Chpt 3 Flashcards
Evaluation and Management
1st section of CPT
Billable services
1st evaluation by healthcare provider
Then implement management plan and record in the medical record
Original guidelines for E/M
AMA & CMS
1995 & 1997
Labor intensive to document all the components needed for code justification
Be aware for audits of retrospective period
Internet links for both at CMS.gov
Revised guidelines
January 1, 2021, AMA -streamlined 99202-99215
January 1, 2023 for other CPT codes
E/M code questions
Is the patient new or established?
Where was the service provided?
What was the level of the service rendered?
New patient points
Same specialty or subspecialty
Same group practice
Three years
Place of Service code
Different than E/M code
Box 24B of CMS-1500
Codes maintained by CMS
Medical decision making
The number and complexity of problems addressed at the encounter
The amount and/or complexity of data reviewed and analyzed
The risk of complications and/or morbidity or mortality of patient management
Risks of complications level
Minimal, low, moderate, high
Based on the risks associated with presenting problems, the diagnostic procedures and possible management problems
Determine the amount and complexity of the data reviewed
More tests and procedures reviewed by the provider, the higher the level of this element
The review of of a report can be documented with a provider note or the provider can initial and date the report
If the provider personally reviews the specimen or image they ordered, the complexity of the reviewed data increases
When documenting the complexity of data reviewed, providers should clearly document the information in order to justify the types of data reviewed
The risk of complications and/or mortality or morbidity of patient management
Select type of risk
Comorbidities and underlying diseases increase the complexity of risk
Surgical and invasive procedures performed during the encounter increase risk
Problems that pose a threat to life or bodily function increase risk
The more complex the diagnostic tests ordered, the greater the risk
The more complex the management options ordered are, the greater the risk
4 types of medical decision making regardless of location
Straightforward, low, moderate , high
99211
Reported for an office or outpatient visit for an established patient that does not require the presence of a physician or other healthcare provider
MDM
Justification of MDM is provider’s documentation
MDM Tables
List the specific elements that are needed for each type of MDM.
2 of 3 elements must be met or exceeded to qualify for a specific level of MDM
MDM decided on time
Requires a face-to-face encounter between the provider and the physician
ROS
Review of systems
Obtained by querying the patient
PFSH
Past, family and/or social history
Past: any past medical information that may affect the decision-making process
Office POS
11
School POS
3
Home POS
12
Assisted living facility
13
Urgent care facility POS
20
Inpatient hospital POS
21
Skilled nursing facility
31
Emergency room-hospital POS
23
Consultation visits require a written report
Observation status
Not required to be located in a designated area
The patient is classified as ‘observation status’
Encounter at hospital spans 2 calendar dates
It is a single service reported on one date
Seen in another site of service, then admitted to hospital
The not hospital visit may be coded, use modifier 25
Other site can include nursing facility or ED
Consultations performed on the same day in relation to an inpatient admission
Use subsequent hospital codes
Prolonged service visits in the hospital/observation
99418
Admit and discharge on one day
Requires a minimum of two encounters
One encounter of the admit and discharge
Select code from the hospital inpatient/ observation initial visit codes
Discharge codes
99238-99239
Used for physician/QHP responsible for discharging services based on duration of time spent discharging the patient
Physician not responsible for discharge
Use subsequent hospital codes
Hospital discharge when the patient has stayed overnight
99238-99239
For same day discharge use 99234-36
Provider responsible for discharging the patient may use the discharge code, no one else
Appropriate source for consultation
Physician, QHP, non-clinical social worker, educator, lawyer, insurance company
Mandated consultation
Modifier 32
3Rs
Consultation
Appropriate source
Recommendations
Report back to requester
Even as an initial consultation
Must be reported as subsequent visit if the consultant saw him prior to admission
Office consultation and hospital consultation
Code office consultation then hospital consultation as subsequent visit
All consultations are initial
MDM
Diagnosis list
Procedure list
99252-99255
May be reported only once per consultant per admission of a patient who is in hospital inpatient or observation status
ED Services
Hospital based, open 24 hours per day
If critical care on same day as ED visit, code only CC
If OBS status, admit and discharge on the same date, nursing facilities do not code ED
Code separately reported E/M services
Patients seen in the ED for the convenience of another physician/QHP code as office
E/M
History/exam
Location of the visit
Type of visit: new/established
Total time
MDM
E/M tables to select the code
Apply all guidelines
ED guidelines continued
Site of service might not solely determine the appropriate codes to report
Reporting additional services or procedures with ED services are permitted, use the appropriate modifiers: 54, 55, 56, 59, etc
