Rational Physician Coding for E/M Consult Services Peter R. Jensen, MD, CPC www.emuniversity.com
Rational Physician Coding for E/M Consult Services Peter R. Jensen, MD, CPC For clinically driven E/M coding education, go to www.emuniversity.com Goals Know the definition of a consult Learn the documentation requirements for consult services Understand how to identify the highest ethical level of care Streamline your documentation to save time Maintain the focus on patient care 1
O q A f tr C m p What is a Consult? 2
Types of Consults E/M Code 99241 99242 99243 99244 99245 Outpatient Consults History PF EPF Detailed Comp Comp Exam PF EPF Detailed Comp Comp MDM Low Mod High 3 out of 3 key components must qualify PF SF Time 15 30 40 60 80 3
E/M Code 99251 99252 99253 99254 99255 Outpatient Consults Inpatient Consults History PF EPF Detailed Comp Comp Exam PF EPF Detailed Comp Comp MDM Low Mod High 110 3 out of 3 key components must qualify SF SF 20 40 55 80 s Time ts 4
Inpatient Consults ted only per ing the es Outpatient vs. Inpatient 5
Inpatient Outpatient Outpatient vs. Inpatient Outpatient Consults E/M Code 99241 99242 99243 99244 99245 E/M Code 99251 99252 Documentation History PF EPF Detailed Comp Comp History PF EPF Exam PF EPF Detailed Comp Comp Exam PF EPF Inpatient Consults MDM Low Mod High MDM 99253 Detailed Detailed Low 55 99254 Comp Comp Mod 80 99255 Comp Comp High 110 PF SF SF SF Time 15 30 40 60 80 Time 3 out of 3 key components must qualify 20 40 6
Coding Based on Time Inpatient Outpatient 7
8
Hx PF E/M Co 99255 Thi fre cod enc Rei abo E/M Co 99255 3 o Comprehensive HPI Brief T R N EPF Brief Det Ext 2 Comp Ext 9
What Does a 99255 Look Like? You You sulin Fina ons and The min 136 3.8 14 101 12 236 24 37 0.8 10
Self li Establ Establ worse New p work- New p work-up planned Decision to obtain old records 1 Review of old records 2 Total Points = 4 Total Points = 4 11
Risk Presenting Problems Diagnostic Procedures Management Options Minimal One self-limited or minor problem, e.g., cold, insect bite, tinea corporis. Laboratory tests Chest X-rays EKG/EEG, Echocardiogram Rest Gargles Superficial dressings Need 2 out of 3 to qualify for given level of MDM 12
Selecting the Target Code E/M Code Inpatient Consults History Exam MDM Time 13
History History Comp HPI Extended ROS 10 PFSH 3/3 Req thre item This HPI PFS RO are cut, Reason for consult: Pre-op clearance Requesting Physician: John Doe, MD HPI: This is a 77 YOWM with multiple medical problems, including well controlled HTN, stab bein requ PM SH: FH: thre RO Ta E/M Insight: Comprehensive History 14
Exam GI GU E/M Insight: Comprehensive Exam 14 hest/breasts Skin 15 16 sculoskeletal 19 Neurologic Psychiatric 17 18 DM High Requires at least two bullets from EACH of NINE organ systems. The example above qualifies based on the following bullets and organ systems:
Medical Decision-Making Assess Plan: Targ 99 Requires Four o Four o High ri The exam points, ev 136 3.8 101 24 14 236 12 37 EKG: NSR; no diagnostic ST changes 16
Reaso Doe, MD HPI: T well controlled ht hip early t orthopedic se and risk asses PMH: FH: M SH: M ROS Vitals: Gen: Eyes: HENT Neck: Lungs CV: R Abd: Ext: N Skin: Asses Plan: 1. Wil 2. Sta 3. D/ 4. Co 5. En 6. Ec 7. Ok 99255 rent Medications nopril 10 mg QD formin 500 mg BID ur 30 mg QD tor 20 mg QD 14 36 0.8 12 37 diagnostic ST changes 17
99245 E/M Code History Exam MDM Time Co Hx PF EPF Det Comp 99245 Comp Comp High 80 18
Yo cre Aft U/S foll The Prob Self limited Established Established worsening New proble work-up pla New proble work-up pla Outpatient Renal Consult 19
Risk Presenting Problems Diagnostic Procedures Management Options Minimal One self-limited or minor problem, e.g., cold, insect bite, tinea corporis. Laboratory tests Chest X-rays EKG/EEG, Echocardiogram Rest Gargles Superficial dressings Low Two or more self-limited or minor problems One stable chronic illness Acute uncomplicated injury or illness, e.g., cystitis, allergic Physiologic tests not under stress, e.g., PFTs Non-cardiovascular imaging studies with contrast ABG Over the counter drugs Minor surgery, with no risk factors PT/OT IV fluids, without Need 2 out of 3 to qualify for given level of MDM 20
Selecting the Target Code e y tal nly of DM gh 21
H C History Rea HPI: cont incr elev RO Pert occ dys Com of a no fi dise Tar 9 E/M Insight: Comprehensive History Requires an extended HPI (four or more HPI elements or the status of 22
GI GU Requires at least E/M Insight: Comprehensive Exam 2 13 14 Chest/Breasts 15 Skin Musculoskeletal 19 Neurologic Psychiatric 17 18 MDM High 16 23
Review of old records: We have a note from Dr. Hayes office dated six months ago, which showed a creatinine of 1.9. At that time, the patient s BP was 160/80. Lisinopril was increased from 10 to 20 mg QD. Patient was l d A 1 2 3 4 P 1 2 3 4 5 Req F F H The deci Medical Decision-Making 142 4.1 18 101 9.8 124 19 29 24
Reason for consult: CKD Requesting Physician: Richard Hayes, e, no lid-lag, PERRLA ormal hard/soft palate thyromegaly on /nodules ropriate affect 25
EPF E/M Co 99254 M us en Re ab E/M Co 99254 3 o Comprehensiv Hx PF Det Comp HPI Brief Brief Ext Ext 99254 26
What Does a 99254 Look Like? You ar patient He is p cholec You di hypern meq o Total ti minute What s Problem Self limited or Established pro Established pro worsening New problem, work-up planne New problem, work-up planne 27
Risk Presenting Problems Diagnostic Procedures Management Options Need 2 out of 3 to qualify for given level of MDM 28
Selecting the Target Code E/M Code Inpatient Consults History Exam MDM Time 29
History History HPI ROS PFSH Re thr of Th HP as PF RO ca yo. R H c y in P S F fa R E/M Insight: Comprehensive History 30
l Exam GI 14 GU hest/breasts Skin 15 16 sculoskeletal 19 Neurologic Psychiatric 17 18 DM Mod s. d organ Lungs Auscultation of lungs Percussion of lungs Assessment of orientation Assessment of affect 31
Medical Decision-Making Assessm Plan: 15 3 Target 992 E/M Insight: Moderate Complexity MDM Requires two out of three: 32
Vitals: 120/80, 28, 111, 99.6 Gen: Well-nourished middle-aged WM; confused Eyes: Anicteric 154 3.3 101 24 14 108 0.8 12 37 33
Hx PF EPF Det Comp E/M Code 99253 E Det 99253 History Exam MDM Time Det Low 55 34
What Does a 99253 Look Like? You are consulted for Problems Self limited or mi Established probl Established probl worsening New problem, no work-up planned New problem, ad work-up planned To MDM Points 35
Risk Presenting Problems Diagnostic Procedures Management Options Minimal One self-limited or minor problem, e.g., cold, insect bite, tinea corporis. Laboratory tests Chest X-rays EKG/EEG, Echocardiogram Rest Gargles Superficial dressings Low Two or more self-limited or minor problems One stable chronic illness Physiologic tests not under stress, e.g., PFTs Non-cardiovascular imaging Over the counter drugs Minor surgery, with no risk factors 36
Selecting the Target Code Inpatient Consults History Exam MDM Time 37
History History Detailed HPI Extended ROS 2 9 PFSH 1/3 Reason for consult: Post-op HTN spontaneous somatic complaints. ROS Requir three from o This e HPI: C PFSH: ROS:. Target Code 99253 Requesting physician: John Doe, MD sional knee pain, he has no 3 out of 3 key components must qualify History Det Exam Det E/M Insight: Detailed History MDM Low 38
Exam Constitutional Eyes ENMT Neck Lungs CV GI GU Target Code 99253 History Det Exam Det E/M Insight: Detailed Exam MDM Low A detailed exam requir The example above contains the 39
Medical Decision-Making Asse Plan Tar Low complexity MDM requires E/M Insight: Low Complexity MDM 40
Vitals: 148/90, 18, 82, 98.6 Gen: NAD, conv 41
E/M Code 99252 EPF 99252 History Exam MDM EPF SF Time 40 42
What Does a 99252 Look Like? Suppose you are consulted to see the Pro Self limited Establishe Establishe worsening New proble work-up pl New proble work-up pl MDM Points 43
Risk Presenting Problems Diagnostic Procedures Management Options Minimal One self-limited or minor problem, e.g., cold, insect bite, tinea corporis. Laboratory tests Chest X-rays EKG/EEG, Echocardiogram Rest Gargles Superficial dressings 44
Selecting the Target Code 45
History History HPI ROS PFSH ROS Target Code 99 An expanded CV: Negative for SSCP/orthopnea/PND History Exam MDM E/M Insight: Expanded Problem Focused History 46
Exam Constitutional Eyes ENMT Neck Lungs CV GI GU 1 2 3 4 5 6 Chest/Breasts 1. A Vit Ge Ne Lun CV Ab T E/M Insight: Ex 6. Abdominal exam This adds up to exactly 47
Medical Decision-Making Target Code E/M In History risk is actually more then enough.) Exam MDM all three dimensions of MDM. (The 48
Vitals: 125/75, 18, 82, 98.6 Gen: NAD, QD 49
E/M Code 99251 PF 99251 History Exam MDM Time PF SF 20 50
Sel Est Est wor Ne wor Ne wor 99251 Example You are asked to evaluate a patient for 51
Risk Presenting Problems Diagnostic Procedures Management 52
Selecting the Target Code 53
History HPI: The Target Code A problem focused History Exam E/M Insight: Problem Focused History MDM 54
Exam Constitutional Eyes ENMT Neck Lungs CV GI GU It is difficult (but not impos E/M Insight: Problem Focused Exam Chest/Breasts Skin Musculoskeletal Neurologic Psychiatric MDM SF 55
Medical Decision-Making La As Pla Ta Straig On On Min The e 56
99251 Reason for consult: three days. Vitals: 125/75, 18, 82, 98.6 Gen: NAD, conversant; labs for the last 57
History Physical MDM Perform the documentation in a purpose-driven manner Don t document more than is necessary to take care of the patient and maintain compliance Three out of three key components are always Peter R. Jensen, MD, CPC Online and On-site Physician-to-Physician E/M Coding Education 1-888-U-EM-CODE pjensen@emuniversity.com Practical E/M Coding Education www.emuniversity.com 58