E & M Coding. Welcome To The Digital Learning Center. Today s Presentation. Course Faculty. Beyond the Basics. Presented by

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1 Welcome To The Digital Learning Center Presented by Your Partner In Building High Performance Practices Today s Presentation E & M Coding Beyond the Basics Course Faculty R. Thomas (Tom) Loughrey, MBA, CCS-P Chairman, CEO & Co-Founder of Economedix Certified Coding Specialist BS Degree from Pennsylvania State University Earned an MBA in Health & Hospital Administration from the University of Florida Former Hospital Administrator Former Owner of a Medical Billing Company Consultant to Physician Practices & Medical Societies Member of Various Professional Organizations Dealing with Medical Practice Management Developed and Presented Thousands of Seminars & Workshops Dealing with Practice Management 1

2 Course Overview Introduction & Instructions Definitions Levels of E&M Services Office, Outpatient & Consult Codes Special Services Codes E&M Code Changes for 2010 Summary Introduction Evaluation and Management Services deal with the most common encounters between patients and physicians. It is at once simple and complex; the complexity arising in the different circumstances under which patients can be seen and cared for. Format of the Terminology The code number followed by a descriptor Hospital Discharge Day management: 30 minutes or less Shorthand convention (follows semi-colon) more than 30 minutes 2

3 Code Symbols Each year the book is updated and codes are added and deleted. Text may be revised as well. New procedures are identified with a New descriptions of codes are identified with a New and revised text other than descriptions are identified with Add-On codes are identified with a + Codes exempt from multiple procedure modifiers (-51) are identified with a. They are not designated as add-on codes Instructions A reminder as to how codes are generally selected Select the name of the procedure that most accurately identifies the service performed List additional services or procedures if performed Add any modifying or extenuating circumstances to the listed service or procedure Adequately document the service in the patient medical record Any procedure or service may be used by any qualified physician Using the Index The index is not a substitute for the code listings in the main sections. Always refer to the main text to ensure the accuracy of the code selection and review relevant notes and descriptions 3

4 Evaluation & Management Codes Definitions New and established patients Chief complaint Concurrent care Counseling Evaluation & Management Codes New Patient Has not received professional services in past three years from: The doctor Another doctor in the same group in the same specialty Tips: Check doctor s specialty listing with Medicare Check patient chart on every visit for last encounter Evaluation & Management Codes Chief Complaint The reason for seeing the doctor this time Usually expressed in the patient s own words: Mrs. Smith is presents today with complaints of a sore throat and nagging cough, particularly at night 4

5 Evaluation & Management Codes Concurrent Care Two Physicians dealing with the same patient at the same time Both Doctors using the same ICD-9 code Surgeon may continue to follow patient following a consult common situation Need to coordinate between physicians to avoid a billing problem Evaluation & Management Codes Counseling A discussion with patient or family: diagnostic results prognosis risks and benefits instructions for treatment & follow-up importance of compliance reducing risk factors education for patient and family Tips Part of almost every exam Key component of exams where counseling is over one-half the time Should be specifically identifiable in the records including time Use different codes for psychotherapy Levels of E&M Services Determined by key components: History HPI, Past, Family and Social History, ROS Examination Based on presenting problem and clinical judgment Medical Decision Making Based on the number of diagnoses, amount or complexity of data and risk associated with the presenting condition 5

6 History o History of the Present Illness (HPI) o Past History of the patient o Family History o Social History o Review of Systems (ROS) History of the Present Illness (HPI) A chronological description from first sign or symptom includes: location quality severity timing context modifying factors signs and symptoms HPI Patient referred by family doctor for gall bladder attacks Abdominal shooting pain that seems worse in evening Some associated nausea and headaches Loss of appetite for past five days and gassy feeling Night sweats first three nights; improved denies fever Seems worse when sitting; better when laying down Insomnia related to discomfort Intensity of pain comes and goes but generally present 6

7 Past History Review of patient s past illness, injuries, treatments and conditions surgeries major illnesses requiring treatment hospitalizations current medications allergies immunizations dietary status May be self completed and reviewed by doctor Social History Age appropriate review including: marital status/living arrangements current employment occupational history use of drugs, alcohol and tobacco level of education sexual history other as deemed relevant May be self completed and reviewed by doctor Family History Review of family medical events health status or cause of death of parents, siblings and children specific diseases related to chief complaint, HPI or ROS family members who have recently had same signs and symptoms diseases of family members which may be hereditary May be self completed and reviewed by doctor 7

8 Review of Systems A review of body systems which the patient is experiencing or has experienced problems Purpose: define the problem clarify the differential diagnosis identify testing create a baseline on data Review of Systems Constitutional symptoms (fever, weight loss, etc) Eyes Ears, nose, mouth and throat Cardiovascular Respiratory GI Genitourinary Musculoskeletal Integumentary (skin) Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergic/Immunologic Examination Problem Focused limited exam of affected body area or organ system Expanded Problem Focused limited exam of affected body area or organ system and other symptomatic or related organ systems Detailed extended exam of the affected body area or organ system and other symptomatic or related organ systems Comprehensive general multi-system exam or complete exam of a single organ system 8

9 Body Areas Head, including the face Neck Chest, including breasts and axilla Abdomen Genitalia, groin, buttocks Back Each extremity Organ Systems Eyes Ears, Nose, Mouth & Throat Cardiovascular Respiratory Gastrointestinal Genotourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic / Lymphatic / Immunologic Medicare Exam Types General, multisystem Eyes Ears, Nose & Throat Cardiovascular Respiratory Genotourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic / Lymphatic / Immunologic Note: No Gastrointestinal Exam 9

10 Medical Decision Making The complexity of establishing a diagnosis and determining a plan of action taking into consideration: The number of possible diagnoses and/or treatment options The amount and complexity of medical records, tests and information that must be considered and evaluated The risk of significant complications. Morbidity, mortality and co-morbidities associated with the problem, the treatment and other options Types of Decision Making Straight-forward Low Complexity Moderate Complexity High Complexity Other Components in Determining Level of E&M Service Counseling Coordination of Care Nature of the presenting problem Time 10

11 Counseling A discussion with patient or family: diagnostic results prognosis risks and benefits instructions for treatment & follow-up importance of compliance reducing risk factors education for patient and family Coordination of Care Case Management when patient is not seen Team Conferences (99361 and 99362) Telephone Calls (99371, & 99373) Care Plan Oversight ( ) Part of other E&M codes when patient is seen Time Most E&M Codes have a typical amount of time associated with the code Face-to-Face Time Time spent with the patient and/or family Does not include time reviewing records, telephone contact, coordinating care with other professionals, etc. Floor/Unit Time Time spent with patient and/or family at bedside and on nursing unit reviewing chart Does not include time spent in other parts of hospital 11

12 Time Time is a key component when counseling takes up more than one-half the time Requires that time and counseling be documented Either list total time in records or beginning and ending times Clinical Examples - Appendix C Provide guidance by example for various specialties: Office visits new and established patients Hospital visits initial and subsequent Consultations outpatient and inpatient Emergency Department (note: all examples are for Emergency Medicine only Critical Care Nursing Facility Assessments Prolonged Services Care Plan Oversight Office or Other Outpatient Services New Patients Established Patients Hospital Observation Services

13 New Patients All 3 key components required History Exam Decision Making Time (minutes) Problem Focused Problem Focused Comprehensive Straight- Forward Expand. Problem Focused Expand. Problem Focused Straight- Forward Detailed Detailed Comprehensive Comprehensive Comprehensive Low Mod High Established Patients 2 of 3 key components required History none Problem Focused Exam none Problem Focused Decision Making Time (minutes) none Comprehensive Straightforward Expanded Problem Focused Expanded Problem Focused Detailed Detailed Comprehensive Low Moderate High Hospital Inpatient Services Initial Hospital Care Subsequent Hospital Care Observation or Inpatient Care (same day admit and discharge) Hospital Discharge Services

14 Consultations Advice or opinion requested by another physician May initiate diagnostic and therapeutic services Request must be documented in medical record Opinion or advice must be documented in medical record Must be communicated to referring physician in a written report Two Categories of Consultations Office New and Established Patients Initial Inpatient Codes for follow-up I/P consults and Confirmatory consults have been deleted Consultations Office/Outpatient History PF EPF Det Comp Comp Exam PF EPF Det Comp Comp Decision Making SF SF Low Mod High Time (minutes)

15 Consultations Initial Inpatient History PF EPF Det Comp Comp Exam PF EPF Det Comp Comp Decision Making SF SF Low Mod High Time (minutes) Medicare and Consults through are no longer paid Relative values are still published Instructed to use appropriate I/P, O/P or SNF codes For I/P it may create a concurrent care problem Attending (admitting) physician is instructed to use AI modifier Beginning to see some trend of other TPPs to no longer pay Emergency Department Services New and established patients Physician directed emergency care Provided from an organized hospital based department designed for unscheduled patients presenting for immediate attention Must be available 24 hours a day 15

16 Emergency Department Services If an emergency department physician provides an emergency department service it is inappropriate for another physician to use an emergency department service code The non-ed physician should use an office/outpatient visit code or a consultation code if properly requested Critical Care Services Critical care is usually provided in a hospital critical care unit but not always! Critical care requires decision making of high complexity Separate codes for adults & infants over one month(99291 and 99292)and neonates/pediatrics ( ) is for 30 to 74 minutes and is for each additional 30 minutes Critical Care Services Critical care includes interpretation of cardiac output measures, chest x-rays, blood gases and stored data Also includes gastric intubation, temporary transcutaneous paceing, ventilator management and vascular access procedures Other services should be listed separately If less than 30 minutes of time is spent on critical care all services should be listed separately Time spent in critical care is bedside and unit time only Physician must be immediately available to patient 16

17 Prolonged Care Total time per day is billed beyond 30 minutes One set of codes for outpatient and One set of codes for inpatient and All codes are billed in addition to the E&M code and other services Prolonged Care Guidelines Total Time per day < 30 minutes minutes minutes minutes minutes minute s Codes None reported And times And times And times And times 4 Prolonged Care Without Direct Patient Contact first hour additional 30 minutes can also be used to report final minutes of prolonged care Prolonged service of less than 15 minutes after first hour or less than 15 minutes beyond final 30 minutes is not reported 17

18 Case Management Team Conferences minutes Deleted in 2009 Team Conferences minutes Deleted in 2009 Use Telephone calls to patient or for consultation deleted Age based Preventive Medicine Does not have a diagnosis If a problem is encountered, the appropriate E&M code should be used with modifier 25 Immunizations and other ancillary services should be separately reported New Patient and Established Patient codes Separate codes for individual counseling ( ) and group counseling ( ) Special E&M Services Life Insurance/Disability Exams Work Related Disability by treating physician by another physician Post-operative visit (Medicine section Revised language now indicates an E&M service was provided as part of a postoperative visit during the global period 18

19 Modifiers Found in Appendix A -21 Prolonged E&M service (deleted in 2009) Use (see next slide) -24 Unrelated E&M during Post-op period -25 Significant, separately identifiable E&M service on same day as procedure (for non-e&m see -59) -32 Mandated service -56 Pre-op management only (do not use E&M code) same for post-op (-55) -57 Decision for surgery Significant E&M Changes for 2011 Medicare continuing to not Pay for Consults Must bill for a visit out-patient or in-patient Must now pay attention to new patient vs. established patient Impact: Example in Southern CA $ $ $ Significant E&M Changes for RVUs for E&M Services Compared to Total Percent Change CPT Description 2010 Total RVUs RVUs office/out-patient visit, new % office/out-patient visit, new % office/out-patient visit, new % office/out-patient visit, new % office/out-patient visit, new % office/out-patient visit, est % office/out-patient visit, est % office/out-patient visit, est % office/out-patient visit, est % office/out-patient visit, est % 19

20 Significant E&M Changes for RVUs for E&M Services Compared to Total Total CPT Description RVUs RVUs Percent Change Initial hospital care % Initial hospital care % Initial hospital care % Subsequent hospital care % Subsequent hospital care % Subsequent hospital care % Hospital discharge % Hospital discharge % Significant E&M Changes for 2011 This same change was made for all the Nursing Facility Codes Summary Many surgeons will have E&M codes among their top services for both volume and revenue Consulting Revenue in 2011 will continue to see a large drop Documentation problems for surgeries are rare but are fairly frequent for E&M services Correct E&M coding can improve patient care as well as improve practice revenue 20

21 Thank you for participating in this seminar presentation from Economedix! Please direct questions to To earn CME credits for this course please complete the Evaluation / CME Form and FAX it back to Economedix within 7 days of the teleconference. 21