Evaluation & Management Place of Service
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1 Evaluation & Management Place of Service Hoda Henein, CHBME, CP President & CEO, Active Management A Practice Management Consulting and Billing Company Fellow, Speaker, Billing & Coding Advisor American Academy of Podiatric Practice Management (AAPPM) & Langer Biomechanics Member of the Editorial Advisory Board for Podiatry Coding Alert Member of Healthcare Billing Management Association(HBMA) Member of American Academy of Professional Coders(AAPC) Member of American Medical Billing Association(AMBA) Member of American Health Information Management Association(AHIMA) activebilling@activemds.com Telephone: Fax:
2 Active Management owns the copyright of the material here presented, including photographs and graphic designs, unless otherwise specifically stated. In the case of some materials, Active Management has licensed rights to third parties. This presentation is designed to be used to educate attendees about medical billing and practice management. The use of Active Management material for any purpose, including in hard copy or compilation for CD-ROM or any other electronic media, is prohibited unless prior written permission is obtained. In addition, the use of Active Management material by unauthorized parties in lectures or seminars is also prohibited.
3 Evaluation & Management = Place of Service How to determine the level to be billed out? History E & M = CPT Code that refers to a level of service in a Time Examination particular setting. These 7 components define the level of service Nature of Presenting Problem E/M Levels Medical Decision Making Key Components Contributory Factors Coordination of Care Counseling
4 E&M How to determine the level to be billed out? Chief Complaint (CC) History of Present Illness (HPI) Review of Systems (ROS) Past / family / social history (PFSH) Exam 97 - Elements Exam 95 - Risk / Complexity (Time)
5 (CC) Chief Complaint A chief complaint is always necessary
6 (HPI) history of present illness - Eight possible elements o Location o Quality o Severity o Duration o Timing o Context o Modifying factors o Associated signs and symptoms
7 (ROS) Review of Systems A system is considered reviewed if the patient s positive responses and pertinent negatives are documented
8 (ROS) Review of Systems 14 possible systems that can be reviewed: Eyes Skin Ears, Nose, Throat Neurological Cardiovascular Psychiatric Respiratory Endocrine Allergic Hematologic Gastrointestinal Musculoskeletal Genitourinary Integumentary
9 (PFSH) Past, Family and/or Social History Past History illnesses, operations, injuries and treatments Family History review of medical events in the patient s direct family members which may be relevant to the patient s CC Social History age appropriate review of past and current activities
10 Determine the level of History TYPE of History HPI ROS PFSH Problem Focused Brief (1) N/A N/A Expanded Problem Problem (1) Brief (1) N/A Focused pertinent Detailed Extended (4) Extended (2) Pertinent (1) Comprehensive Extended (4) Complete (10) Complete (NP-3) (EST-2)
11 Determine the level of Exam Four possible types of Examinations Problem Focused (1 body area / organ system) Expanded Problem Focused (2 to 7 body areas / organ systems; Limited) Expanded Problem Detailed (2 to 7 body areas / organ systems; Extended) Comprehensive (8 or more body areas / organ systems)
12 (MDM) Medical Decision Making Four levels of MDM based on number of diagnoses or management options amount and/or complexity of data reviewed risk to the patient
13 Putting It All Together Level of History Level of Exam Level of MDM Time face to face Physician and patient Only considered if >50% of face to face time is spent in counseling
14 Hot Sheet of 97 Guidelines
15 Example: E&M How to determine the level to be billed out? Learn 97 Guidelines Document your bullets Use a Template Be prepared to be audited Dr Billed Dr Audited Determined should be billed Dr Receives bill for $70,000 recoupment
16 Notes/Documentation Suggestion: itemize each procedure separately Reason: when the non-clinical adjudicator reviews your procedure notes they can clearly see all the procedures performed and the Medical Necessity to justify them. If it is not written down It didn t happen Note: If it is difficult to interpret, the insurance employee will disallow.
17 E M R How to determine the level to be billed out? Why should you get EMR? $$$ It s the economy stupid incentives! How can EMR make money? $$$ It will document what you do Fast, Complete, and Legible. Are you prepared to change your work flow? $$$ Trade off - More work upfront Less work at the back end. Are you going to use it? $$$ Take time to learn your software
18 Consultation Codes NOT for Medicare Use Office Consultation Impatient Consultation
19
20 Place of Service
21 Place of Services POS is the location where the service was performed: POS Description E&M Codes 11 Office / Adult Day Care (New) / (Est) (Consult New or Est) 12 Patient s Home and DMERC products (New) / (Est) 20 Urgent Care Facility (New Code) (New) / (Est) 21 Inpatient Hospital (New) / (Est) (Consult New / Est) 22 Outpatient Hospital (New) / (Est) 23 Emergency Room Surgical Center N/A 31 Skilled Nursing Facility (SNF) (New) Not used by DPM 32 Nursing Facility (Est) 33 Custodial Care Facility / Assisted Living / Domiciliary (Rest Home) 34 Hospice (New) / (Est)
22 POS Description Code Place Of Service 11 Office Description Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis Patient s Home and DMERC products Location, other than a hospital or other facility, where the patient receives care in a private residence.
23 Code Place Of Service Description 20 Urgent Care Facility 21 Inpatient Hospital 22 Outpatient Hospital 23 Emergency Room 24 Surgical Center POS Description Location distinct from a Hospital ER, an Office, or clinic, who s purpose is to diagnose and treat illness or injury for unscheduled ambulatory patients seeking immediately medical attention. A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and non-surgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions. A portion of a hospital which provides diagnostic, therapeutic (both surgical and non-surgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided. A freestanding facility, other than a physician's office, where surgical and diagnostic services are provided on an ambulatory basis.
24 POS Description Code Place Of Service 31 Skilled Nursing Facility (SNF) 32 Nursing Facility 33 Custodial Care Facility Assisted Living Domiciliary (Rest Home) Description A facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital. A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than mentally retarded individuals. A facility which provides room, board and other personal assistance services, generally on a long-term basis, and which does not include a medical component.
25 Podiatry Billing Modifiers DME Receivables Management Thank you!!! Hoda Henein, CHBME, CP President & CEO, Active Management Management Consulting & Billing Company All rights reserved. This material may not be reproduced, displayed, modified or distributed without the express prior written permission of the copyright holder. Telephone: Fax:
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Modifiers. Hoda Henein, CHBME, CP President & CEO, Active Management A Practice Management Consulting and Billing Company
Modifiers Hoda Henein, CHBME, CP President & CEO, Active Management A Practice Management Consulting and Billing Company Fellow, Speaker, Billing & Coding Advisor American Academy of Podiatric Practice
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