: Constitutional Eyes Ears, Nose, Mouth, and Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic/Lymphatic/Immunologic Endocrine system (thyroid) 21 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

DOCUMENTATION GUIDELINES FOR EXAMINATION Specific abnormal and relevant negative findings of the examination should be documented. A notation of “abnormal” or “positive” without elaboration is insufficient. Abnormal or unexpected findings of the examination of any asymptomatic body area(s) or organ system(s) should be described. A brief statement or notation indicating “negative” or “normal” is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s). When pelvic or rectal exam for an adult is deferred, document the reason. The exam is real time. One cannot indicate “no change in exam from previous encounter. ” 22 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

KEY COMPONENT #3: COMPLEXITY OF MEDICAL DECISION-MAKING Medical decision-making refers to the complexity of establishing a diagnosis and/or selecting a management option. The complexity of the assessment and plan of care for a patient is measured by: number of possible diagnoses and/or management options amount and complexity of medical records, diagnostic tests and other data to be obtained, reviewed analyzed risk of significant complications, morbidity and mortality 23 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

KEY COMPONENT #3: COMPLEXITY OF MEDICAL DECISION-MAKING There are four (4) types of medical decisionmaking. To qualify for a given type of medical decision-making, two of the three elements in the table must be either met or exceeded. 24 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

ELEMENTS Amount and/or complexity of data obtained, reviewed, and analyzed Risk of complications and/or morbidity or mortality Type of Decision Making Minimal (1) Minimal or none (1) Minimal (1) Straightforward Limited (2) Low Complexity Multiple (3) Moderate Complexity Extensive (>4) High Complexity Number of diagnoses or management options 25 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

MEDICAL DECISION-MAKING BOX A. 1: DIAGNOSES EXAMPLE MEDICAL DECISION MAKING Number of Diagnose s A “problem” is defined as definitive diagnosis or, for undiagnosed problems, a related group of presenting symptoms and/or clinical findings. Each new or and/or treatment confirmation established plan is problem evident for with which the or without diagnosis diagnostic Per Problem 1 Point 3 CKD, HTN, DM Each new or established problem for which the diagnosis and/or treatment plan is not evident. 2 plausible differential diagnoses, comorbidities or complications (not counted as separate problems) clearly stated and supported by information in record: requiring diagnostic evaluation or confirmation Per Problem 2 Points 26 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

MEDICAL DECISION-MAKING BOX A: DIAGNOSES EXAMPLE 3 plausible differential diagnoses, comorbidities or complications (not counted as separate problems) clearly stated and supported by information in record: requiring diagnostic evaluation or confirmation Per Problem 3 Points 4 or more plausible differential diagnoses, comorbidities or complications (not counted as separate problems) clearly stated and supported by information in record: requiring diagnostic evaluation or confirmation Per Problem 4 Points Total Diagnoses (Box A 1) If total is greater than total points for box A 2, use in box D. 3 27 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

MEDICAL DECISION-MAKING BOX A. 2: MANAGEMENT OPTIONS Important Note: These tables are not all inclusive. The entries are examples of commonly prescribed treatments and the point values are illustrative of their intended quantifications. Many other treatments exist and should be counted when documented. Points Do not count as treatment option’s notations such as: Continue “same” therapy or “no change” in therapy (including drug management) if specified therapy is not described (record does not document what the current therapy is nor that the physician reviewed it. 0 Drug management, per problem. Includes “same” therapy or “no change” in therapy if specified therapy is described (i. e. , record documents what the current therapy is and that the physician reviewed it). Dose changes for current medications are not required; however, the record must reflect conscious decision-making to make no dose changes in order to count for coding purposes. 1 > 3 new or current medications per problem ≤ 3 new or current medications per problem 2 Open or percutaneous therapeutic cardiac, surgical or radiological procedure; minor or major 1 Physical, occupational or speech therapy or other manipulation 1 28 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

$MEDICAL DECISION-MAKING BOX A. 2: MANAGEMENT OPTIONS Closed treatment for fracture or dislocation 1$

MEDICAL DECISION-MAKING BOX A. 2: MANAGEMENT OPTIONS Closed treatment for fracture or dislocation 1 IV fluid or fluid component replacement, or establish IV access when record is clear that such involved physician decision-making and was not standard facility “protocol” 1 Complex insulin prescription (SC or combo of SC/IV), hyperalimentation, insulin drip or other complex IV admix prescription 2 Conservative measures such as rest, ice/heat, specific diet, etc. 1 Radiation therapy 1 Joint, body cavity, soft tissue, etc. injection/aspiration 1 Patient education regarding self or home care 1 Decision to admit to hospital 1 Discuss case with other physician 1 Other-specify 1 Total Management Points: If total is greater than total for Box A 1, use in Box D. 29 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

MEDICAL DECISION-MAKING BOX A. 2: MANAGEMENT OPTIONS Drug Management “Continue present management” but don’t document what current med regimen is = 0 points PER Problem: Document current regimen and decision to continue or modify: • • 1 -3 meds for the problem = 1 point 4 or more meds for the problem = 2 points Performing or deciding to perform major or minor surgical procedure = 1 point 30 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

MEDICAL DECISION-MAKING BOX A. 2: MANAGEMENT OPTIONS IV meds order (not just IV saline) = 1 point Complex insulin Rx or other IV admix Rx = 1 point Injection/aspiration = 1 point Dietary counseling or conservative measures (ice, bandages, rest) = 1 point Counseling on home/self care techniques (example: glucose monitoring) = 1 point Discuss cases w/other physician (not resident or fellow) = 1 point Admit patient = 1 point 31 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

MEDICAL DECISION-MAKING BOX A. 2: Remember that Box A is the number of diagnoses OR management options - Use the one (A. 1 or A. 2) with the highest score. Maximum score for either diagnoses or management options is 4 points. If you reach 4 points, stop and move onto Box B. 32 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

MEDICAL DECISION-MAKING BOX B: DATA REVIEWED OR ORDERED Table B Data Reviewed or Ordered Point Value Order and/or review medically reasonable and necessary clinical laboratory procedures. Note: Count laboratory panels as one procedure. 1– 3 procedures Order and/or review medically reasonable and necessary diagnostic imaging studies in Radiology section of CPT. 1– 3 procedures >4 procedures 1 2 Order and/or review medically reasonable and necessary diagnostic procedures in Medicine section of CPT. 1– 3 procedures >4 procedures 1 2 Discuss test results with performing physician. 1 Discuss case with other physician(s) involved in patient’s care or consult another physician (i. e. , true consultation meaning seeking opinion or advice of another physician regarding the patient’s care). This does not include referring patient to another physician for future care. 1 33 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

MEDICAL DECISION-MAKING BOX B: DATA REVIEWED OR ORDERED Order and/or review old records. Record type and source must be noted. Review of old records must be reasonable and necessary based on the nature of the patient’s condition. Practice/facility protocoldriven record ordering does not require physician work. Thus should not be considered when coding E/M services. Perfunctory notation of old record ordering/review solely for coding purposes is inappropriate and counting such is not permitted. Order/review without Summary Order/review and summarize 1 2 Independent visualization and interpretation of an image, EKG or laboratory specimen not reported for separate payment. Note: Each visualization and interpretation is allowed one point. 1 Review of significant physiologic monitoring or testing data not reported for separate payment (e. g. , prolonged or serial cardiac monitoring data not qualifying for payment as rhythm electrocardiograms). 1 Total points for Box B. Bring results to box D. 34 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

MEDICAL DECISION-MAKING BOX B For ordering and/or reviewing medically reasonable and necessary lab tests: 1 lab panel = 1 procedure (Example: Chem 7) 1 to 3 procedures = 1 point 4 or more procedures = 2 points For ordering and/or reviewing medically reasonable and necessary radiology tests: 1 to 3 procedures = 1 point 4 or more procedures = 2 points For ordering and/or reviewing medically reasonable and necessary medical tests: Medical tests: EKGs, treadmills, sleep studies, PFTs, EEGs, EMGs 1 to 3 procedures = 1 point 4 or more procedures = 2 points 35 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

MEDICAL DECISION-MAKING BOX B Discussing case (during encounter) w/other physician managing patient’s care (PCP) or ordering a consult (referral doesn’t count) = 1 point Discussing test results w/ performing physician (during encounter) = 1 point Old Records: Ordering records (document type and source) = 1 point Reviewing records (document summary of review findings) = 2 points 36 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

MEDICAL DECISION-MAKING BOX B: Document review of significant physiologic monitoring or test data not separately coded/billed for payment (home glucose or BP logs) = 1 point Independently visualizing and interpreting a radiology image, EKG or lab specimen not separately coded/billed for payment (visualizing and documenting your own interpretation of a chest x-ray already viewed and reported by the radiologist) = 1 point per visualization and interpretation l Note: Can’t double-count (e. g. take a point for reviewing chest x-ray under radiology and take a point for independently visualizing and interpreting same chest x-ray) 37 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

TABLE OF RISK: BOX C: Use highest level of risk on Table. Level of Risk Presenting of Problem(s) Diagnostic Procedure(s) Ordered Management Options Selected Minimal • One self-limited or minor problem (e. g. , cold, insect bite, venipuncture tinea corporis) Laboratory tests requiring • Chest x-rays • EKG/EEG • Urinalysis • Ultrasound (e. g. , echocardiography) • KOH prep • • Rest Gargles Elastic Bandages Superficial Dressings Low • Two or more self-limited or minor problems • One stable chronic illness (e. g. , well controlled hyper- tension, non-insulin depen- dent diabetes, cataract, BPH) • Acute uncomplicated illness or injury (e. g. , cystitis, allergic rhinitis, simple sprain) • Physiologic tests not under stress (e. g. , pulmonary function tests) • Non-cardiovascular imaging studies with contrast (e. g. , barium enema) • Superficial needle biopsies • Clinical laboratory tests requiring arterial puncture • Skin biopsies • • • Over-the-counter drugs Minor surgery with no identified risk factors Physical therapy Occupational therapy IV fluids without additives 38 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

TABLE OF RISK: BOX C Level of Risk Moderate Presenting of Problem(s) • One or more chronic illnesses with mild exacerba tion, progression, or side effects of treatment • Two or more stable chronic illnesses • Undiagnosed new problem with uncertain prognosis (e. g. , lump in breast) • Acute illness with systemic symptoms (e. g. , pyelonephritis, pneumonitis, colitis) Diagnostic Procedure(s) Ordered • Physiologic tests under stress (e. g. , cardiac stress test, fetal contraction stress test) • Diagnostic endoscopies with no identified risk factors • Deep needle or incisional biopsy • Cardiovascular imaging studies with contrast and no identified risk factors (e. g. , arteriogram, cardiac catheterization) • Obtain fluid from body cavity (e. g. , lumbar puncture, thoracentesis, culdocentesis) Management Options Selected • Minor surgery with identified risk factors • Elective major surgery (open, percutaneous or endoscopic) with no identified risk factors • Prescription drug management • Therapeutic nuclear medicine • IV fluids with additives • Closed treatment of fracture or dislocation without manipulation 39 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

TABLE OF RISK: BOX C Level of Risk High Presenting of Problem(s) • One or more chronic illnesses with severe exacerba tion, progression, or side effects of treatment • Acute or chronic illnesses or injuries that pose a threat to life or bodily function (e. g. , multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progres sive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure An abrupt change in neuro logic status (e. g. , seizure, TIA, weakness, sensory loss) Diagnostic Procedure(s) Ordered • Cardiovascular imaging studies with contrast with identified risk factors • Cardiac electrophysiological tests • Diagnostic endoscopies with identified risk factors • Discography Management Options Selected • Elective major surgery (open, percutaneous or endoscopic) with identified risk factors • 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 40 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

Final Assignment of Medical Decision Making Type Line A – Use Total Diagnosis Points or the Total Management Option Points from Section A (Tables A. 1 and A. 2). Line B – Use Total Points from Section B (Table B). Line C – Use highest level of risk from Section C (Table C). Choose final Type of Medical Decision Making. Final Type Requires 2 of the 3 MDM Components below be met or exceeded. 41 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

TABLE D FINAL ASSIGNMENT OF MEDICAL DECISION-MAKING TYPE Number of diagnoses or management options 1 point - Minimal 2 points Limited Amount and complexity of data reviewed or order ≤ 1 point None-Minimal 2 points Limited 3 points Multiple 4 points Extensive Minimal Low Moderate High Straightforward Low Complexity Moderate Complexity High Complexity Risk Type of medical decisionmaking 3 points Multiple 4 points Extensive Final Medical Decision-Making requires 2 of 3 components met or exceeded. 42 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

WHEN TO USE TIME BASED CODING In an inpatient setting, when more than 50% of the total visit time by the teaching physician is counseling and/or coordinating the patient’s care, the time used to code must be provided at the patient’s bedside and/or on the patient’s hospital floor or unit. When coding based on time, the teaching physician may not: Add time spent by the resident in the absence of teaching physician to face-to-face time with the patient by the teaching physician with or without the resident present. Count time counseling or coordinating the patient’s care after leaving the patient’s floor or after beginning to care for another patient. 43 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

WHEN TO USE TIME BASED CODING In addition to documenting history and/or physical exam provided, the documentation should include: Total visit time and time spent counseling and coordinating care, and, Description of the medical decision making and counseling discussion and/or activities coordinated. Example of documenting support for coding based on time based: “I spent a total of 45 of 60 minutes on the floor coordinating Mr. Brown’s care and in discussion with Mr. Brown regarding his newly diagnosed lung cancer, prognosis and treatment options. We discussed side effects of medication. We also discussed the possibility of a clinical trial. I have requested that Dr. Jones visit Mr. Brown to discuss the clinical trial. ” (99253 Consult) 44 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

CASE 1: HISTORY 16 year old white male with osteosarcoma presents for admission for scheduled chemotherapy. First diagnosed in L proximal tibia in July 2008. Had increasing pain (7/10) prior to surgical intervention in July. Has been tolerating treatments – no mucositis, nausea or vomiting, ROS, MSK as per HPI, no decreased ROM. No abnormal weight loss, vision, respiratory, cardiovascular, GI, GU, endocrine normal. FMHx negative for cancer; PMHx, T&A age 2, L tibial intervention July 08. Maintaining B average in school, lives with parents and sibling. 45 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

CASE 1: HISTORY LEVELING Chief Complaint New Patient Est. Patient Consultation History HPI (History of Present Illness) √ Location √ Duration Timing Context √ Mod Factors Quality √ Severity Brief (1 -3 elements) Associated signs/symptoms None ROS (Review of Symptoms √ Constitutional ENMT Psych √ Allergic/Immunologic √ Musculo Integ Resp Endo Eyes √ GU √ Card/vac Neuro √ GI Hem/Lymph PFSH (Past medical, Family and Social History) √ Past (patient’s illness, operation, injuries & treatments) √ Family (review of medical events in pt’s family incl. hereditary disease placing patient at risk √ Social (age appropriate review of past and current activities) Complete PFSH: 2 Hx areas: a) established patient office visit, domiciliary care; home care, b) Emergency dept visit, and c) Subsequent nursing facility care, 3 Hx areas: a) New patients – office visit; domiciliary care, home care, b) consultations, c) initial hospital care; d) hospital observation; and e) comprehensive nursing facility assessments. Pertinent to problem (1 system) Extended 2 -9 system including 1 pertinent Pertinent None Problem Focused (FP) Extended 4 or more elements (1 History area) Expanded Problem Focused (EPF) Detailed (D) Complete 10 or more systems including pertinent Complete New or Consult 3 history areas Established: 2 history areas Comprehensive (C) Final level of history requires 3 components above meet or exceed the same level 46 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

CASE 1: EXAM Temp 98, pulse 86, RR 20 -24, BP 123/60. Head normal; eyes PERRLA, mouth, teeth, throat normal; neck and thyroid normal; normal heart rhythm, s 1, s 2; lungs normal; abdomen, liver, spleen normal; lymph nodes normal; upper and lower extremities normal ROM; + alopecia, + well healed L tibia scar. 47 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

Body Areas: √Head (w/face) Chest w/Brest & Axilla √ Neck Abdomen Genitourinary /groin /buttocks (thyroid) Back (w/spine) 1 body area or system limited exam of affected area + 2 -7 body or systems Expanded exam (3 elements of affected area + 2 -7 additional body areas or systems Problem Focused Expanded Problem Focused Detailed 8 or more organ systems (can include thyroid) Each Extremi ty Organ Systems: Consti tional √ Eyes √ Ears, nose mouth, throat 1/15/2009 √ Skin √ Resp √ Cardio √ GI GU Neuro √ Muscu √ Heme /Lymp /Imm Psyc www. codingnetwork. com © 2006 The Coding Network, LLC Comprehensive 32

If vital signs are taken by UHS/CSR staff, they cannot be counted as constitutional

CASE 1: MEDICAL DECISION-MAKING Hb/Hct 15/42, platelet 376, WBC 10. 6, Glu 258, Ca+ 11. 5, MTX level 820 Assessment: Osteosarcoma L proximal tibia; proceed with chemotherapy; re-evaluation per prn orders. 50 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

CASE 1: MEDICAL DECISION-MAKING Box A. 1: # Diagnoses = 2(osteosarcoma, admission for chemotherapy), Limited; Box A. 2: # mgmt options = 1, Minimal( Use box A. 1 since score is higher than box A. 2. ) Box B: Labs = 2 points due to more than four labs, Limited Box C: Nature of presenting problem = high diagnostic tests ordered = minimal; management options selected = high, High 51 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

Number of diagnoses or 1 point - Minimal management options Amount and complexity of ≤ 1 point data reviewed or Non-Minimal order Risk of complication and/or morbidity or mortality Type of MDM 2 points Limited 3 points Multiple 4 points Extensive 2 points Limited 3 points Multiple ≥ 4 points Extensive Minimal Low Moderate High Straightforward Low Complexity Moderate Complexity High Complexity 2 of 3 of the above components are met or exceeded. 35 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

CASE 1: FINAL LEVELING Initial Inpatient Admission: History, Exam, and Medical Decision-Making must meet or exceed the same level in order to assign a specific code (3 out of 3 same level or higher Code History Exam MDM 99221 D D S or L Average Time 30 99222 C C M 50 99223 C C H 70 36

CATEGORIES AND SUBCATEGORIES OF E&M SERVICES Hospital Observation Discharge Services 99217 Hospital Observation Discharge Services 99218 - 99220 Hospital Inpatient Services 99221 – 99223 – Initial Hospital Care 99231 – 99233 – Subsequent Hospital Care 99234 – 99236 – Observation or Inpatient Care Services including Admission and Discharge 99238 – 99239 – Hospital Discharge Services Consultations 99241 – 99245 – Office Consultations 99251 – 99255 – Initial Inpatient Consultations 54 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

CATEGORIES AND SUBCATEGORIES OF E&M SERVICES Prolonged Services 99356 – 99357 With Direct Patient Contact Critical Care Services 99291 – 99292– Adult 55 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

Newborn Care Service 99460 -99463 Critical Care Service Delivery/Birthing Room Attendance and Resuscitation Services 99464 -99465 99499 Unlisted E&M Service Pediatric Critical Care Transport 99466 -99467 Initial Neonatal and Pediatric Critical Care 99468 -99476 Initial and Continuing Intensive Care Services 99477 -99480 56 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

CATEGORY: Consultation GENERAL Service provided by a physician or qualified nonphysician practitioner whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. (Excludes residents, fellows and interns) due to the consultant’s expertise in a specific medical area beyond the requesting provider’s knowledge. 57 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

Four (4) Requirements for Using Consult Codes A request for a consultation from an appropriate source and the need for consultation (i. e. , the reason for the consultation service) shall be documented by the consultant in the patient’s medical record and included in the requesting physician or qualified NPP’s plan of care in the medical record. The consultant’s opinion and any services performed or ordered must also be documented in the patient’s medical record. (Render service) After the consultation is provided, the consultant shall prepare a written report of his findings and recommendations, which shall be provided to the requesting physician to use in the management of and/or decision making for the patient. 58 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

Note: A request to take care of the problem is a referral and

Intent is to return the patient to the requesting provider for ongoing care of the problem. During the service, the consultant may perform or order diagnostic tests or initiate a treatment plan, including performing emergent procedures. Additional follow up visits after the initial inpatient consultation are billed using the subsequent hospital care codes (99231 -99233). 60 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

INPATIENT CONSULTATIONS: 99251 - 99255 For new or established hospital inpatients, residents of nursing facilities or patients in a partial hospital setting. One initial consult per consultant per patient admit. Subsequent services during the same admission are reported using subsequent hospital care codes (9923199233) or subsequent nursing facility care codes (9930799310), including services to complete the initial consultation, monitor progress, revise recommendations, or address a new problem. 61 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

ACCEPTABLE CONSULT PHRASES The patient is seen in consultation at the request of Dr. Welby for evaluation of abdominal pain. Dr. Ben Casey has requested consultation on Jane Doe for preoperative clearance. 62 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

UNACCEPTABLE CONSULT PHRASES The patient was referred by Dr. John Smith for treatment of diabetes. Thank you for referring Betty Brown to me for management of her shortness of breath. 63 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

EXAMPLE DISPOSITION BOXES ON EXAM TEMPLATES Return to Requesting M. D. with recommendations and treatment options Return to Requesting M. D. ’s care after completion of additional diagnostic testing with final recommendations. Return to Requesting M. D. ’s care after evaluation of trial of therapeutic regimen. Will follow for GI problems in parallel with PCP if PCP agrees. 64 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

INPATIENT CONSULTATIONS CPT 99251 PF PF SF ROS 0 PFSH 0 EXAM 1 BA/OS MDM Straightforwar d 99252 EPF SF 1 -3 1 0 2 -7 BA/OS Straightforwar d 99253 DDL 4+ 2 -9 1 2 -7 BA/OS Low 99254 CCM 4+ 10+ 3 8+ OS Moderate 99255 CCH 1/15/2009 HPI 1 -3 4+ 10+ 3 8+ OS High www. codingnetwork. com © 2006 The Coding Network, LLC 66

Observation or Inpatient Hospital Care (Including Admission and Discharge Services) Codes 99234 -99236 are used by a provider to report observation or inpatient hospital care services provided to patients admitted and discharged on the same date of service. Code History Exam 99234 Detailed or Comp Straightforward or low 99235 Comprehensiv e Comprehensive Moderate 99236 Comprehensiv e Comprehensive High 1/15/2009 Medical Decision Making Comments Usually problem(s) requiring admission are of low severity Usually problem(s) requiring admission are of moderate severity Usually problem(s) requiring admission are of high severity www. codingnetwork. com © 2006 The Coding Network, LLC 67

Observation or Inpatient Hospital Care (Including Admission and Discharge Services) Notes: When performed on the same date as the admission, all other outpatient services provided by the physician in conjunction with that admission are considered part of the initial hospital or observation care. CPT does not indicate time parameters for the encounter. However, CMS (Medicare) has specific time guidelines. Note discussion on Medicare and Carelink. 67 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

Observation or Inpatient Hospital Care – Medicare and Care. Link Codes 99234 -99236 are used by a provider to report: Admitting and discharging a patient on the same calendar day for >8 hours but <24 hours, or Placing a patient under observation and discharging the patient on the same calendar date for >8 hours but <24 hours 68 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

Observation or Inpatient Hospital Care – Medicare and Care. Link Code History Exam Medical Decision Making Comments 99234 Detailed or comprehensive Straightforwa rd or low Usually problem(s) requiring admission are of low severity 99235 Comp Moderate Usually problem(s) requiring admission are of moderate severity 99236 Comp High Usually problem(s) requiring admission are of high severity 69 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

Observation or Inpatient Hospital Care – Medicare and Care. Link Notes: In addition to meeting the documentation requirements for history, exam and medical decision-making, documentation in the medical record should include: Statement that the stay for observation care or inpatient hospital care involved eight hours, but less than 24 hours. Admission and discharge notes written by the billing provider. Personal documentation by the billing provider indicating presence and face-to-face services were provided. 70 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

Hospital Observation Services Admit to Observation Status* Initial observation care: Codes 99218, 99219 or 99220 Admission & discharged on same calendar date: *Code 99234, 99235 or 99236 Subsequent visit by admitting physician or visit by another provider Code 99212, 99213, 99214, or 99215 Outpatient consultation: Code 99241, 99242, 99243, 99244, or 99245 Then use discharge code 99217 Then admit as inpatient: Code 9922199223) Notes: Prior to observation, patient may have been evaluated at another site of service (e. g. outpatient hospital, office, emergency department, or nursing facility). 72 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

Hospital Observation Services – Medicare and Care. Link In Observation < 8 hours and discharged same calendar date: Code 99218, 99219 or 99220 Admit to Observation Status In Observation > 8 hours but < 24 hours and discharged same calendar date: Code 99234, 99235 or 99236 (see slide 15) In Observation > 24 hours: Code 99218, 99219 or 99220 In Observation > 48 hours: Code 99218, 99219 or 99220 then 99212 -99215 When discharged, use observation care discharge day management: Code 99217 If admitted, use initial hospital visit: Code 99221, 99222 or 99223 Notes: Prior to observation, patient may have been evaluated at another site of service (e. g. , outpatient hospital, office, emergency department, or nursing facility). 73 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

Hospital Observation Services These codes are used to report a patient placed under observation and include initiation of observation status, supervision of care, and periodic assessments. Code 99218 -99220 99217 99218 -99220 + 99212 -99215 + 99221 -99223 Type Initial Observation Care + Established Patient, Office or other Outpatient Visit + Observation Care Discharge Services Initial Observation Care + Established Patient, Office or other Outpatient Visit + Initial Hospital Visit + Observation Care Discharge Services Duration of Service 1 st calendar day - placed under observation + 2 nd calendar day - subsequent service + 3 rd calendar day - discharged 1 st calendar day - placed under observation + 2 nd calendar day - subsequent service + 3 rd calendar day - admitted to inpatient status Comments 1/15/2009 1 st calendar day - placed under observation + 2 nd calendar day - discharged Code both services Code all services www. codingnetwork. com © 2006 The Coding Network, LLC 74

Hospital Observation Services Notes: Billed only by the physician who admitted the patient to observation and was responsible for the patient during his/her stay. All other providers should bill the outpatient E/M codes that describe their participation in the patient’s care (i. e. , office and other outpatient service codes or outpatient consultation codes) 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC 75

Hospital Observation Services – Medicare and Care. Link Code 99234 -99236 99218 -99220 + 99217 99218 -99220 + 99212 -99215 + 99221 -99223 Type Initial Observation Care Observation or Inpatient Care Services (Including Same Day Admission and Discharge) Initial Observation Care + Observation Care Discharge Services Initial Observation Care + Established Patient, Office or other Outpatient Visit + Observation Care Discharge Services Initial Observation Care + Established Patient, Office or other Outpatient Visit + Initial Hospital Visit Duration of Service Placed under observation with discharge on different calendar date or Under observation <8 hours and discharged on same calendar date Placed under observation and discharged on same calendar date for >8 hours but <24 hours >48 hours: 1 st calendar day - placed under observation + 2 nd calendar day - discharged >48 hours: 1 st calendar day - placed under observation + 2 nd calendar day - subsequent service + 3 rd calendar day – admitted to inpatient status Comments 1/15/2009 99218 -99220 Do not also code a discharge day service if observation was <8 hours Code both services Code all services Do not also code a discharge day service www. codingnetwork. com © 2006 The Coding Network, LLC 76

HOSPITAL OBSERVATION SERVICES – MEDICARE AND CARELINK Notes: Billed only by the physician who admitted the patient to observation and was responsible for the patient during his/her stay. All other providers should bill the outpatient E/M codes that describe their participation in the patient’s care (i. e. , office and other outpatient service codes or outpatient consultation codes). 76 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

Initial Hospital Observation Services History, exam, and medical decision-making must meet or exceed the same level in order to assign a specific code (i. e. , 3 out of 3 same level or higher). Code Exam Medical Decision Making Comments 99218 Detailed or Comprehensive Straightforward or low Usually problem(s) requiring admission to observation status are of low severity 99219 Comprehensive Moderate Usually problem(s) requiring admission to observation status are of moderate severity 99220 1/15/2009 History Comprehensive High Usually problem(s) requiring admission to observation status are of high severity www. codingnetwork. com © 2006 The Coding Network, LLC

Hospital Observation Services Notes: The descriptors for these codes include the phrase “per day”, meaning care for the day. Select a code that reflects all services provided during the date of the service. The observation record for the patient must contain dated and timed physician’s admitting orders regarding the care the patient is to receive while in observation, and progress notes prepared by the physician while the patient was in observation status. This information is in addition to any record prepared as a result of an emergency department, outpatient clinic, or nursing facility encounter. In rare instances when a patient is held in observation status for more than two calendar dates, the physician must code subsequent services before the discharge date using outpatient/office visit codes (99212 -99215). 78 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

Observation Care Discharge Services Code 99217 is used to report discharge services of a patient in observation status. 99217 History Observation care discharge day management Comments Face-to-face time between the attending and the patient 79 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

Observation Care Discharge Services Notes: Billed only by the physician who was responsible for observation care during this stay. Discharge service is billed on the date of the actual visit by the provider. Includes: Final patient exam Discussion of the hospital stay Instructions for continuing care Preparation of discharge records, prescriptions, and referral forms All other providers performing a final visit should use outpatient/office visit codes (99212 -99215). Do not bill the hospital observation discharge management code (99217) if patient was Admitted to inpatient status, use codes 99221 -99223. Placed under observation and discharged on the same calendar date, use codes 9923499236. 80 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

Hospital Observation During A Global Surgical Period The global surgical fee includes payment for hospital observation (codes 99217, 99218, 99219, 99220, 99234, 99235 and 99236) services unless specific requirements are met. Observation services may be paid in addition to the global surgical fee only if both of the following requirements are met: The hospital observation service meets the criteria needed to justify billing it with modifiers: § 24 - Unrelated E/M service by the same physician during a post-operative period § 25 - Significant, separately identifiable E/M service by the same physician on the same day of a procedure or other service § 57 - Decision for major surgery The hospital observation service furnished by the surgeon meets all the criteria for the hospital observation code billed. 81 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

How to Use Observation Codes - Examples Date 9/18 Medicare & Care. Link Admitted to Observation by Provider A on 9/18 at 1 AM; seen and discharged by Provider A at 7 AM on 9/18 99234 -99236 (Provider A) 99218 -99220 (Provider A) Admitted to Observation by Provider A on 9/18 at 1 AM; seen and discharged by Provider A at 9/18 4 PM 99234 -99236 (Provider A) 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC 9/19 9/20 83

How to Use Observation Codes - Examples Admitted to Observation by Provider A on 9/18 at 1 AM; seen by Provider B 9/18 at 3 PM; seen and discharged on 9/19 at 7 AM by Provider A Note: Provider A is from a different specialty than Provider B and the service was not a consultation. 1/15/2009 99218 -99220 (Provider A) 99212 -99215 (Provider B) www. codingnetwork. com © 2006 The Coding Network, LLC 99217 (Provider A) 84

How to Use Observation Codes - Examples Admitted to Observation by Provider A on 9/18 at 1 AM; seen by Provider A on 9/19; and, seen and discharged by Provider A on 9/20 Admitted to Observation by Provider A on 9/18 at 1 AM; seen by Provider A on 9/19; and, admitted by Provider A to inpatient status 9/20 1/15/2009 99218 -99220 (Provider A) 992129921 5 (Provider A) 99217 (Provider A) 99218 -99220 (Provider A) 992129921 5 (Provider A) 992219922 3 (Provider A) www. codingnetwork. com © 2006 The Coding Network, LLC 85

CATEGORY: Hospital Inpatient Services GENERAL Care provided to patient admitted to hospital facility. Four (4) subcategories of Hospital Inpatient Services: Initial Hospital Care (99221 - 99223) Subsequent Hospital Care (99231 - 99233) Observation or Inpatient Care Services (Including Admission and Discharge) (99234 -99236) Hospital Discharge Services (99238 - 99239) 85 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

INITIAL HOSPITAL CARE: 99221 – 99223 There is no distinction between new or established patients. Used only by one admitting physician per admission. All E&M services provided on the same day are included in initial hospital care and cannot be billed separately. Frequently disallowed as part of the global surgery package if performed on the day before or the day of a surgical procedure. 86 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

99221 Det/Comp SF/Low HPI 4+ ROS: 2 -9 Systems PFSH: 1 Exam: 2 -7 MDM: Low 99222 Comp Mod 99223 Comp High 1/15/2009 HPI: 4+ ROS: 10 + Systems PFSH: 3 Exam: 8+ Systems MDM: Moderate HPI: 4+ ROS: 10+ Systems PPSH: 3 Exam: 8+ Systems MDM: High Physicians that participate in the care of a patient but are not the admitting physician of record should bill the inpatient evaluation and management services codes that describe their participation in the patient’s care (i. e. , subsequent hospital visit or inpatient consultation). www. codingnetwork. com © 2006 The Coding Network, LLC 89

CODING A HOSPITAL ADMISSION THAT OCCURS IN THE COURSE OF AN OFFICE VISIT E/M office visit code Admitted patient to the hospital via the office and didn’t see patient in the hospital on the same date Initial hospital care code Admitted patient to the hospital via the office and saw patient in the hospital on the same date E/M office visit Code + Initial Hospital care code Admitted patient to the hospital via the office and saw patient in the hospital on the following date 88 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

SUBSEQUENT HOSPITAL CARE: 99231 - 99233 Physicians can only bill one hospital code per day to encompass all visits for the patient on a given day. In a hospital inpatient situation involving one physician covering for another, if physician A sees the patient in the morning and physician B, who is covering for A, sees the same patient in the evening, physician B is typically not paid separately for the second visit. The hospital visit descriptors include the phrase “per day” meaning care for the day. If the physicians are each responsible for a different aspect of the patient’s care, both visits are paid if the physicians are in different specialties and the visits are billed with different diagnoses. There are circumstances where concurrent care may be billed by physicians of the same specialty. Review of medical record, diagnostic studies and changes in the patient’s status (changes in history, physical condition and response to management) since last assessment by the physician. 89 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

The acuity of the patient’s condition is a key factor in selection of the level of hospital visit. CPT describes the patient’s condition at each level of service as follows. 99231 – usually the patient is stable, recovering or improving. 99232 – usually the patient is responding inadequately to therapy or has developed a minor complication. 99233 – usually the patient is unstable or has developed a significant complication or a significant new problem. 90 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

99231 PF PF SF/Low HPI: 1 -3 ROS: None PFSH: None Exam: 1 BA/System MDM: Low 99232 EPF Mod 99233 D D High 1/15/2009 HPI: 1 -3 ROS: 1 - System PFSH: None Exam: 2 -7 BA/System MDM: Moderate HPI: 4+ ROS: 2 -9 System PPSH: None Exam: 2 -7 BA/System MDM: High www. codingnetwork. com © 2006 The Coding Network, LLC 93

OBSERVATION OR INPATIENT CARE SERVICES (INCLUDING ADMISSION AND DISCHARGE SERVICES (99234 -99236) Used to report observation or inpatient hospital care services provided to patients admitted and discharged on the same date. 99234 Det/Comp SF/Low HPI 4+ ROS: 2 -9 Systems PFSH: 1 Exam: 2 -7 BA/Systems MDM: Low 99235 C C Mod HPI: 4+ ROS: 10 + Systems PFSH: 3 Exam: 8+ Systems MDM: Moderate 99236 C C High HPI: 4+ ROS: 10+ Systems PPSH: 3 Exam: 8+ Systems MDM: High 92 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

HOSPITAL DISCHARGE SERVICES: 99238 – 99239 Includes final exam of patient, discussion of hospital stay, instructions for continuing care to all relevant care givers and preparation of discharge records, prescriptions and referral forms Less than 30 minutes or greater than 30 minutes. Document the time spent for appropriate code selection. Only the attending of record can discharge the patient. There may only be one hospital discharge service per patient per hospital stay. 93 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

CATEGORY: Prolonged Services PROLONGED SERVICES: 99356– 99357 Used to report prolonged services involving direct (face-to-face) patient contact beyond the usual E&M services in the outpatient or inpatient setting. CPT 99356 -57 are used in addition to the designated E&M service at any level and any other physician services provided at the same session. Time based codes. Time does not have to be continuous. However, the total duration of time must be considered. 94 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

CATEGORY: Prolonged Services Prolonged services codes can be billed only if the total duration of all physician or qualified NPP direct face-to-face service (including the visit) equals or exceeds the threshold time for the evaluation and management service the physician or qualified NPP provided (typical/average time associated with the CPT E/M code plus 30 minutes). Time spent reviewing charts or discussion of a patient with house medical staff and not with direct face-to-face contact with the patient or waiting for end of a therapy, or for use of facilities cannot be billed as prolonged services. 95 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

CATEGORY: Prolonged Services Resident/Fellow time does not count. The medically necessary reason for prolonged encounter must be documented as well as the total time spent with patient or in review/communication. 96 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

The medical record must be appropriately and sufficiently documented by the physician or qualified NPP to show that the physician or qualified NPP personally furnished the direct face-to-face time with the patient specified in the CPT code definitions. The start and end times of the visit shall be documented in the medical record along with the date of service. 97 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

Do not report prolonged service if it is less than 30 minutes. Codes 99356 -99357 are used to report the total duration of unit time spent by a physician on a given date providing prolonged service to a patient. Code 99356 is used to report the first hour of prolonged service on a given date. 98 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

Code 99357 is used to report each additional 30 minutes beyond the first hour. This code may also be used to report the final 15 -30 minutes of prolonged service on a given date. Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately. The use of the time based add-on codes requires that the primary E&M service have a typical or specified time published in the CPT book. Use CPT 99356 in conjunction with 99221 -99233, 9925199255, 99304 -99310, 90822 and 90829. 99 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

The following table illustrates the correct reporting of prolonged physician service with direct patient contact in the office setting: Total Duration of Prolonged Service Code(s) Less than 30 minutes (less than ½ hour) Not reported separately. 30 – 74 minutes (½ hr. – 1 hr. 14 min. ) 99356 X 1 75 – 104 minutes (1 hr. 15 min. – 1 hr. 44 min. ) 99356 X 1 AND 99357 X 1 105 – 134 minutes (1 hr. 45 min. – 2 hr. 14 min. ) 99356 X 1 AND 99357 X 2 135 – 164 minutes (2 hr. 15 min. – 2 hr. 44 min. ) 99356 X 1 AND 99357 X 3 165 – 194 minutes (2 hr. 45 min. – 3 hr. 14 min. ) 99356 X 1 AND 99357 X 4 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC 100

In those E&M services in which the code level is selected based on time (counseling and coordination of care), prolonged services can only be reported with the highest code level in that family of codes as the companion code. In the inpatient setting, prolonged service codes can only be assigned with a level three initial encounter(99223) or subsequent encounter(99233) or a level five consultation (99255). 101 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

CLINICAL EXAMPLE: A 34 year old primigravida presents to hospital in early labor. Admission history and physical reveals severe preeclampsia. Physician supervised management for preeclampsia, IV magnesium initiation and maintenance, labor augmentation with pitocin, and close maternal-fetal monitoring. Physician face-to-face involvement includes 40 minutes of continuous bedside care until the patient is stable, then is intermittent over several hours until the delivery. 102 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

PROLONGED SERVICES: Threshold Time for Prolonged visit Codes 99356 and/or 99357 billed with Inpatient

Code Typical Time for Code Threshold Time to Bill Code 99356 Threshold Time to Bill codes 99356 & 99357 99252 40 70 115 99253 55 85 130 99254 80 110 155 99255 110 140 185 99304 25 55 100 99305 35 65 110 99306 45 75 120 104 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

Code Typical Time for Code Threshold Time to Bill Code 99356 Threshold Time to Bill codes 99356 & 99357 99307 10 40 85 99309 25 55 100 99310 35 65 110 99318 30 60 105 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

SELECT THE APPROPRIATE CODE BASED UPON THE TYPE OF HISTORY, EXAM AND MEDICAL DECISION-MAKING RENDERED AND DOCUMENTED. CONSIDER THE IMPACT OF TIME AS APPROPRIATE. 106 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

CHOOSING EVALUATION AND MANAGEMENT CODES Identify the subcategory of service. Determine the extent of history obtained. Determine the extent of examination performed. Determine the complexity of medical decision-making. 1/15/2009 Identify the category of service. Determine the approximate amount of intra-service time if counseling or coordination of care is greater than 50%. www. codingnetwork. com © 2006 The Coding Network, LLC 107

INITIAL VISITS Require all 3 key components (History, Exam and Medical Decision-Making). First time encounters include: Hospital observation services Initial hospital visits Initial office and inpatient consults 108 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

SUBSEQUENT VISITS Require 2 of the 3 key components (History, Exam and Medical Decision-Making). Subsequent encounters include: Subsequent hospital visits 109 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

INPATIENT E&M CODES HOSPITAL OBSERVATION KEY COMPONENTS OUTPATIENT E&M CODES 99217 HISTORY EXAM MEDICAL DECISION PROBLEM TIME OBSERVATION CARE DISCHARGE DAY MANAGEMENT 99218 DET-COM STRT-LOW 99219 COMPRE MODERATE 99220 COMPRE HIGH MOD-HIGH 3 of 3 Key Components must be met for initial visit 110 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

INPATIENT E&M CODES HOSPITAL ADMISSIONS KEY COMPONENTS INPATIENT E&M CODES HISTORY EXAM MEDICAL DECISION PROBLEM TIME 99221 DET-COM COMPRE LOW 30 99222 COMPRE MODERATE 50 99223 COMPRE HIGH MOD-HIGH 70 3 of 3 Key Components must be met for initial visits 111 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

INPATIENT E&M CODES OBSERVATION OR ADMIT WITH SAME DAY DISHARGE KEY COMPONENTS INPATIENT E&M CODES HISTORY EXAM MEDICAL DECISION PROBLEM 99234 DET-COMP STRT-LOW 992352 COMPRE MODERATE 99236 COMPRE HIGH TIME 112 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

INPATIENT E&M CODES HOSPITAL VISITS KEY COMPONENTS INPATIENT E&M CODES EXAM MEDICAL DECISION HISTORY PROBLEM TIME 99231 FOCUSED STRT-LOW STABLE 15 99232 EXP/FOC MODERATE MINOR CMP 25 99233 DETAILED HIGH UNSTABLE 35 99238 99239 HOSPITAL DISCHARGE DAY MANAGENENT LESS THAN 30 MIN. HOSPITAL DISCHARGE DAY MANAGEMENT GREATER THAN 30 MIN. 2 of 3 Key Components must be met for subsequent visits 113 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

INPATIENT E&M CODES CONTINUATION INPATIENT CONSULTATIONS KEY COMPONENTS INPATIENT E&M CODES HISTORY EXAM MEDICAL DECISION PROBLEM TIME 99251 FOCUSED STRTFWD MINOR 20 99252 EXP/FOC STRTFWD LOW-MOD 40 99253 DETAILED LOW MODERATE 55 99254 COMPRE MODERATE MOD-HIGH 80 99255 COMPRE HIGH MOD-HIGH 110 3 of 3 Key Components must be met for initial visits 114 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

MEDICAL NECESSISTY The CMS Manual, publication 100 -4, Chapter 12, 30. 6. 1 – Selection of Level of Evaluation and Management Service states the following: “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. 115 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

MEDICAL NECESSISTY Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record. Instruct physicians to select the code for the service based upon the content of the service. The duration of the visit is an ancillary factor and does not control the level of the service to be billed unless more than 50 percent of the face-to-face time (for non-inpatient services) is spent providing counseling or coordination of care. ” 116 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

MEDICAL NECESSISTY Medically Necessary Services are services required to: Diagnose or prevent an illness, injury or condition Treat an illness, injury, or condition Keep condition from getting worse Lessen pain or severity of condition Help improve condition Restore lost skills (rehabilitation) 117 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

MEDICAL NECESSISTY Medically Necessary Services: Are consistent with diagnosis; Meet accepted standards of good medical practice; Can be safely provided. 118 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

DIAGNOSTIC CODING ICD codes describe the reason a service (CPT code) was provided. List the primary diagnosis, condition, problem or other reason for the medical service or procedure. List secondary diagnoses that impact the medical decisionmaking for the encounter. Exclude diagnoses that relate to the patient’s previous medical condition or problem and have no bearing on the patient’s present problem. 119 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

DIAGNOSTIC CODING Assign all codes to the highest level of specificity (4 th or 5 th digits). Code signs and symptoms if a definitive diagnosis has not been determined. Do not code probable, possible or suspected conditions as definitive diagnoses. Be specific in describing the condition, illness or disease of the patient. (e. g. , renal failure vs. chronic kidney disease, Stage III). 120 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

DIAGNOSTIC CODING Distinguish between acute and chronic conditions. Identify how injuries occur by using E codes. Use V codes to indicate why a service was rendered when there is no complaint, i. e. routine physical, well baby care, aftercare following surgery, need for prophylactic vaccination, etc. Avoid unspecified codes when there is a more specific code to describe the patient’s illness, condition or injury. Diagnoses may be taken from the final assessment or chief complaint. 121 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

DIAGNOSES New or established problems Addressed during the visit • Qualify the diagnosis (e. g. , acute severe, chronic, mild, moderate, etc. ). Co-morbid conditions include conditions that coexist at the time of the visit and influence, require, or affect patient care or treatment. CPT – Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M service unless their presence significantly increases the complexity of the medical decision-making. Documentation needs to demonstrate that the comorbidity was a significant influence. 122 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

DIAGNOSES Example: • • Assessment 1) CKD – continue present management, 2) Anemia X Assessment 1) CKD – continue present management, 2) Anemia secondary to CKD – continue present management 123 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

DIAGNOSES Possible code series to consider in addition to co-morbid conditions or complications. History of cancer (V 10) Personal medical history (V 11 -V 15) Family history (V 15 -V 19) Condition influencing health status (V 40 -V 41) Tissue Transplant or artificial device (V 42 -V 44) Post-procedural status (V 45) Must be supported by documentation in the current note. 124 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

LINKING DIAGNOSIS CODES Assessment Codes 1. 493. 02 Childhood asthma w/ acute exacerbation 2. 477. 9 2. Allergic rhinitis 1. 493. 02 E/M Service Established Procedures: Bronchodilation Responsiveness spirometry as in 94010, pre and postbronchodilator administration 99232 -25 94060 2. 477. 9 493. 02 125 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

MEDICAL RECORD DOCUMENTATION Complete Documentation Correct Medical Coding Appropriate Reimbursement The critical factor in determining the level of care: Not what you did…. but what you documented! 126 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

E&M MODIFIERS 127 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

MODIFIERS Modifiers are two-digit additions to CPT codes to indicate that a performed service or procedure has been altered by a specific circumstance but not changed in its definition or code. Some modifiers impact reimbursement while others simply convey information. 128 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

EVALUATION AND MANAGEMENT MODIFIERS - 24 Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period. Used to indicate that an E&M service performed during the postoperative period is unrelated to the original procedure. The diagnosis for the E&M service must support the fact that the service was unrelated. If the service is unrelated, Medicare will pay for the E&M service with the 24 modifier. 129 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

- 25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service. Reflects that the day of a minor surgical procedure, the patient’s condition required a significant, separately identifiable E&M service above and beyond the other service provided or beyond the usual operative and postoperative care associated with the procedure that was performed. The term “separately identifiable service” means an additional service that is not part of the surgery or procedure. The E&M service must require additional history, exam, knowledge, skill, work, time, and risk above and beyond that of the surgery or procedure and its pre- and post-procedure components. Moreover, the E&M service should be able to stand alone from the same-day procedure. 130 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

Generally used with established patient visits. A significant, separately identifiable E&M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E&M service to be reported. . The E & M service may be prompted by the symptom or condition for which the procedure and/or service was provided. Different diagnoses are not required for reporting of the E & M service on the same date. Initial consultations and additional procedures may be reported without the use of modifier 25. 131 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

- 32 Mandated Services Used to identify mandated consultation and/or related services (e. g. , PRO, third party payer, governmental, legislative, or regulatory requirement). Generally allowed at 100% since the service is mandated. Used with second surgical opinions 132 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

- 57 Decision for Surgery Indicates initial decision to perform major surgery the same day or next day of the E&M service. Removes service, normally consultative, from the global surgical package. Codes with this modifier are reimbursed separately by the carrier. 133 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

OTHER MODIFIERS - 22 Increased Procedural Services When the work required to provide a service is substantially greater than typically required, modifier 22 may be added to the usual procedure code. Documentation must support the additional work and the reason for it (i. e. , increased intensity, time, technical difficulty of procedure, or severity of patient’s condition, physical and mental effort required). This modifier should not be appended to an E&M Service. 134 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

OTHER MODIFIERS - 26 - GC Professional component or interpretation of a diagnostic test or study Service performed in part by a resident under direction of a teaching physician 135 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

EVALUATION AND MANAGEMENT SERVICES WITH PROCEDURES Any specifically identifiable procedure (i. e. , identified with a specific CPT code) performed on or subsequent to the date of initial or subsequent Evaluation and Management Services should be reported separately. The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant separately identifiable E/M service above and beyond other services provided or beyond the usual preservice and postservice care associated with the procedure that was performed. The E/M service may be caused or prompted by the symptoms or condition for which the procedure and/or service was provided. This circumstance may be reported by adding the modifier -25 to the appropriate level of E/M service. As such, different diagnoses are not required for reporting of the procedure and the E/M services on the same date. 136 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

PERFORMANCE AND/OR INTERPRETATION OF DIAGNOSTIC TESTS The actual performance and/or interpretation of diagnostic tests/studies ordered during a patient encounter are not included in the levels of E/M services. Physician performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code. Results are the technical components of a service. Testing leads to results; results lead to interpretation. Reports are the work product of the interpretation of numerous test results. 137 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

PERFORMANCE AND/OR INTERPRETATION OF DIAGNOSTIC TESTS The physician’s interpretation of the results of diagnostic tests/studies (i. e. , professional component) with preparation of a separate distinctly identifiable signed written report may also be reported separately, using the appropriate CPT code with the modifier -26 appended. 138 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

DOCUMENTATION EXAMPLES 139 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

SAMPLE DOCUMENTATION - 99222 Level II Initial Hospital Care This 42 -year old diabetic female Hispanic patient is admitted today with four-day history of fever, chills, harsh cough productive of moderate amounts of greenish and foul-smelling sputum, shortness of breath at rest and general malaise. Onset of symptoms occurred rather suddenly, though the patient admits to a mild dry cough for several weeks, changing to a productive cough over the last four days. Denies rhinorrhea or nasal congestion. Patient fainted today after walking up a flight of steps; says she “could not find my breath and then got dizzy. ” Feeling weak and just “really sick. ” Temperature taken at home last night 102 degrees. Had TB as a child in her native country in South America. Was apparently treated successfully at that time without sequelae. No history of asthma. 140 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

ROS: Head: no complaints except for recent dizziness. Ears: no complaints. Eyes: wears glasses. Last exam five years ago in her native country. Nose: denies rhinitis, as above. Throat: extremely sore secondary to deep cough. Resp: Cough, SOB as above. Breasts: has never had mammograms; denies history of nodule/mass. Cardio: patient is hypertensive, controlled with Monopril 20 mg/day. Takes her Bp every other day at local drug store. GI: no NVD. Appetite diminished. GU: no complaints. Last Pap some years ago - normal. Musculoskeletal: admits to general arthralgias with onset of fever. No history of arthritis. Neuro: without complaint. Endo: patient is diabetic; controlled on daily Glucophage 1500 mg/day. Last glucose level taken at home a few days ago by home glucometer. Patient doesn’t remember the result. Admits to being less than compliant in taking the med and monitoring the blood glucose. 141 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

PMH: Hypertension and diabetes for years. No major surgeries. Usual childhood illnesses. Immunizations: unknown. Allergy: severely allergic to penicillins: hives , no anaphylaxis. FH: Noncontributory to this illness. Mother was nonhypertensive; nondiabetic. Never knew her father and therefore history is unavailable. Three siblings, alive and well. SH: No smoking or drinking. Doesn’t exercise. Married with two children. 142 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

O: General: febrile-appearing female, short with barrel-shaped chest, lying supine in bed. T: 101. 6; P: 72; R: 30, shallow, guarded. Bp: 132/82. Head: normocephalic. No lesions, signs of trauma or fall. Eyes: PERRLA. Sclerae sl. yellow. Ears: Canals clear. TM’s WNL. Nose: mucosa pale. No exudates. Turbinates sl. Congested. Septum deviated to left. Throat: posteropharyngeal wall erythematous. Tonsils small, red without exudates. Tongue geographic, thick. Dentition poor. Gold fillings throughout. Neck: +3 anterior cervical lymphadenopathy. Thyroid not palpable. Chest auscultation reveals LUL clear; LLL with high-pitched rales. RUL nonaudible; RML and RLL some wheezing. Chest percussion reveals dull sounds over RML/RLL but tinny sounds over RUL. Breasts: WNL. No mass or tenderness. Areolae WNL: No discharge. Cardio: Normal S 1, S 2. No murmur or rub. Abdomen: no hepato-or splenomegaly. Some tenderness over epigastrium. BS active. GU: deferred. Rectal: deferred. Skin: Dry; no petechiae or purpura. Extremities: Warm. No pedal edema. Pulses +2 in upper/lower extremities. No digital clubbing. No CVA tenderness. Neuro: no focal deficits. DTRs +2 upper extremities; +1 lower extremities. STAT portable chest x-ray ordered. Laboratory tests ordered: SMA-12 including CBC w/diff. STAT ABG. Blood glucose; Hg Alc; UA; sputum culture/sensitivity, and gram stain, AFB x 3. Oximetry reported 90 percent. 143 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

A: 1. Community acquired pneumonia of LUL. Probably bacterial. 2. R/O pneumothorax. 3. R/O atypical pneumonitis. 4. NIDDM. 5. HTN. P: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Patient admitted today to Medical Service ward. Await chest x-ray/ labs. Obtain Pulmonary consult. Begin IV antibiotics – Erythromycin 500 mg q. 6 h. Begin Tylenol for fever. 1500 cal/day ADA diet. Finger sticks before meals. Lispro insulin before meals. Hold Glucophage for now. Resp. isolation. Nasal oxygen 2 liters by nasal cannula. 144 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

Addendum: Patient now reports she thinks she has visited the ER here about eight months ago for lower respiratory infection, at which time she underwent chest x-ray. Old films to be pulled for comparative review. (Multisystem-Primary Care Physician) St. Anthony’s Guide to Evaluation and Management Coding and Documentation 145 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

SAMPLE DOCUMENTATION - 99231 Level I Subsequent Hospital Visit The patient was admitted three days ago with bleeding gastric ulcer, now stable. Since admission, she has received three units of packed RBCs; hematocrit 29. 9, hemoglobin 9. 2. Tolerating clear liquids well. She is on H 2 blocker, Sucralfate and antacids. No GI complaints at this time. NG tube was removed. Stools remain melanotic. Blood pressure, pulse, respirations are stable; temperature normal. Abdominal exam is basically unchanged from yesterday. 146 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

AMENDED CHART NOTES It is not unlawful to amend a physician’s chart notes to add inadvertently omitted information. Amendments should be made as follows: Don’t revise a closed note, one that’s already been signed and dated by the physician. Don’t replace an original note with new notes. Instead, add the extra information as an amendment or addendum. Identify the amendment as an amendment of “late entry. ” Have the physician sign the amendment and date it. 147 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

AMENDED CHART NOTES Date it with the date the amendment is made, not the date of the original note. Otherwise, you risk fraud allegations for misrepresentation. Obviously, amend a note only when the additional work actually was performed and was medically justified. Avoid adding elements to raise the level of service. Make amendments to notes within a reasonable timeframe. It is questionable whether a physician remembers details of a patient’s care weeks later. 148 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

TEACHING PHYSICIAN GUIDELINES 149 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

MEDICARE TP ATTESTATION REQUIREMENT The 11/22/02 revisions to the regulations provide that for E&M services, the TP does not have to duplicate any resident documentation. The TP must be present during the key portions of the service and personally document his or her presence. The resident note alone, the TP note alone or a combination of the two may be used to support the level of service billed. Documentation by a resident of the presence and participation of the TP is not sufficient. Documentation may be dictated and typed, hand-written or a computer statement initiated by the TP. 150 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

TEACHING PHYSICIAN ATTESTATION FOR E/M SERVICES The attending physician who bills for evaluation and management (E&M) services in the teaching setting must, at a minimum, personally document: His or her participation in the management of the patient; and That he or she performed the service or was physically present during the critical or key portion(s) of the service performed by the resident (the resident’s certification that the attending physician was present is not sufficient) You have to include some of your history, exam, assessment, and plan – merely stating “reviewed and agree” is no longer enough When properly attested, the resident’s documentation and the faculty’s documentation are both considered in determining the E/M level. Use your attestation to augment/supplement what the resident documented. 151 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

MEDICARE’S EXAMPLES OF ACCEPTABLE TP NOTES CMS’ examples of minimally acceptable documentation: Admitting Note: “I performed a history and physical examination of the patient and discussed his management with the resident. I reviewed the resident’s note and agree with the documented findings and plan of care. ” Follow-up Visit: “I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident’s note. ” or “I saw and examined the patient. I agree with the resident’s note except the heart murmur is louder, so I will obtain an echo to evaluate. ” Initial or Follow-up Visit: “I was present with resident during the history and exam. I discussed the case with the resident and agree with the findings and plan as documented in the resident’s note. Follow-up Visit: “I saw the patient with the resident and agree with the resident’s findings and plan. 152 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

MEDICARE’S EXAMPLES OF UNACCEPTABLE TP NOTES “Agree with above. ” followed by legible countersignature or identity; “Rounded, Reviewed, Agree. ” followed by legible countersignature or identity; “Discussed with resident. Agree. ” followed by legible countersignature or identity; “Seen and agree. ” followed by legible countersignature or identity; “Patient seen and evaluated. ” followed by legible countersignature or identity; and “A legible countersignature or identity alone. The preceding six and similar statements don’t make it possible to determine whether the TP was present, evaluated the patient, and/or had any involvement with the plan of care. 153 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

MEDICARE’S SUPERVISION GUIDELINES FOR PROCEDURES PERFORMED WITH RESIDENTS Minor procedures of <5 minutes: Must be present the entire time Endoscopies (other than surgical operations): TP must be present for entire viewing including insertion and removal 154 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

DOCUMENTATION GUIDELINES FOR MINOR PROCEDURES Procedure name Names of the teaching physician and assistants Pre-operative and post-operative diagnoses, if different Description of the procedure Post-operative instructions Anesthetic agent, if any Additional information to support the procedure performed Legible signature(s) 155 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

DOCUMENTATION GUIDELINES FOR MINOR PROCEDURES Attestation for minor procedures: Present for entire procedure. Presence demonstrated by personal note. “I was present for the entire bone biopsy performed by Dr. Resident. ” 156 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

MEDICARE SUPERVISION GUIDELINES FOR SPECIFIC PROCEDURES Time-based procedures billed on TP time only Critical care Hospital discharge day management Prolonged services Care plan oversight E&M counseling/coordination of care 157 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

MEDICARE SUPERVISION GUIDELINES FOR SPECIFIC PROCEDURES Specific complex or high-risk procedures require continual personal TP supervision Interventional radiologic/cardiology codes Cardiac cath, stress tests, transesophageal ECG 158 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

KEY POINTS FOR DOCUMENTING INPATIENT SERVICE Must be legible. SOAP note must include a chief complaint, ie, follow -up for gastroenteritis Document time for admissions, discharges, critical care, time-based coding, and start/stop times for prolonged services. Resident (if applicable) and faculty must sign. Faculty attestation must show active participation (“Reviewed and agree won’t do it – your documentation needs to supplement the resident’s note). Cannot use documentation notes of non-UT Medicine auxiliary staff or mid-levels. 159 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

COMPLETING FEE TICKET Select E/M level and any CPT procedure codes. Select and sequence

COMPLETING FEE TICKET #1 = CC or primary reason for appointment Code additional diagnoses or co-morbid conditions that coexist at the time of the service and influence, require, or affect patient care or treatment as supported in documentation. Pay attention to sequencing when providing an E/M service and a procedure in same visit. Sequencing required to link diagnoses to E/M codes and procedures performed. 161 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

COMPLETING FEE TICKET • Remember ICD-9 codes explain why you performed the service • If procedures are performed, sequencing is critical since the correct diagnosis code must be linked to the procedure for the procedure to be paid. Select modifiers 25 modifier is checked or written next to E/M code selected when a procedure is performed (otherwise one of the service codes may not be paid). Sign fee ticket (paper). 162 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

IN CLOSING Avoid reckless disregard for the rules. Understand the rules of documentation Avoid using the same level code for all services of the same type (i. e. consultations). Avoid down-coding which suggests lack of understanding. Document all requests for consultations. 163 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

In closing, (con’t) Avoid use of the word "referral" for consultations. Evaluate your charge documents annually. Never bill for services for which you were not present. Audit your practice every 6 months. Have a mandatory education program in place for physicians and billing staff. 164 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

Outpatient Evaluation &. Management CPT Code Criteria New Patient Avg time (mins) 99201 10 CC: Required 99202 20 CC: Required 99203 30 CC: Required 99204 45 CC: Required 99205 60 CC: Required Requires all three key Components HPI: 1 -3 ROS: None PFSH: None HPI: 1 -3 ROS: 1 Pertinent PFSH: None HPI: 4+ ROS: 2 -9 PFSH: 1 Pertinent HPI: 4+ ROS: 10+ PFSH: 3 PE: 1 BA/OS PE: 2 -7 BA/OS w/detail PE: 8+OS MDM: Straightforward MDM: Low MDM: Moderate MDM: High Established Patient Avg time (mins) 1/15/2009 99211 5 99212 10 99213 15 www. codingnetwork. com © 2006 The Coding Network, LLC 99214 25 99215 40 174

Outpatient Evaluation &. Management CPT Code Criteria CC: Required HPI: Requires two of the CC: Required HPI: 1 -3 HPI: 4+ ROS: None ROS: 1 ROS: 2 -9 ROS: 10+ PFSH: None PE: 1 BA/OS PFSH: 1 PE: 2 -7 BA/OS PFSH: 2 -3 PE: 8+OS MDM: Straightforward MDM: Low PFSH: 1 PE: 2 -7 BA/OS w/detail MDM: Moderate three key components PFSH: None PE: MDM: High Office Consultation New or Established 1/15/2009 99242 99243 www. codingnetwork. com © 2006 The Coding Network, LLC 99244 99245 175

Outpatient Evaluation &. Management CPT Code Criteria Avg time (mins) 15 30 40 60 80 CC: Required CC: Required HPI: 1 -3 HPI: 4+ ROS: 10+ Requires all three ROS: None key components PFSH: None PE: 1 BA/OS ROS: 1 Pertinent ROS: 2 -9 PFSH: None PFSH: 1 Pertinent PFSH: 3 PE: 2 -7 BA/OS w/detail PE: +OS MDM: Low Straightforward 1/15/2009 PE: 8+OS MDM: Moderate MDM: High www. codingnetwork. com © 2006 The Coding Network, LLC 176

Hospital Inpatient Services Evaluation & Management CPT Code Criteria Initial Hospital Care 99221 Avg time (mins) 30 CC: Required HPI: 4+ ROS: 2 -9 PFSH: 1 Requires all three PE: 2 -7 BA/OS w/detail key MDM: Low components 99222 50 CC: Required HPI: 4+ ROS: 10+ PFSH: 3 PE: 8+OS MDM: Moderate 99223 70 CC: Required HPI: 4+ ROS: 10+ PFSH: 3 PE: 8+OS MDM: High Subsequent Hospital Care 99231 99232 99233 Avg time (mins) 15 25 35 177 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

Hospital Inpatient Services Evaluation & Management CPT Code Criteria CC: Required HPI: 1 -3 ROS: None Requires two of the PFSH: None PE: 1 BA/OS three key MDM: Low components Initial Inpatient Consultation Avg time (mins) 99251 20 CC: Required HPI: 1 -3 ROS: None Requires all three PFSH: None key PE: 1 BA/OS components MDM: Straightforward CC: Required HPI: 1 -3 ROS: 1 Pertinent PFSH: None PE: 2 -7 BA/OS MDM: Moderate CC: Required HPI: 4+ ROS: 2 -9 PFSH: None PE: 2 -7 BA/ OS / detail MDM: High 99252 99253 40 CC: Required HPI: 1 -3 ROS: 1 Pertinent PFSH: None PE: 2 -7 BA/OS MDM: Straightforward 55 CC: Required HPI: 4+ ROS: 2 -9 PFSH: 1 Pertinent PE: 2 -7 BA/ OS w/detail MDM: Low 99254 80 CC: Required HPI: 4+ ROS: 10+ PFSH: 3 PE: 8+OS MDM: Moderate 99255 110 CC: Required HPI: 4+ ROS: 10+ PFSH: 3 PE: : 8+OS MDM: High 178 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

History Components HPI: History of Present Illness PFSH: Past, family & Social History Location Timing Quality Context Severity Modifying Factors Duration Associated signs/symptoms Past medications, illnesses, injuries, operations, hospitalization, allergies, immunizations status Family health status and dx of family members or cause of death Social marital status, current employment/occupational, environment, drugs, alcohol and tobacco use, sexual history ROS: Review of Systems 2 ROS documented, remainder “all other systems negative” = complete ROS Constitutional Respiratory Musculoskeletal Psychiatric Allergic/Immunologic Eyes Gastrointestinal Integumentary Endocrine Cardiovascular ENMT Genitourinary Neurological Hematologic/Lymphatic 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC 179

Examination Components BA: Body Area OS: Organ System Abdomen GU/groin/pelvic/buttocks Back, Spine Head & Face Chest, Breasts Neck Each Extremity Constitutional systems Gastrointestinal Musculoskeletal Cardiovascular Genitourinary Neurological Ears Nose Mouth Throat Hematologic/Lymphatic/Immunologic Psychiatric Eyes Integumentary (skin and breast) Respiratory 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC 180

Risk of Complications and/or Morbidity or Mortality Level of Risk Category I Presenting Problems Category II Diagnostic Procedure(s) Minimal One self-limited or minor Laboratory tests requiring (1) problem, e. g. venipuncture Cold, insect bite, tinea corporis Chest X-rays EKG/EEG Urinalysis Ultrasound, e. g. , echocardiography KOH prep 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC Category III Management Options Selected Rest Gargles Elastic bandages Superficial dressings 181

Risk of Complications and/or Morbidity or Mortality Low Two or more self-limited or Physiologic tests not under (2) minor problems stress, e. g. One stable chronic illness, pulmonary function tests e. g. , well controlled Non-cardiovascular imaging Hypertension or non-insulin studies with contrast, dependent e. g. , barium enema diabetes, cataract, BPH Superficial needle biopsies Acute uncomplicated illness Clinical laboratory tests or injury. requiring arterial puncture e. g. , cystitis, allergic Skin biopsies rhinitis, simple sprain 1/15/2009 Over the counter drugs Minor surgery with no identified risk factors Physical therapy Occupational therapy IV fluids without additives www. codingnetwork. com © 2006 The Coding Network, LLC 182

Risk of Complications and/or Morbidity or Mortality Moderat One or more chronic Physiologic tests under stress, e. g. Minor surgery with identified e illnesses with mild stress test risk factors (3) exacerbation, progression or Diagnostic endoscopies with no Elective major surgery (open, side effects of treatment identified risk factors percutaneous or Two or more stable chronic Deep needle or incisional biopsy endoscopic) illnesses Cardiovascular imaging studies Prescription drug management Undiagnosed new problem with contrast and no Therapeutic nuclear medicine with uncertain prognosis, identified risk factors, e. g. IV fluids additives e. g. , lump in breast arteriogram, cardiac Closed treatment of fracture Acute illness with systemic catheterization or dislocation without symptoms, Obtain fluid from body cavity, manipulation e. g. , pyelonephritis, e. g. lumbar puncture, pneumonitis, colitis thoracentesis, culdocentesis Acute complicated injury, e. g. , head injury with brief loss of consciousness 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC 183

Risk of Complications and/or Morbidity or Mortality High One or more chronic Cardiovascular imaging studies Elective major surgery (open, (4) illnesses with severe with contrast with identified risk percutaneous or exacerbation, progression or factors endoscopic) with identified side effects of treatment Cardiac electrophysiological risk factors Acute or chronic illnesses or tests Emergency major surgery injuries that pose a Diagnostic endoscopies with (open, percutaneous threat to life or bodily identified risk factors Or endoscopic) function, e. g. , multiple Discography Parenteral controlled trauma, acute MI, pulmonary substances embolus, severe Drug therapy requiring respiratory distress, intensive monitoring for progressive severe toxicity rheumatoid arthritis, Decision to not resuscitate or psychiatric illness with to de-escalate care potential threat to self or because of poor prognosis others, peritonitis, acute renal failure An abrupt change in neurologic status, e. g. , seizure, TIA, weakness or sensory loss 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC 184

EVALUATION AND MANAGEMENT Trail. Blazer Coding and Documentation Reference Guide HEALTH ENTERPRISE, LLC © CP 7 codes, descriptions, and other data only are copyright 2007 American Medical Association. All rights reserved. Applicable FARS/DFARS clauses apply. 1 ) HISTORY Status of 1 -2 chronic conditions 1 condition Location 2 conditions OR Severity 3 conditions Timing Duration Context Brief (1 -3) Extended (4 or more) N/A Pertinent to problem (1 system) Extended (Pert and others) (2 -9 systems) Complete (Pert and all others) (10 systems) N/A Pertinent (1 history area) "Complete (2 or 3 history areas) PROBLEMFOCUSED Associated signs and symptoms Status of 3 chronic conditions EXP. PROBLEM -FOCUSED DETAILED Status of 3 chronic conditions Modifying factors Quality Status of 1 -2 chronic conditions Brief (1 -3) HPI (History of Present Illness): Characterize HPI by considering either the Status of chronic conditions or the number of elements recorded. 1 condition 2 conditions 3 conditions Quality Duration Context Associated signs and symptoms HPI (History of Present Illness): Characterize HPI by considering either the Status of chronic conditions or the number of elements recorded. Location Severity Timing Modifying factors ROS (Review of Systems): Constitutional Ears, nose, Gl Integumentary Endo (wt loss, etc. ) mouth, throat (skin, breast) Eyes Card/vase GU Neuro Hem/lymph Musculo Psych All/immuno Resp PFSH (Past, Family, Social History): Past history (the patient's past experiences with illnesses, operations, injuries and treatments) Family history (a review of medical events in the patient's family, including diseases that may be hereditary or place the patient at risk) Social history (an age-appropriate review of past and current activities) "Complete PFSH: 2 history areas: a) established patients - office (outpatient) care, domiciliary care, home care; b) emergency department; c) subsequent nursing facility care; and, d) subsequent hospital care. 3) history areas: a) new patients - office (outpatient) care, domiciliary care, home care; b) consultations; c) initial hospital care; d) hospital observation; and, e) initial nursing facility care. COMPREHENSIVE Final History requires all 3 components above met or exceeded 185 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC

EVALUATION AND MANAGEMENT Coding and Documentation Reference Guide Trail. Blazer HEALTH ENTERPRISE, LLC © CP 7 codes, descriptions, and other data only are copyright 2007 American Medical Association. All rights reserved. Applicable FARS/DFARS clauses apply. 2) EXAMINATION " — CRT Exam Description 95 Guideline Requirements 97 Guideline Requirements CRT Type of Exam Limited to affected body area or organ system One body area or organ system 1 -5 bulleted elements PROBLEM-FOCUSED EXAM Affected body area or organ system and other symptomatic or related organ systems 2 -7 body areas and/or organ systems 6 -11 bulleted elements EXPANDED PROBLEMFOCUSED EXAM Extended exam of affected body area or organ system and other symptomatic or related organ systems 2 -7 body areas and/or organ systems 12 -17 bulleted elements for 2 or more systems DETAILED EXAM 8 or more body areas and/or organ systems 18 or more bulleted elements for 9 or more systems General multi-system Complete single organ system exam 1/15/2009 Not defined COMPREHENSIVE EXAM See requirements for individual single system exams www. codingnetwork. com © 2006 The Coding Network, LLC 186

EVALUATION AND MANAGEMENT Coding and Documentation Reference Guide Trail. Blazer HEALTH ENTERPRISE, LLC © CP 7 codes, descriptions, and other data only are copyright 2007 American Medical Association. All rights reserved. Applicable FARS/DFARS clauses apply. MEDICAL DECISION-MAKING Instructions for Using Trailblazer’s MDM Coding Method Coding Medical Decision-Making (MDM) begins with separately coding the three distinct components of MDM. Two of the three components determine the final level of MDM complexity documented in a record of Evaluation and Management (E/M) service. These components are: 1. Number of diagnoses and/or management options. 2. Amount and/or complexity of data reviewed or ordered. 3. Risk of complication and/or mortality. The Trail. Blazer MDM coding method corresponds directly to the components above as follows: • Section A corresponds to number of diagnoses and/or management options. • Section B corresponds to amount and/or complexity of data reviewed or ordered, • Section C corresponds to risk of complication and/or mortality. Code each component separately using respective Tables A-C, then compare results from Tables A-C to requirements in Table D to determine the overall MDM level. Section A Coding Number of Diagnoses or Management Options – Use the Table A. 1 and A. 2 on page 2 to determine the numbers of diagnoses or management options. Note: In all cases, the information in the clinical record (history and physical) must clearly support diagnostic impressions. Diagnostic impressions listed but not supported elsewhere I the clinical record must be included in the problem list for coding purposes. 1/15/2009 www. codingnetwork. com © 2006 The Coding Network, LLC 187