Evaluation and Management Coding and Medicare Part B

1
Evaluation and Management Coding and Medicare
Part B

• Rachel Mitchell, CPC-H
• Applied Medical Systems, Inc.
• August 26, 2003

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What is documentation and why is it
important?

• Medical record documentation is required for
  reporting pertinent findings, facts and
  observations about a patients health history.
  The medical record documents patient care showing
  the chronology of treatment, communication
  between physicians, quality of care and
  collection of data.

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General principles of documentation

• Medical record should be complete and legible.
• Documentation should include
• Chief complaint
• Exam and diagnostic test results
• Assessment
• Plan

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Components of EM visits

• History
• Exam
• Medical decision making
• Counseling and/or coordination of care

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Continued.

• Rationale of ordering diagnostic testing
• Past and present diagnoses and/or conditions.
• Health risk factors
• Progress with regards to treatment

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Elements of HPI

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

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Elements of ROS

• Constitutional
• Eyes
• Ears, nose, throat, mouth
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Integumentary (skin and/or breast)
• Neurological
• Psychiatric
• Endocrine
• Hematologic/Lymphatic
• Allergic/Immunologic

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Past/Family/Social History

• Past History the patients history of
  illnesses, operations, injuries, treatments,
  medications.
• Family History a review of medical events in
  the patients family, including diseases which
  may be hereditary or place the patient at risk.
• Social History an age appropriate review of
  past and current activities. Ex marital status
  sexual history tobacco, alcohol, and drug use
  history job/career status.

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Physical Exam

• Problem Focused
• Limited exam of affected area/system (1 body area
  or system)
• Expanded Problem Focused
• Affected area/organ system other symptomatic or
  related systems (2 to 7 systems)
• Detailed
• Extended exam of affected area other
  symptomatic or related organ systems (2 to 7
  systems)
• Comprehensive
• General multi-system exam (8 or more systems)
• or complete exam of a single organ system

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Body Areas vs. Organ Systems

• BODY AREAS
• Head, incl. Face
• Neck
• Chest, incl. Breasts axillae
• Abdomen
• Genitalia, groin, buttocks
• Back, incl. Spine
• Each extremity

• ORGAN SYSTEMS
• Constitutional (vitals general appearance)
• Eyes
• ENT, mouth
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Skin
• Neurologic
• Psychiatric
• Hematologic/Lymphatic/Immunologic

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Medical Decision Making

• Diagnoses/Management Options
• Amount/Complexity of Data
• Risk of Complication

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Table of Risk Examples

• Presenting Problem
• Minimal One self-limited or minor problem.
• Low Two or more minor problems, one stable
  chronic illness, acute uncomplicated illness.
• Moderate Chronic illness with exacerbation, two
  of more stable chronic illnesses, undiagnosed new
  problem with uncertain prognosis, acute illness
  with systemic pneumonitis, acute complicated
  injury
• High Chronic illness with severe exacerbation,
  acute or chronic illness that poses threat to
  life, abrupt change in neurologic status.

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Level of Service (contd)

• Time matters!
• You may code the level based only on time if more
  than 50 of the visit is spent counseling the pt.
  The total time must be recorded as well as a
  statement that more than 50 of the visit was
  counseling.

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Evaluation and Management Codes
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99253 Initial Inpatient Consult

• New or established
• Requires detailed history and exam (extended exam
  of 7 organ systems/body areas)
• Low complexity medical decision making
• Presenting problem of moderate severity
• 55 minutes of bedside or floor time

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Clinical Examples

• Requested by internal medicine 45 year old
  male with 12 day history of incapacitating gout,
  unable to walk now, not improved by bed rest.
• Requested by internal medicine, for treatment
  recommendations for patient admitted with
  persistent inability to walk following soft
  tissue injury to knee.

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99254 Initial Inpatient Consult

• New or established
• Required comprehensive history and exam (general
  multisystem exam of 8 or more systems OR complete
  exam of single organ system).
• Moderate complexity medical decision making.
• Presenting problem of moderate or high severity.
• 80 minutes of bedside or floor time

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Clinical example

• Consult request for a 13 year old patient with
  painless swelling of the thigh with lytic lesion
  by xray
• Or
• Consult request for a 65 year old 72 hour
  status post mitral valve replacement who develops
  acute respiratory distress syndrome.

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99255 Initial Inpatient Consult

• New or established
• Required comprehensive history and exam (general
  multisystem exam of 8 or more systems OR complete
  exam of single organ system).
• High complexity medical decision making.
• Presenting problem of high severity.
• 110 minutes of bedside or floor time

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Clinical Example

• Consult request for a 74 year old male with
  chest pain and massive GI bleed.
• Or
• Consult request for a patient with multiple
  failed back surgeries continuing to have low back
  and neck pain.

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99301 99303 Nursing Facility Visits

• All three codes are assessment codes for new or
  established patients
• 99301 is used annually for the recertification of
  the care plan. (30 minutes)
• 99302 is used when a patient incurs a permanent
  change in physical condition and the care plan
  requires a revision. (40 minutes)
• 99303 is used to establish the medical care plan
  for a new admission to the nursing facility. (50
  minutes)

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99311 99313 Subsequent Nursing Facility Care

• New or established patients
• Daily care visits
• 99311 is used when a patient is stable,
  recovering or improving. (15 minutes)
• 99312 is used when a patient is responding
  inadequately to therapy or has developed a minor
  complication. (25 minutes)
• 99313 is used when a patient has a serious
  problem, but is not required to be admitted to a
  hospital. (35 minutes)

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99331 Domiciliary Care

• Established visit requiring problem focused
  history, problem focused exam and low complexity
  medical decision making.
• Patient is usually stable, recovering or
  improving.
• This code can be used when patients are residents
  of nursing facilities, assisted living and
  retirement communities.

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99261 Follow-up Inpatient Consult

• Established visit requiring problem focused
  history, problem focused exam and low complexity
  medical decision making. (2 of 3 components)
• Patient is stable, recovering or improving.
• Physician typically spends 10 minutes at bedside
  or on the unit.

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Clinical Examples

• Follow-up with a 75 year old female who urinary
  incontinence to review results of a diagnostic
  test the day of initial consult.
• Or
• Follow-up with a 94 year old male nursing home
  resident for re-evaluation of hemorrhoids
  following conservative treatment on initial
  consult.

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99262 Follow-up Inpatient Consult

• Established visit requiring expanded problem
  focused history, exam and moderate complexity
  medical decision making. (2 of 3 components)
• Patient is responding inadequately to therapy or
  has developed a minor complication.
• Physician typically spends 20 minutes at bedside
  or on the unit.

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Clinical Example

• Follow-up with a 51 year old male for test
  results from initial consult of the etiology of
  postop hyponatremia following TURP procedure.

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99263 Follow-up Inpatient Consult

• Established visit requiring detailed history,
  exam and high complexity medical decision making.
  (2 of 3 components)
• Patient is unstable or has developed significant
  complication or new problem.
• Physician typically spends 30 minutes at bedside
  or on the unit.

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Clinical Example

• Follow-up of 62 year old male who was initially
  evaluated for pansinusitis now with sudden onset
  of proptosis.

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99344 Home Services

• New patient visit which requires a comprehensive
  history, exam and moderate medical decision
  making.
• Presenting problems are usually of high severity.
• Physician typically spends 60 minutes face to
  face with the patient and/or family.

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99345 Home Services

• New patient visit requiring comprehensive
  history, exam and high complexity medical
  decision making.
• Patient is unstable or has developed a
  significant new problem requiring immediate
  physician attention.
• Physician typically spends 75 minutes face to
  face with the patient and/or family.

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99348 Home Services

• Established visit requiring expanded problem
  focused history, exam and low complexity medical
  decision making. (2 of 3 components)
• Presenting problem(s) are of low to moderate
  complexity.
• Physicians typically spend 25 minutes face to
  face with patient and/or family

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99356 Prolonged Services

• Physician services within the inpatient setting
  that requires direct patient contact. First
  hour.
• This CPT is to be listed in addition to the
  evaluation and management service.

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ICD9CM Coding

• Medical necessity is an important factor.
• Can code from signs and symptoms.
• Will no longer use Volume 3.
• Utilize the Medicare Local Medical Review
  Policies website.
• Code to the highest specificity

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CMS-1500 a.k.a HCFA-1500
36
(No Transcript)
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Patient Information

• Block 1 Type of Insurance Indicator
• Block 1a Insured ID
• Block 2 Patient Name
• Block 3 Patients DOB
• Block 4 Policy Holder
• Block 5 Patient Address
• Block 6 Relationship to the Insured
• Block 7 Policy Holders Address

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Patient Information Continued

• Block 8 Patient Status
• Block 9 Medigap Info
• Block 10 Accident Indicator
• Block 11 Primary to Medicare Insurance
• Block 12 Patient Authorization
• Block 13 Insured Authorization
• Block 14 Illness Date
• Block 15 (not required by Medicare
• Block 16 Unable to Work Date

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Treatment Information

• Block 17 Referring Physician
• Block17a UPIN
• Block 18 Hospitalization Dates
• Block 19 Local Use
• Block 20 Outside Lab
• Block 21 Diagnosis Codes
• Block 22 Medicaid Resubmission Code (not required
  by Medicare)
• Block 23 Authorization

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Treatment Information Continued

• Block 24d CPTs and Modifiers
• Block 24e Diagnosis Code Reference
• Block 24f Charges
• Block 24g Units/Days
• Block 24h, i and j not required by Medicare
• Block 27k Provider Number (individual)

• Block 24b Place of Service
• Block 24c Type of Service
• Block 24a Treatment Date

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Provider Information

• Block 29 Amount Paid
• Block 30 Balance Due (not required by Medicare)
• Block 31 Physician Signature and Printed Name
• Block 32 Services Rendered Name and Address
• Block 33 Physician Billing Address

• Block 25 Provider Tax ID
• Block 26 Patient Account Number
• Block 27 Accept Assignment Indicator
• Block 28 Total Charges

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Place of Service Codes

• 11 Office
• 12 Home
• 13 Assisted Living Facility
• 21 Inpatient Hospital
• 22 Outpatient Hospital
• 23 Emergency Room

• 31 Skilled Nursing Facility
• 32 Nursing Facility
• 33 Custodial Care Facility
• 34 Hospice
• 51 Inpatient Psychiatric Facility
• 72 Rural Health Clinic

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Type of Service Codes

• 01 Medical Care
• 02 Surgery
• 03 Consultation

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Part B Billing

• Billed on a HCFA-1500 (CMS-1500)
• Does not require revenue codes
• Provides payment for physician and outpatient
  hospital services as well as medical equipment.
• 100 per year calendar deductible
• Sent to a carrier in Nashville, Tennessee
• Primary diagnosis code is the main code
  recognized.
• Providers can choose whether or not to
  participate.

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Websites for Claim Filing,etc.

• www.payerpath.com
• www.easyhcfa.com
• www.ezclaim.com
• www.softlookup.com
• www.justclaims.com
• www.hcfaware.com
• www.claimsbpo.com

• ICD9CM look-up
• www.flashcode.com
• www.unicormed.com
• Medicare Local Medical
• Review Policies
• www.lmrp.net

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Physician Billing Software Websites

• www.medisoft.com
• www.a4healthsystems.com
• www.perfectpracticemd.com
• www.pmsi.com
• www.misyshealth.com