07-slide_set_1_-_general_session-07.ppt

Webcast Session IAn Introduction to Evaluation and Management (EM) Coding

Accurate Coding for Evaluation and Management (EM) Services

A webcast designed for headache and migraine specialists

PresentersStuart B. Black, MD

American Headache Society (AHS)Sheila J. Madhani, MA, MPH, CCS-P

MARC Associates

October 9, 2007

Goals• Introduction to CPT EM codes

• Review of CPT coding guidelines and practices

• Application of CPT coding guidelines and practices to clinical scenarios relevant to headache specialists

What Will We Discuss?• Importance of accurate coding• CPT codes vs. ICD codes• Components of EM codes• Types of EM codes• How to properly select and report EM

codes/services• Use of modifiers• Clinical examples• Coding resources

Importance of Accurate Coding• Full and fair description of services

provided

• Avoid over-coding (fraud and abuse) and under-coding (not reporting all the services you have provided)

• Improve quality of patient care

CPT codes vs. ICD codes

CPT codes vs. ICD codes• CPT codes

– CPT is an acronym for Current Procedural Terminology

– CPT codes are published by the American Medical Association and are used by CMS and many private insurers to report physician services

– A CPT code is a five digit numeric code that is used to describe

medical, surgical, radiology, laboratory, anesthesiology, and evaluation/management services

– There are approximately 7,800 CPT codes ranging from 00100 through 99602

– Two digit modifiers may be appended when appropriate to clarify or modify the description of the procedure

CPT codes vs. ICD codes

• ICD– ICD stands for International Classification of

Diseases

– It is a coding system used to code signs, symptoms, injuries, diseases, and conditions

CPT codes vs. ICD codes• Relationship between CPT and ICD

– Both types of codes must be reported on claims to Medicare and many private insurers

– CPT code• Describes medical procedure or service

– ICD code• Describes clinical condition of patient to support

the medical necessity of the procedure or service

CPT codes vs. ICD codes• ICD-9-CM

– Diagnosis coding classification system used in the delivery of patient care

• ICD-10– Used to track mortality data

• ICD-10-CM– Currently under development

Components of EM codes

Components of EM codes• All EM services follow a similar format

– Unique code number– Place and/or type of service– Content of service– Nature of the presenting problem– Time typically associated with service

Components of EM codes• Ex. 99213, Office or other outpatient visit, est. patient

Unique code number 99213

Place and/or type of service

Office or other outpatient visit¹

Content of service •Expanded problem focused history•Expanded problem focused examination•Medical decision making of low complexity

Nature of the presenting problem

Usually, the presenting problem(s) are of low to moderate severity

Time typically associated with the procedure

Physicians typically spend 15 minutes face-to-face with the patient and/or family

¹ Includes hospital outpatient

Categories of EM codes

Categories of EM codes• Physicians use EM codes to report

professional services

• Documentation in the medical record must support the EM code and ICD-9 code(s) submitted

• Submitting a code that is not supported by documentation may be considered fraud

Categories of EM codesOffice or other Outpatient Services,

New Patient99201-99205

Office or other Outpatient Services, Established Patient

99211-99215

Hospital Inpatient Services,

Initial Hospital Care

99221-99223

Hospital Inpatient Services, Subsequent Hospital Care

99231-99233

Office or Other Outpatient Consultations,

New or Established Patient

99241-99245

Inpatient Consultations,

New or Established Patient

99241-99255

Categories of EM codes• Levels of service

– Within each category there are various codes representing the different levels of service

– Increased levels of service reflect the increased levels of time, intensity, and complexity of the service

– Ex. Office or other outpatient visit, new patient• 99201 – Level 1• 99202 – Level 2• 99203 – Level 3• 99204 – Level 4• 99205 – Level 5

How to properly select and report EM codes/services

5 Steps to Selecting Appropriate EM codes/services

• Step 1.- Type of Service: What type of service is the patient receiving? (office visit, consultation etc.)

• Step 2.- New or Established: If this is an office visit, is this a new or established patient?

• Step 3.- Key Components: What level of the key components (history, examination, medical decision making) have been met or exceeded

• Step 4.- Time: Will time determine the level of E/M service?

• Step 5.- Documentation: Document! Document! Document!

Step 1: Type of Service• What type of service is the patient

receiving (office visit, consultation etc.)?– Common EM services performed by

headache specialists• Office/Outpatient Services

– 99214» 2005 Medicare utilization by neurologists: 1,768,059

• Consultation Services– 99244

» 2005 Medicare utilization by neurologists: 519,888

Step 1: Type of Service• When is a consultation a consultation?

– Consultation• A type of service provided by a physician whose

opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source

– Not a Consultation• Ongoing management of the patient by the

consultant physician

Step 1: Type of Service• When is a consultation a consultation?

– CMS Transmittal 788 – effective 1/17/06– To bill for a consultation, there must be

documentation of the request– If there is no request, an outpatient/office visit (new or

established) should be reported• “…a consultation request may be verbal however the

verbal interaction identifying the request and reason for a consult shall be documented in the patient’s medical record by the requesting physician or qualified NPP, and also by the consultant physician or qualified NPP in the patient’s medical record.” (CMS Transmittal 788)

Step 1: Type of Service• When is a consultation an office visit?

– Transfer of care • A transfer of care occurs when a physician

requests another doctor to assume the care of the patient for a specific condition

• Once a transfer occurs consultations can no longer be reported

• Established patient EM codes must be reported

Step 2: New or Established Patient?

• CPT differentiates between new and established patients (office/outpatient)

• New patients– More physician work– Greater documentation requirements– Higher reimbursement

Step 2: New or Established Patient?• Is this a new or established patient?

– New patient: one who has not been seen by the physician or another physician of the same specialty who belongs to the same group within the past 3 years

– Established patient: one who has been seen by the physician or another physician of the same specialty who belongs to the same group within the past 3 years

Step 3: Key Components• There are six components that are used to

define the level of an E/M service– History– Examination– Medical Decision Making– Counseling– Coordination of Care– Nature of Presenting Problem– Time

Step 3: Key Components• The three key components must be

considered and supported by documentation in the medical record before selecting a code – History– Examination– Medical decision making

Step 3: Key Components History

• Elements– Chief complaint– History of the present illness (HPI)– Review of symptoms– Past medical, family, and social history (PFSH)

• Levels– Problem focused– Expanded problem focused– Detailed– Comprehensive


• Chief complaint– “A chief complaint is a concise statement

describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter, usually stated.”

American Medical Association. Current Procedural Terminology CPT 2007. Chicago, Ill: AMA press;2007


• History of Present Illness (HPI) – Must be performed by physician

HPI Elements

LevelsProblem Focused

Expanded Problem Focused

Detailed Comprehensive

•Location•Quality•Severity•Duration•Timing•Context•Modifying factors•Associated signs or symptoms

Brief

(1-3 elements)

Brief

(1-3 elements)

Extended

(4 or more elements)

Extended



• Review of Systems (ROS) – Can be performed by medical extender

ROSLevels

Problem Focused



•Constitutional (wt loss etc)•Eyes•ENT, Mouth•Respiratory•Cardiovascular•GI•GU•MS•Neuro

•Integumentary•Endocrine•Hem/lymph•Allergy/Immun•Psychiatric•All others negative

None Problem specific (1 system)

Extended

(2-9 systems)

Complete

(Greater than 10

systems or some with all

others negative)


• Past Medical, Family, and Social History (PFSH)– Can be performed by medical extender

PFSH Levels

Problem Focused



Pertinent

At least 1 item from at least 1 history.

Complete

Specifics of at least 2

history areas documented. All 3 for new

patient.

None None Pertinent Complete

Step 3: Key Components History• Summary

Elements Problem Focused



HPIHistory of Present Illness

Brief

(1-3 elements)

Brief

(1-3 elements)

Extended


Extended


ROSReview of Systems

None Problem Specific Extended Complete

PFSHPast Medical, Family and Social History

None None Pertinent Complete

Step 3: Key Components Physical Examination

• The level of exam is determined by the number of body areas or organ systems documented

• Levels – Problem focused– Expanded Problem Focused– Detailed– Comprehensive

Step 3: Key Components Physical Examination

CPT Descriptors For Four Levels of Physical Examination

Problem focused - A limited examination of the affected body area or organ system(s)

Expanded problem focused - A limited examination of the affected body area or organ system and other symptomatic or related organ system(s)

Detailed - An extended examination of the affected body area or organ system and other symptomatic or related organ system(s)

ComprehensiveA general multi-system examination or a complete examination of a single organ system


Step 3: Key ComponentsPhysical Examination

• Documentation guidelines for physical examination– 1995 Guidelines (general exams)– 1997 Guidelines (specialty exams)

– Single system (specialty) examination» Neurological – recommended for headache

specialists– General multisystem examination


Constitutional

EyesCardiovascular

Neurological

Measurement of any 3 of 7 vital signs General appearance of the patient Ophthalmoscopic examination Examination of carotid arteries Auscultation of heart Examination of peripheral vascular system Higher cortical functions Cranial nerves Sensation Muscle strength Muscle tone Deep tendon reflexes Coordination Gait and station

• 1997 Guidelines – Neurological


• SummaryLevel of Exam 1997 Single Organ System

Problem focused 1-5 elements

Expanded Problem Focused At least 6 elements

Detailed At least 12 elements

Comprehensive Perform all elements

Document all elements in•Constitutional•Eyes•Musculoskeletal•Neurological

Document 1 element in•Cardiovascular

Step 3: Key Components Medical Decision Making (MDM)

• What is medical decision making (MDM)?– MDM refers to the complexity of establishing a

diagnosis and/or selecting a management option

• Of the three key components of EM, MDM is the most challenging to meet and document


• How is MDM measured?– Number of diagnoses or management options

• Number of possible diagnoses• Number of options that must be considered

– Amount and/or complexity of data to be reviewed• Amount and/or complexity of medical records, diagnostic tests

and/or other information that must be obtained, reviewed and analyzed

– Risk of complications and/or morbidity or mortality• The risk of significant complications, morbidity and/or mortality

associated with the patient’s presenting problem• The risk of comorbidities associated with the patient’s presenting

problem• The risk of the diagnostic procedure(s) and/or the possible

management options


• What are the different levels of MDM?– Straightforward– Low complexity– Moderate complexity– High complexity


• SummaryNumber of

diagnoses or management

options

Amount and/or complexity of data

to be reviewed

Risk of complications

and/or morbidity or mortality

Type of decision making

(Level of MDM)

Minimal Minimal or None

Minimal Straightforward

Limited Limited Low Low Complexity

Multiple Moderate Moderate Moderate Complexity

Extensive Extensive High High Complexity

Step 3: Key Components• Choosing an appropriate level of EM

service based on key components– New patient, office/outpatient and office

consultations• You must meet or exceed ALL of the requirements

to qualify for a particular level of an EM service

– Established patient, office/outpatient• You must meet or exceed 2 out of the 3

requirements to qualify for a particular level of an EM service

Step 3: Key Components Summary

• New Patient – Office/OP (3 out of 3)Code History Exam Medical Decision

Making

99201 Problem focused Problem focused Straightforward

99202 Extended problem focused

Extended problem focused

Straightforward

99203 Detailed Detailed Low complexity

99204 Comprehensive Comprehensive Moderate Complexity

99205 Comprehensive Comprehensive High Complexity


• Office or other Outpatient Consultation (3 out of 3)

Code History Exam Medical Decision Making


99242 Extended problem focused

Extended problem focused

Straightforward

99243 Detailed Detailed Low complexity

99244 Comprehensive Comprehensive Moderate Complexity



• Established Patient – Office/OP (2 out of 3)Code History Exam Medical Decision

Making

99211 Minimum services; Physician not required


99213 Extended Problem Focused

Extended Problem Focused

Low complexity

99214 Detailed Detailed Moderate Complexity


Step 4: Time• Time is included in the definition of levels

of EM services– Ex. “99213 Office or other outpatient visit…

physicians typically spend 15 minutes face-to-face with the patient and/or family.”

• This time is considered average time that may be higher or lower depending on specific circumstances

Step 4: Time

In certain circumstances the three key

components (history, physical examination and MDM) are not

the controlling factor

in determining the level of an EM service

Step 4: Time

In certain circumstances

TIME

is the controlling factor

in determining the level of an EM service

Step 4: Time• Time determines the level of E/M service

when counseling and/or coordination of care dominate (> 50%) the encounter– Counseling and coordination is separate from the

history, physical exam and medical decision making

– More common scenario for headache specialists

– The extent of counseling and/or coordination of care must be documented in the medical record independent of the three key components

Step 4: Time• Counseling patient and/or family

– Diagnostic results, impressions, and/or recommended diagnostic studies

– Prognosis– Risks and benefits of management (treatment options)– Instructions for management (treatment) and/or follow-up– Importance of compliance with chosen management (treatment)

options– Risk factor education– Patient and family education


Step 5: Documentation• General Principles of Medical Record Documentation¹

– Medical record complete and legible

– The documentation of each patient encounter includes:• Reasons for the encounter and relevant history, physical

examination findings and prior diagnostic test results;• Assessment, clinical impression or diagnosis;• Plan for care; and• Date and legible identity of the provider

– If not documented, the rationale for ordering diagnostic and other ancillary services easily inferred

¹ 1997 EM Guidelines, Centers for Medicare and Medicaid Services (CMS)

Step 5: Documentation• General Principles of Medical Record

Documentation¹– Past and present diagnoses accessible

– Appropriate health risk factors identified

– Patients progress and response to changes in treatment included

– CPT and ICD-9 codes supported by documentation¹ 1997 EM Guidelines, 1997 EM Guidelines, Centers for Medicare and Medicaid Services (CMS)

Use of modifiers

Use of Modifiers• What is a modifier?

– Modifiers indicate that a service was altered in some way from the stated CPT descriptor without changing the definition

• Why use modifiers?– When you need to communicate something unusual

about the service to Medicare

• What is the impact of modifiers?– Modifiers can maintain, reduce or increase

reimbursement levels for a service

Use of Modifiers• Common modifiers for EM services

– -21: Prolonged evaluation and management services• Only can be used with the highest level EM service

– -25: Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service

• Appropriate documentation for the need of the EM service should be recorded in the patient’s medical record

– -52: Reduced services• Should not be used if there is a code at a lower level that

describes the service provided

Clinical examples

Case #1 – History (HPI, ROS, PFSH)

32 year old woman with PMH of “TTH”. Onset of H/A age 14. H/A associated with vomiting, photophobia & dysfunction. 8 year history of chronic daily headaches. Taking Vicodan daily (4-6/D) for 5 years; was taking Butalbital before Vicodan. Disability for 2 years. New onset: “visual blurring” OD; Numbness in RUE; Transient Confusion

Case #1Level of Care 99241?; 99242?; 99243?; 99244?; 99245?

99201?; 99202?; 99203?; 99204?; 99205?

Physical Exam Exam: 23 Bullets

BP 210/105; Pulse 72 Irreg.; RR 15; General Exam: Otherwise WNL

Neurological Exam

Higher Cortical Function; Cranial Nerves; Motor; Coordination; Gait; Reflexes

Sensation; All WNL

Diagnosis 1. Migraine with aura; 2. Chronic Daily H/A; 3.Medication Overuse Headache; 4. Hypertension; 5. R/O Cardiac Arrthymia; 6. R/O CNS Mass Lesion; 7. R/O Cerebral Vascular Disease (TIA, Cerebral Emboli, Infarct)

Complexity of Data Reviewed

Reviewed

22 pages of prior records; Head Ct without contrast (2004); CT cervical spine (2004)

Ordered

MRI Head with contrast; Lab; EKG; Cardiology Consult; Hospital Care?

Risk Risk of Presenting Problem:

Minimal?; Self Limited or Minor?; Low severity?; Moderate severity?

High severity?

Risk of Management Options?; Risk of Diagnostic Procedures?

Case #1Pre-service

– Reviewed the medical history form completed by the patient and vital signs obtained by clinical staff

Intra-service– A comprehensive History– A comprehensive neurological exam > 23 Bullets

Medical Decision Making– Number of Diagnoses or Treatment Options >4– Amount / Complexity of Data Reviewed > 4– Using Table of Risk:

• “One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment”

• “An abrupt change in neurologic status, e.g. seizure, TIA, weakness, sensory loss”

• “Drug therapy requiring intensive monitoring for toxicity”

Case #1

Post-service– Complete the medical record documentation – Provide necessary post evaluation care and

coordination of care

The Level of Care would be 99205 because History and Exam were Comprehensive and MDM was High Complexity. This would not be a Consultation or 99245 because the referral requires a transfer of care for further E /M.


29 year old woman with PMH of MH without aura. Established Pt. Hospitalized 2 years ago due to medication overuse headache; took Fiorocet daily for 3 years; now on Topamax; limits abortive triptan to 2 days per week. Is Bipolar; Has insomnia; Had “Syncopal Spell” one day ago with loss of bladder control; struck head . New onset vertigo.

Case #2Level of Care Office Visit: 99212?; 99213?; 99214?; 99215?


BP 130/80; Pulse 72 regular RR 16; Bruise on R frontal area from trauma when fell; General Exam: Otherwise WNL

Neurological Exam

Awake, alert, coherent. Memory/intellect intact No aphasia or dysarthria CN’s: WNL; Motor exam wnl Coordination intact; Gait; no ataxia; Reflexes: wnl; Sensation: intact

Diagnosis 1.Migraine with aura; 2. Medication overuse headache by history; 3. Bipolar disorder; 4. Sleep disorder; 5.Syncope; 6. Head trauma due to #5; 6. R/O vasovagal syncopy; 7. R/O seizure; 8. New onset Vertigo


Reviewed

1.Current chart; 2. Hospital records; 3. All current meds

Ordered

1.Lab; 2.Repeat MRI of head; 3.EEG; 4.EKG

Risk Risk of Presenting Problem:

Minimal?; Self Limited or Minor?; Low severity?; Moderate severity?

High severity?

Risk of Management Options?; Risk of Diagnostic Procedures?

Case #2Pre-service

– Reviewed the medical history form completed from the patient, vital signs obtained by the clinical staff

Intra-service– Obtained a comprehensive history including a review of all medications for possible drug

interactions. Compared status to last visit. Performed comprehensive neuro exam. Considered relevant data, options, and risks; formulated a diagnosis; developed a treatment plan. Discussed diagnosis, treatment options and risks with patient and family. Ordered and arranged diagnostic testing.

Medical Decision Making– Number of Diagnoses or Treatment Options list 5 established Dx. & 2 R/O Dx .– Amount / Complexity of Data Reviewed >4– Using the Table of Risk:

• “One or more chronic illness with severe exacerbation, progression, or side effects of treatment”

• “An abrupt change in neurologic status, e.g.. seizure, TIA, weakness, sensory loss”“Drug therapy requiring intensive monitoring for toxicity”

Case #2Post-service– Complete medical record documentation. Provide

necessary communication and coordination of care. Respond to testing results and revise treatment plan.

The level of care would meet the criteria for 99215 because not only 2 out of 3 but 3 out of 3 requirements were met; a comprehensive History, Exam and High Complexity MDM


33 year old woman; 10 year history of MH without aura. Established pt. Hospitalized at another clinic 5 years ago because of MOH. Did well until 4 mo ago; recurrent daily “migraine” with 7 days a week of OTC use & triptans bid 4 days a week. On Inderal for headache and BP control. New onset stress; crying; not sleeping. C/O difficulty “Coping”.

Case #3Level of Care Office Visit: 99212?; 99213?; 99214?; 99215?


BP 160/90; Pulse; 90 Regular; RR 17; Pt appeared depressed; crying

Neurological Exam

MS. Awake, alert, coherent; affect flat; judgment impaired; intellect and memory intact; no dysarthria/aphasia; CN disc flat OU, 3,6,7,12 intact: Motor: Coordination: Gait: intact

Diagnosis 1.Migraine without aura; 2. New Onset Chronic Daily Headache; 3.Medication Overuse Headache (OTC, Triptans); 4. Hypertension; 5. New Onset Depression; 6. R/O acute CNS lesion


1.Records including prior medication history reviewed; 2. Patient has had no recent lab; studies ordered to include CBC, SMA, Sed rate, Thyroid profile; 3. Repeat MRI? ; 4. Will Discuss meds, clinical change, with PCP

(Time spent with patient: 35 minutes)

Risk Greater than 50% of the time was spent in coordination of care

1.Discussed prognosis if not treated; 2. Discussed Risk of Medication Overuse; 3. Discussed Risk and benefits of treatment options; 4. Discussed Risk of non-compliance; 5. Discussed tests ordered and future tests if need; 6. Discussed instructions for treatment and follow-up.

Case #3Pre-service

– Reviewed the medical history form completed by the patient and vital signs obtained by the clinical staff. Discussed new symptoms with the NP.

Intra-service– An extended problem focused history including current meds for headache

control and antihypertensive meds. Discussed new onset daily headaches and depression. Discussed risk of using triptans with hypertension and use of Inderal in depression

– Performed an extended problem focused examination including mental status

Medical Decision Making– Number of Diagnoses or Treatment Options > 4– Amount / Complexity of Data Reviewed > 2– Using the Table of Risk:

• “One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment”

• “Prescription drug management”

Case #3

Post-service– Complete medical record documentation– Provide coordination of care and review with PCP; consider Psych

consult

The H & P are Extended Problem Focused. The CPT level of care would be 99213. However, since greater than 50% of time was spent in Counseling and Coordination of Care, if that criteria were used, the level of care would be coded as 99214.

The counseling and discussion included prognoses, risks andbenefits of treatment options, instructions for treatment and follow up, importance of compliance, risk factors of current course, and risk factor reduction with proper management.

Coding resources

Coding resources• American Headache Society (AHS)

– AHS’s Headache Coding Corner• http://www.americanheadachesociety.org/professionalresources/AHSsHead

acheCodingCorner.asp

• American Medical Association– CPT-related resources

• http://www.ama-assn.org/ama/pub/category/3113.html

• Centers for Medicare and Medicaid Service (CMS)– Evaluation and Management Services Guide

• http://www.cms.hhs.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf

– 1997 Documentation Guidelines for Evaluation and Management Services

• http://www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp

http://www.americanheadachesociety.org/professionalresources/AHSsHeadacheCodingCorner.asp

http://www.americanheadachesociety.org/professionalresources/AHSsHeadacheCodingCorner.asp

http://www.ama-assn.org/ama/pub/category/3113.html

Next AHS Coding Webcast

Don’t forget to register for our next Webcast: Understanding Medical Decision Making (MDM) on October 16.

To register please go directly to: https://americanheadachesociety.webex.com/americanheadachesociety/onstage/g.php?p=0&t=m

https://americanheadachesociety.webex.com/americanheadachesociety/onstage/g.php?p=0&t=m



Thank You

The American Headache Society thanks you for your participation.

We will now take questions.

Please contact American Headache Society (AHS) headquarters for further information: [email protected] or 856-423-0043.

mailto:[email protected]

07-slide_set_1_-_general_session-07.ppt

Business

icd codes cpt codes

icd codes icd icd

types of codes

various codes

icd codes relationship

level of em service

service icd code

management em services