Introduction. Procedure

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1 Page 1 of 8 Training Guide Clinical Evaluation Criteria for Technical Services TRAINING GUIDE FOR USE OF CLINIC EVALUATION & MANAGEMENT (E&M) CRITERIA FOR TECHNICAL CHARGES Introduction The following guidelines pertain to all aspects of generating an evaluation and management (E&M) visit technical charge in the clinics of University of Illinois Medical Center at Chicago (UIMC). It is important to have a standardized and consistent methodology for reporting E&M visits performed. The guidelines developed for UIMC are based on the expert panel recommendations produced by the American Hospital Association (AHA) and the American Health Information Management Association (AHIMA) at the request of the Centers for Medicare and Medicaid Services (CMS). CMS has not yet mandated uniform criteria for hospitals to adopt; therefore, it is the responsibility of each individual hospital to develop standards and criteria by which clinic charges are to be made. Upon submission of a bill, the payer expects that clinic charges are consistent with UIMC-specific methodology. The level of interventions on the Clinic E&M Criteria sheet represent hospital (technical) resources consumed and used during a clinic visit; therefore, physician services are NOT considered in applying the technical coding level. Hospital resources may include use of the room and associated utilities, nursing time, medical assistant time, clerical time, other non-physician staff member time and supplies. This charge represents the hospital overhead costs associated with all services that do not have a separate procedure charge. Procedures that have separate CPT codes include an evaluation and management component. You do not routinely charge for a separate E/M service in addition to the procedure. The purpose of the patient visit should help guide staff members in determining whether a charge should be initiated for an office visit (E and M) only, a distinct procedure only, or whether there is evidence of both a procedure and identifiably distinct evaluation and management service. In some circumstances, an event that occurs during a procedure could lead to a separately billable E and M service. Conversely, a visit that starts out as an E and M service, could result in a separately billable procedure performed. In either case, the appropriate modifier must be attached to reflect a distinct E and M service when a procedure is also billed. Procedure Review the Clinic E&M Technical Criteria and become familiar with the layout of the form. Each time an intervention is performed on a patient, mark it on the form designated for charging that patient. Please note that not all interventions will occur in each clinic. The charging system consists of five levels of intervention (levels I-V). Staff should select all interventions done for the patient that are supported by documentation in the medical record. Contributory factors can be used to increase the intervention level by one, to a maximum of Level V. For example, if the highest intervention you performed for an established patient was vital signs, your intervention would be Level I. If you also arrange for scheduling and coordination of an ancillary service of that patient, it counts as a contributory factor, increasing the intervention to Level II for that patient.

2 Page 2 of 8 Three or more documented interventions levels I-IV will increase the technical component to the next level; a contributory factor in this case will also increase the technical component to the next level. The contributory factors must be documented, but will not affect the charge, as the highest level has already been attained. Some supplies used in the clinics can be separately charged; please continue to charge for supplies using current practice. Guideline for selecting new vs. established patient visits for technical services The CPT codes used to report visits differentiate between new and established patients. Effective January 1, 2009 per the November 24, 2008 OPPS Final Rule published in the federal register (73FR68679), a new patient (on the technical side) is one who has NOT been registered as either an inpatient or outpatient of the hospital within the past 3 years. An established patient is one who has been registered as an inpatient or outpatient of the hospital within the past 3 years. Staff should determine in the Hospital Information System if the patient has a registration listed within the last 3 years of the date of service prior to the appointment and designate them appropriately based on this determination. CPT codes for new patients to be used are 99201, 99202, 99203, 99204, and CPT codes for established patients to be used are 99211, 99212, 99213, 99214, and For technical charges, there is no acknowledgment of consult status those CPT codes apply to only physician charges. Procedure only (no separate E/M): some areas may wish to issue this form to every patient as an internal control for reconciliation at the end of the day. In that case, if the purpose of the visit is for a procedure only and there is no separately identifiable evaluation and management service provided, the patient label would be attached, this item would be selected and no further information is required.

3 Page 3 of 8 Technical Staff Interventions Interventions not listed or defined below should be self-explanatory and charged only once per episode unless indicated on the charge criteria. The guidelines stated are separated into the major sections as listed on the Clinic E&M Criteria. Level I Interventions (99201, 99211) Registration/check-in Exam room utilization Blood pressure check/recheck ONLY Weight check only Specimen collection (patient self-collects) Three or more interventions at this level = level II (99202/99212) Patient appointment confirmation and check-in on arrival Clean, set up and stock room Select if only BP is taken without other VS. Providing instructions of patient on proper specimen collection (mid-stream urine, sputum). Patient is performing collecting. Does not include venipuncture, which has its own CPT code. Level II Interventions (99202, 99212) Single specialized clinical measurement Vital signs Suture and staple removal Wound management 15 sq cm or less Heplock flush *Face-to-face education up to 5 minutes Create/update medication list (1-5 meds) Examples: BMI, positional blood pressure, head circumference, cardiac monitor rhythm strip done by a nurse or tech Initial set only; includes pains screen/score only. If comprehensive pain assessment is performed and documented by non-md clinician, select level 4 pain screening and assessment. Pulse oximetry is considered a vital sign if performed routinely on all patients. Performed by a non-physician When not separately billable. Includes cleansing, assessment, measurement, photographing, ankle brachial index, or dressing of wound. Includes steri-strips and other adhesives, butterflies and eye patch. For multiple wounds, add the total size of all wounds. Documentation to support the content of education, time involved, and any factors that impacted time required. Education may be performed by any health care professional (excluding physicians), such as dieticians, nurses and pharmacists. Includes face-to face review of written instructions by assistive personnel Examples: Crutch training, diabetic teaching, counseling regarding diet, exercise, and other lifestyle changes. Includes collection and recording current

4 Page 4 of 8 *Face-to-face assessment up to 5 minutes Review summary list elements w/pt; no updates Three or more interventions at this level = level III (99203/99213) prescribed, OTC meds and herbal supplements at the time of service via interview of patient, review of records, and/or transcribed from current Rx containers. If patient education on medication management is also provided, also select and document appropriate patient education category by time criteria (eg face-to-face education 6 to 15 minutes) Other assessments not otherwise specified (fall risk, nutritional, etc.) may be performed by any health care professional (excluding physicians), such as dieticians, nurses and pharmacists. Nature, scope, and time length of assessment must be documented. Patient self-assessments are excluded. Face-to-face review with pt of currently documented allergies; significant problems; surgical procedures patient confirms all information is current with no updates required Level III Interventions (99203, 99213) Administration of medication Administration of single disposable enema Application of preformed splint(s)/elastic bandages/slings/or immobilizer Create/update summary list elements *Face-to-face education 6-15 min Routes of administration include oral, topical, rectal, parenteral, nasogastric and sublingual. For injections, use specific CPT code Preformed is off-the-shelf. Not to be used for fracture or dislocation injuries (those procedures are separately billable). Includes collection and recording lists of allergies (especially medications and products), significant medical problems, and significant procedures at the time of service via interview or patient and/or review or records. If medication list is also created/updated, also select and document appropriate medication list category by volume criteria (eg Create/update medication list 1-5 meds ) Documentation to support the content of education, time involved, and any factors that impacted time required. Education may be performed by any health care professional (excluding physicians), such as dieticians, nurses and pharmacists. Includes face-to face review of written instructions by assistive personnel Examples: Crutch training, diabetic teaching, counseling regarding diet, exercise, and other lifestyle changes.

5 Page 5 of 8 First aid procedures Foreign body removal from skin, subcutaneous or soft tissues Frequent monitoring/ assessment as evidenced by two sets of vital signs or assessments (including initial set) O2 administration Specimen collection by nurse, medical assistant or tech Wound management sq cm Create/update medication list (6-9 meds) *Face-to-face assessment 6-15 min Three or more interventions at this level = level IV (99204/99214) Examples: Control bleeding, ice, monitor vital signs, cool body, remove stinger from insect bite, cleanse and remove secretions Without anesthesia or incision, when not a separately billable procedure This is integral to current interventions and/or patient s condition. Examples: Additional vital signs, assessment of cardiovascular, pulmonary or neurological status, assessment of pain scale, pulse oximetry or peak flow assessment. Initiation or adjustment from baseline oxygen regimen. Includes conversion to hospital-supplied oxygen with rate adjustments, as well as initiation of oxygen administration. Other than venipunctures. Includes collection of specimen (not the performance of lab test), e.g. throat culture collection. Does not Include collection of blood from a completely implanted vascular access device (36540). When not separately billable. Includes cleansing, assessment, measurement, photographing, ankle brachial index, or dressing of wound. Includes steri-strips and other adhesives, butterflies and eye patch. For multiple wounds, add the total size of all wounds. Note: For multiple wounds, add the total size of all wounds. Includes collection and recording current prescribed, OTC meds and herbal supplements at the time of service via interview of patient, review of records, and/or transcribed from current Rx containers. If patient education on medication management is also provided, also select and document appropriate patient education category by time criteria (eg face-to-face education up to 15 minutes) Other assessments not otherwise specified (fall risk, nutritional, etc.) may be performed by any health care professional (excluding physicians), such as dieticians, nurses and pharmacists. Nature, scope, and time length of assessment must be documented. Patient self-assessments are excluded. Level IV Interventions (99204, 99214) Pain screening AND assessment Documentation of comprehensive pain assessment when performed by RN or other non-physician clinician. Pain screening score only (without assessment) is reported as Vital Signs (level 1)

6 Page 6 of 8 Create/update medication list (10 or more meds) Assist physician with exam Catheter or ostomy device care *Face-to-face education min Frequent monitoring and assessment with greater than 2 sets of vital signs Includes collection and recording current prescribed, OTC meds and herbal supplements at the time of service via interview of patient, review of records, and/or transcribed from current Rx containers. If patient education on medication management is also provided, also select and document appropriate patient education category by time criteria (eg face-to-face education up to 15 minutes ) Includes pelvic exam, eye exam/slit lamp exam of eye, other exams without specific CPT codes. Chaperoning. Documentation must support assistance/presence in room unless written protocol exists. Care of devices or catheters (both indwelling and in & out) (vascular or nonvascular) and ostomy devices (other than insertion or reinsertion) Documentation to support the content of education, time involved, and any factors that impacted time required. Education may be performed by any health care professional (excluding physicians), such as dieticians, nurses and pharmacists. Includes face-to face review of written instructions by assistive personnel Examples: Crutch training, diabetic teaching, counseling regarding diet, exercise, and other lifestyle changes. This is integral to current interventions and/or patient s condition. Examples: Additional vital signs; assessment of cardiovascular, pulmonary or neurological status; assessment of pain scale; pulse oximetry or peak flow assessment; urgent and emergent care interventions When not separately billable. Includes cleansing, assessment, measurement, photographing, ankle brachial index, or dressing of wound. Includes steri-strips and other adhesives, butterflies and eye patch. For multiple wounds, add the total size of Wound management sq cm all wounds. Other assessments not otherwise specified (fall risk, nutritional, etc.) may be performed by any health care professional (excluding physicians), such as dieticians, nurses and pharmacists. Nature, scope, and time length of assessment must be documented. Patient self-assessments are *Face-to-face assessment min excluded. Three or more interventions at this level = level V (99205/99215)

7 Page 7 of 8 Level V Interventions (99205, 99215) Assessment, crisis intervention and supervision of imminent behavioral crisis threatening self or others Continuous eye irrigation with therapeutic lens *Face-to-face education >30 min Continuous monitoring and assessment Suctioning (nasotracheal or orotracheal) Wound management >50 sq cm Airway insertion *Face-to-face assessment >30 min Includes Morgan lens Documentation to support the content of education, time involved, and any factors that impacted time required. Education may be performed by any health care professional (excluding physicians), such as dieticians, nurses and pharmacists. Includes face-to face review of written instructions by assistive personnel Examples: Crutch training, diabetic teaching, counseling regarding diet, exercise, and other lifestyle changes. Includes urgent care When not separately billable. Includes cleansing, assessment, measurement, photographing, ankle brachial index, or dressing of wound. Includes steri-strips and other adhesives, butterflies and eye patch. For multiple wounds, add the total size of all wounds. Other assessments not otherwise specified (fall risk, nutritional, etc.) may be performed by any health care professional (excluding physicians), such as dieticians, nurses and pharmacists. Nature, scope, and time length of assessment must be documented. Patient selfassessments are excluded. *Note: Education and assessment time is cumulative. Each non-physician provider documents the education and assessment services provided and the time spent. All provider time is then added together to determine the total time of education and/or assessment provided during the visit.

8 Page 8 of 8 Contributory Factors Contributory factors are services or other factors that, when present, may increase the E&M level from one level to the next highest level. Only one factor is required to for this increase to a higher level. These factors apply to levels I through IV you cannot increase a level V to critical care using the contributory factors. Evidence of contributory factors must be documented in the record. For example, your patient meets a level II intervention and has two contributory factors. These factors, regardless of the number, increase the intervention by only one level. You cannot increase a level II intervention selection to a level IV intervention by using contributory factors alone. The following factors are used to increase level I to level II, level II to level III, level III to level IV, or level IV to level V. Contributory Factors Altered mental status Arrangements for social service intervention Scheduling/coordination of care Admission or transfer to hospital or other facility Mandatory Reporting to law enforcement, protective services, Infection control, etc. Isolation Simultaneous care by greater than one staff member Special needs requiring additional facility resources Ex: Pt with dx of Alzheimer s Includes reporting of child abuse, battery, elder abuse etc.; Coordinating consultation with social work or social service agency Includes booking future appointments while the patient is present such as admission to the hospital, Surgicenter; scheduling diagnostic testing, etc. This does not include scheduling of routine return to clinic visits. Patient discharged to place other than home new admission to the hospital, skilled nursing facility, etc Includes gunshot, sexually transmitted disease and infection reporting Includes prisoner precautions and holding