How To Document and Select Outpatient Levels of Evaluation and Management (E&M) Service in RHC

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Burns, CPC, CPC-I, CPMA, CEMC Vice President, Audit and

1 How To Document and Select Outpatient Levels of Evaluation and Management (E&M) Service in RHC John F. Burns, CPC, CPC-I, CPMA, CEMC Vice President, Audit and Compliance Services

2 Your Faculty John F. Burns, Vice President of Audit and Compliance Services, ARHPC 22 years in healthcare coding, billing and compliance Doctors Management and NAMAS Modern Conventions in Compliance Civilian volunteer to US Department of Defense Medical Management Institute

Medical Decision Making Know when you can and cannot use time as a controlling factor in E&M code assignment Content and

3 LEARNING OBJECTIVES: Learn and understand the differences between AMA (CPT ) Documentation Guidelines compared to CMS Documentation Guidelines Master the process of documenting to meet the various levels of History, Physical Examination and Medical Decision Making Know when you can and cannot use time as a controlling factor in E&M code assignment Content and references made are based on 2018 CPT Professional Edition nomenclature authored by the American Medical Association (AMA). All right reserved.

4 Rural Health Clinic Reminders According to Medicare, RHC visits are medically necessary face-to-face medical or mental health visits or qualified preventive visits between the patient and a physician, NP, PA, CNM, CP, or CSW during which a qualified RHC service is furnished. RHC encounters do not take place in hospital (inpatient or outpatient) Except for the following, multiple visits with multiple RHC practitioners on the same date are considered a single visit Separate illness/injury unrelated and subsequent to the initial encounter A medical visit and a mental health visit furnished on the same date IPPE with a separate medical or mental health encounter on the same date Lab tests (except venipuncture) & technical components are paid separately

Evaluation and Management Services (99xxx) Represent largest code expenditure to Medicare E&M coding guidelines were established by Congress in 1995 and revised in 1997 Benchmarks (utilization) can

5 Evaluation and Management Services (99xxx) Represent largest code expenditure to Medicare E&M coding guidelines were established by Congress in 1995 and revised in 1997 Benchmarks (utilization) can assist with identifying risk What s a chief complaint? Is it always required? How is time defined and can it be used as factor in E&M code selection? What are the key components History HPI, ROS, PFSH Physical examination 1995 versus 1997, body areas/organ systems vs bullets/elements Medical decision making Risk versus complexity Realize the levels of each E&M key component CPT 2018 is a registered trademark of the American Medical Association (AMA) and the ARHPC claims no rights to nomenclature. For educational purposes only!

6 New vs Established Patient Definitions, per CPT A new patient is one who has not received any face to face professional service from the physician/qualified healthcare professional or another physician/qualified healthcare professional of the exact same specialty/subspecialty who belongs to the same group practice within the past three years vmedicare regulation states: "Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician v An interpretation of a diagnostic test, reading an x-ray or EKG, etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient

Office or other Outpatient Services Report 99201-99205 for new patients

for established patients 99211 does not qualify for AIR (Medicare)

7 Office or other Outpatient Services Report for new patients Require all 3 KEY COMPONENTS Remember the 3-year rule Report for established patients does not qualify for AIR (Medicare) Require 2 of the 3 KEY COMPONENTS One of the components should be the MDM process

8 CPT Preventive Medicine Services (new patients) and (established patients) Medicare does NOT pay an annual physical! Refer to IPPE (G0402) and AWV (G0438-G0439) HCPCS II codes for these service codes Medicare does recognize separate AIR encounter rates for patients who receive the IPPE and a medical and/or mental health visit on the same date of service Initial Preventive Physical Examination (IPPE) Paid once w/in 12 months of Part B enrollment Annual Wellness Visit (AWV) Paid for once per year after the 12-month enrollment period has expired You may want to consider ABNs for preventive services with limited coverage

9 Preventive Services in the RHC Medicare Benefit Policy Language (Chapter 13) CMS sets the trend but private insurance plans often follow unique policies Section 40 ( visits ), Section 50 ( services ), 220 ( preventive services ) How preventive and problem-oriented services differ Essentially, if the patient presents lacking a chief complaint, its preventive, right? Properly assigning ICD-10-CM codes is critical When can multiple visits be claimed on the same date? Payment/FQHCPPS/Downloads/RHC-Preventive-Services.pdf

Introductory pages in this section of CPT provide some excellent tables [charts] designed to assist coders assign the accurate levels of E&M

10 Problem-Oriented & Preventive Services For the sake of argument, a preventive E/M service differs from a problem-oriented E/M service only in that a patient who presents for the former lacks a chief complaint. Introductory pages in this section of CPT provide some excellent tables [charts] designed to assist coders assign the accurate levels of E&M service Who are you seeing? New, established, initial, subsequent, consultation, etc. Where are you seeing them? Outpatient, inpatient, emergency department, home, RHC, etc Why are you seeing them? Preventive versus problem-oriented

E&M Documentation Considerations CPT Guidelines vs. CMS Guidelines 1995 vs 1997 exam guidelines Chief complaints/presenting problems Preventive vs.

11 E&M Documentation Considerations CPT Guidelines vs. CMS Guidelines 1995 vs 1997 exam guidelines Chief complaints/presenting problems Preventive vs. Problem-Oriented Complete reviews of systems (ROS) Medical decision making vs medical necessity Are these the same thing? Using time to drive level of E&M When to report modifiers, global period considerations Modifier -CG reported with medical and/or mental health code that represents the primary reason for the face-to-face encounter What about coding wizards offered with EHR products?

12 History Exam The Anatomy of an E&M Service Code Medical Decision Making KEY COMPONENTS Nature of Presenting Problem Counseling Coordination of Care Time CONTRIBUTORY COMPONENTS

guidelines, the CC may be combined with the HPI.

13 History- Subjective Chief complaint clear, concise statement detailing the reason the patient is presenting today, usually in the patient s own words According to CMS guidelines, the CC may be combined with the HPI. But, the HPI MUST be documented by the PROVIDER!! HPI (history of present illness) ROS (review of system) PFSH (past family social history)

14 Determining the Level of History Remember to always start in the highest level of history and work toward the lowest the element located in the lowest level will determine the overall level of history. It is also possible to have an Extended HPI with the documented status of 3 or more chronic conditions

15 History Documentation Reminders CC, ROS and PFSH may be listed as separate elements of history or included in documentation of the HPI ROS and/or PFSH may be recorded by ancillary staff or patient as long as the provider documents confirmation of the information this is NOT the case with the history of present illness (HPI) Providers can use and get credit for ROS and PFSH obtained at another visit as long as it is relevant and can be located within the same record Remainder of ROS and PFSH unchanged since 1/30/2018 in this record If the provider is unable to obtain history from the patient or another source, he/she can document the patient s situation or condition that precludes getting it taking credit for comprehensive history level

Examinations- Objective 1995 guidelines (CPT) Count the number of systems/areas Single system exams are not well-defined Often the best option for RHCs 1997 DGs benefit Psychiatry/Mental Health 1997

16 Examinations- Objective 1995 guidelines (CPT) Count the number of systems/areas Single system exams are not well-defined Often the best option for RHCs 1997 DGs benefit Psychiatry/Mental Health 1997 guidelines (CMS) Count the number of elements or bullets performed Most single system specialty exams are defined Harder to meet without templates/macros Per CMS Guidelines, auditors must consider both 1995 and 1997 Examination Guidelines; whichever suit the provider best

17 Physical Examination Guidelines EXAMINATION LEVEL / TYPE 1995 PROBLEM FOCUSED 1 EXPANDED PROBLEM FOCUSED 2-7 limited DETAILED *2-7* extended COMPREHENSIVE 8+ Organ Systems BODY AREAS Head, incl. the face Neck Chest, incl. breasts and axillae Abdomen Genitalia, groin, buttocks Back, including spine Each extremity ORGAN SYSTEMS Constitutional (e.g., vital signs, gen appearance) Eyes Ears, nose, mouth and throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic/lymphatic/immunologic Page CPT AMA authors the information above. Some carriers (MACs) [e.g., Novitas, Palmetto, NGS, FCSO, etc] may impose more restrictive guidance

18 Physical Examination Guidelines EXAMINATION LEVEL / TYPE 1997 (General Multisystem) 1997 (Single Organ System) PROBLEM FOCUSED EXPANDED PROBLEM FOCUSED DETAILED COMPREHENSIVE 18+ (Document 2 elements from 9 or more areas/systems) Perform ALL, Document all shaded, document at least 1 unshaded **Remember** 1997 guidelines are slightly different (and less restrictive) for Eye and Psych exams There are not multiple interpretations of the 1997 guidelines. It is simply a matter of counting elements (e.g., bullets) that relate to body areas/systems Page CPT

19 Examination Documentation Reminders A notation of abnormal without elaboration is insufficient documentation. A brief statement/notation indicating negative or normal findings is sufficient Normal or negative findings must be listed by body area or organ system. CPT states the only difference between an Expanded Problem Focused examination and a Detailed examination is that the first is limited and the other is extended You will need to determine which guidelines suit your providers best and consider local carrier instruction

20 Medical Decision Making A. Number Of Diagnosis or Management Options Number Points Results Self-limited or minor (stable, improved or worsening) Max = 2 1 Est. problem: stable or improved 1 Est problem: worsening, failing to change 2 New problem: no additional work-up planned Max = 1 3 New problem: additional work-up planned 4 Total: This is a cumulative process based on the the # of problems worked up and evaluated

21 B: Amount and/or Complexity of Data to Be Reviewed Points Review and/or order of clinical lab test 1 Review and/or order of tests in the radiology section of CPT 1 Review and/or order of tests in the medicine section of CPT 1 Discussion of test results with performing physician 1 Decision to obtain old records and/or obtaining history from someone other than patient 1 Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider Independent visualization, tracing or specimen itself (not simply review of report) Total 2 2

22 Minimal C: TABLE OF RISK (element in highest level determines overall risk) Presenting Problems Diagnostic Procedures ordered Management Options Selected 1 self-limited or minor problem (eg. Cold, insect bite, tinea corporis Lab tests requiring venipuncture EKG/EEG Urinalysis Ultrasound, X-RAYS KOH prep Rest Gargles Elastic bandages Superficial dressings Low Moderate 2 or more self-limited or minor problems 1 stable chronic illness Acute uncomplicated illness or injury 1 or more chronic illnesses w/mild exacerbation, progression or side effects of treatment 2 or more stable chronic illnesses Undiagnosed new problem w/ uncertain prognosis Acute illness with systemic symptoms Acute complicated injury Physiologic test not under stress Non-cardiovascular imaging Superficial needle biopsies Clinical lab test requiring arterial puncture Skin biopsies Physiologic test under stress Diagnostic endoscopies w/no identified risk factors Deep needle or incisional biopsy Cardiovascular imaging studies w/contrast, no identified risk factors Obtain fluid from body cavity Over-the-counter drugs Minor surgery w/ no identified risk factors Physical therapy Occupational therapy IV fluids without additives Minor surgery with identified risk factors Elective major surgery w/o risk (open,percutaneous, or endoscopic) Prescription drug management Therapeutic nuclear medicine IV fluids with additives Closed treatment of fracture or dislocation w/o manipulation High 1 or more chronic illnesses w/ severe exacerbation, progression, side effects of treatment Acute or chronic illnesses or injuries that pose a threat to life or bodily function Abrupt change in neurologic status Cardiovascular imaging studies w/contrast w/ identified risk factors Cardiac eletrophysiological tests Diagnostic endoscopies w/indentified risk factors Discography Elective major surgery (open, percutaneous or endoscopic) w/risk Emergency major surgery (open, percutaneous or endoscopic) Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Decision not to resuscitate or to de-escalate care because of poor prognosis

23 DETERMINING THE FINAL COMPLEXITY MEDICAL DECISION MAKING Final Complexity of Medical Decision Making is determined by 2 of the 3 elements from the table below: Number of diagnoses or management options Amount and complexity of data to be reviewed 1 Minimal 1 Minimal 2 Limited 2 Limited 3 Multiple 3 Multiple 4 Extensive 4 Extensive Risk of complications and/or morbidity or mortality Minimal Low Moderate High TYPE OF DECISION MAKING Straight Forward Low Complexity Moderate Complexity High Complexity Per CMS and various MACs, Medical Necessity Determines Payment. Medical necessity of a service is the overarching criterion for payment. Do not submit a higher level of E/M service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which the service is submitted. Select the code for the service based upon the content of the service. The service furnished and submitted must meet the definition of the code.

For example, if a 30-minute office visit with an established patient involved more

24 Selecting E&M Service Codes Based on Time For visits that involves more than 50 percent counseling or coordination of care, time can determine the level of coding. For example, if a 30-minute office visit with an established patient involved more than 15 minutes of counseling and coordination of care, time could be used to support CPT code

25 CPT Code Time Threshold CPT Code Time Threshold (Unit/Floor) minutes minutes minutes minutes minutes minutes minutes minutes minutes minutes 99211* 5 (*no MD presence*) minutes minutes < or equal to 30 min minutes > 30 minutes minutes minutes minutes minutes minutes minutes minutes minutes minutes minutes minutes 99291, , +30 minutes minutes OUTPATIENT TIME= FACE TO FACE TIME INPATIENT TIME= UNIT / FLOOR TIME

27 John F. Burns, CPC, CPC-I, CEMC, CPMA Vice President, Audit and Compliance Services, ARHPC

Medical Necessity verses Medical Decision Making. Presented Kevin Solinsky,CPC, CPC-I, CEDC, CEMC of Healthcare Coding Consultants, LLC

Medical Necessity verses Medical Decision Making Presented Kevin Solinsky,CPC, CPC-I, CEDC, CEMC of Healthcare Coding Consultants, LLC Objectives We will first look at Medical Decision Making in detail.