Determine the Appropriate Level E/M Code Based on the Encounter
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1 Determine the Appropriate Level E/M Code Based on the Encounter Jeffrey D. Lehrman, DPM, FACFAS, FASPS, FAPWH APMA Coding Committee Expert Panelist, Codingline.com Fellow, American Academy of Podiatric Practice Management
2 Types of visits Diagnosis code Treatment Code E +M Procedure
3 Where am I? Office (includes wound care center) Hospital outpatient Hospital Nursing Home
4 New/Initial versus Established Office: New patient is one never seen by you or your practice or one that has not been seen by you or your practice in 3 years Hospital / NH: Initial encounter is first time you see patient during THAT admission regardless of if/when you have seen them previously
5 Examples Saw patient three times for plantar fasciitis. They return 2 years later with new complaint of a wart. New or established? See patient in your office and you bill E+M visit. One week later you admit them to the hospital on your service. Initial or estebalished?
6 Examples Follow a patient in the hospital that you had never seen before. The week after discharge they follow up with their first visit ever to your office. New or established? Patient you were following discharged from hospital and you re-admit 2 days later. Initial or established?
7 Consultations codes Never use for Medicare!
8 Consultations codes Consultation is when another physician requests your opinion / advice Consultant offers opinion/advice and sends patient BACK Consultant may initiate diagnostic and/or therapeutic services Current Procedural Terminology 2013, AMA NOT when you take over complete care of the patient for that problem Must determine consult vs. transfer of care
9 Examples PCP sends you patient with heel pain. You do x-ray, injection, and f/u 2 weeks. 9924X or 9920X? Another surgeon is planning subtalar arthroeresis. Family comes to you on recommendation from a friend for second opinion. You agree and they plan to go back to their surgeon for procedure 9924X or 9920X? NOT MEDICARE
10 Examples Rheumatologist sends you gout patient for your opinion. You say acute flare has passed and send them back for 24 hour urine, blood work, and work up for long term suppression 9924X or 9920X Rheumatologist sends you new patient with painful 1 st MPJ. You diagnose gout. You do injection and send patient back to rheumatologist for 24 hour urine, blood work, and work up for long term suppression 9924X or 9920X NOT MEDICARE
11 Examples Inpatient admitted under service of hospitalist for diabetic foot infection. You receive a consult. You plan a TMA for that week. 9925X or 9922X? Patient admitted with osteomyelitis by ED to service of hospitalist. Hospitalist realizes it is primarily a foot problem and transfers to your service, then you see patient for first time 9925X or 9922X? NOT MEDICARE
12 How NOT to determine the That felt like a appropriate level That person asked a lot of questions. I m using on that one! Felt like I was in there forever. I m using I haven t billed a all day. Better do it now That patient was a real pain. I m billing a higher level This carrier pays well. I m using 99205
13 Three Key Components History History of Present Illness Past Medical History, Social History, Family History Review of Systems Exam Decision Making When using these three key components to determine code level, time is NOT a factor
14 History History of Present Illness: Nature, Location, Duration, Onset, Character, Alleviate/Aggaravate, Treatment attempted PMH, SH, FH Review of Systems
15 History History of Present Illness: PMH, SH, FH PMH includes illnesses and operations Social history is current and past Family History Review of Systems
16 History History of Present Illness: PMH, SH, FH Review of Systems A subjective questioning Have you recently experienced NOT a repeat of the HPI NOT See HPI If review 1-9 systems need to document all positives and pertinent negative If review 10 systems must individually document systems with positives and pertinent negatives and can document all others negative.
17 History..must have all 3 History of Present Illness: Nature, Location, Duration, Onset, Character, Alleviate/Aggaravate, Treatment attempted PMH, SH, FH PMH includes illnesses and operations Social history is current and past Family History Review of Systems A subjective questioning Have you recently experienced NOT a repeat of the HPI NOT See HPI If review 1-9 systems need to document all positives and pertinent negative If review 10 systems must individually document systems with positives and pertinent negatives and can document all others negative.
18 2 Types of Exam Single Organ System Components from one system General Multi-System From multiple systems Rare for podiatrist Type and content of examination based upon clinical judgment, the patient s history, and the nature of the presenting problem(s).
19 Levels of exam 1 Bullet 6 Bullets 12 Bullets One entire Organ System
20 Exam Single Organ Systems Cardiovascular Ears, Nose, Mouth, and Throat Eyes Genitourinary (Female) Genitourinary (Male) MUSCULOSKELETAL Neurological Psychiatric Respiratory Skin Hematologic/Lymphatic/ Immunologic
21 Exam Single Organ Systems Every organ system exam except for Musculoskeletal contains something podiatrists would not normally do
22 Decision Making need 2/3 # Possible Diagnoses/Treatment Options Amount and/or Complexity of Data Reviewed Risk of Complications, Morbidity, Mortality
23 Decision Making need 2/3 # Possible Diagnoses/Treatment Options Number of each that are considered Amount and/or Complexity of Data Reviewed Risk of Complications, Morbidity, Mortality
24 Decision Making need 2/3 # Possible Diagnoses/Treatment Options Amount and/or Complexity of Data Reviewed Diagnostic tests ordered or reviewed Old medical records Obtain history from sources other than the patient Risk of Complications, Morbidity, Mortality
25 Decision Making need 2/3 # Possible Diagnoses/Treatment Options Number of each that are consideredmount andor Complexity of Data Reviewed Risk of Complications, Morbidity, Mortality Based on presenting problem and management options Document comorbidities that complicate things See Table of Risk
26 1997 CMS Documentation Guidelines for Evaluation and Management Services
27 Greater than 50% rule If you spend minutes with the patient and greater than 50% of that time was spent in counseling and/or coordination of care Office: face to face time with patient / family Inpatient / nursing home: face to face time plus floor/unit time
28 Thank You!!
29 References 1997 CMS Documentation Guidelines for Evaluation and Management Services Learning-Network- MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf 1995 CMS Documentation Guidelines for Evaluation and Management Services Learning-Network- MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf
30 References Vicchrilli, S., COT, OCS, Confused About the Consult Codes? Here s How to Avoid Denied Claims, m American Medical Association CPT 2013 Standard Edition (Current Procedural Terminology (Standard). Bickley, L Bates' Guide to Physical Examination and History Taking, Eighth Edition
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