Coding And Reimbursement/ E&M Flashcards
Which of the following scenarios qualifies for a consultation code?
a. An internal medicine physician is requested to take over the monitoring and management of a patient’s Coumadin regimen while he is hospitalized for a schizophrenic episode. The request was made by the patient’s psychiatrist.
b. A patient followed by her primary care physician for diabetes is referred to an endocrinologist in the same group practice to review the patient’s current regimen and offer suggestions for ongoing treatment. Her diabetes has been difficult to keep under control.
c. A patient presents to the emergency department with an open fracture following a motorcycle accident. It is determined the patient will need surgery. The patient is admitted by the orthopedic attending with planned surgery for the morning.
d. A patient presents to a rheumatologist for a second opinion regarding her lupus. She is not confident in her current physician.
b. A patient followed by her primary care physician for diabetes is referred to an endocrinologist in the same group practice to review the patient’s current regimen and offer suggestions for ongoing treatment. Her diabetes has been difficult to keep under control.
A 77-year-old Medicare beneficiary has a digital rectal examination for prostate cancer screening and the provider orders a PSA. How would this be reported?
G0102
Rationale: CMS has very specific guidelines on eligibility and coding of preventive services. There is no specific CPT® code for a digital rectal exam. Code 45990 is a diagnostic exam that includes a diagnostic anoscopy and rigid proctoscopy. Neither service is documented nor is it stated that the patient received an annual exam. The service provided is best represented by HCPCS code G0102.
(https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html)
Dr. H sees Mrs. Jones in Clinic Eight for syncope while watching the Olympic Torch go by. He is a new provider to the neurology department. Dr. D is also in the neurology department and saw Mrs. Jones last month but is on medical leave for a couple months. Dr. H performs a medically appropriate history and exam. Dr. H orders a CT scan, comprehensive metabolic panel, and CBC panel test. The final diagnosis given is suspected psychogenic syncope. The patient makes a follow-up appointment to see Dr. R in one week. What diagnosis and E/M codes are reported for this visit?
99214, R55
Rationale: E/M Guidelines define an established patient as one who has received professional services from the provider – or another provider of the same specialty who belongs to the same group practice – within the past three years. The patient was seen the previous month by another member in the same group practice of the neurology department making this an established patient. MDM is moderate reporting 99214 for undiagnosed new problem with uncertain prognosis (Moderate), ordering of CT scan, metabolic panel and CBC lab tests (Moderate).
The psychogenic syncope is not reported because it suspected. Look in the ICD-10-CM Alphabetic Index for Syncope directing you to code R55.
A 75-year-old established patient sees his regular primary care provider for a physical screening prior to joining a group home. He has no new complaints. The patient has an established diagnosis of cerebral palsy and type 2 diabetes and is currently on his meds. A comprehensive history and examination are performed. The provider counsels the patient on the importance of taking his medication and gives him a prescription for refills. Blood work was ordered. PPD was done and flu vaccine given. Patient already had a vision exam. No abnormal historical facts or finding are noted. What CPT® code is reported?
99397
Rationale: According to CPT® guidelines Preventive Medicine Services codes provide a means to report a routine or periodic history and physical examination in asymptomatic individuals. They include only those evaluation and management services related to the age specific history and examination provided by the provider. The patient is here for a preventive service. He did not have any complaints and the provider did not identify any new problems. In the CPT® Index look for Preventive Medicine/Established Patient. You are referred to 99382-99397. The code selection is based on age. Code 99397 is the correct code for a patient who is older than 65 years.
Patient has a urinary tract infection and is given a prescription for ciprofloxacin by her primary care physician. What is level for risk of complications and/or morbidity or mortality of patient management?
Moderate
Rationale: Prescription of the ciprofloxacin is counted as prescription drug manamgent for a moderate level.
An established patient presents to the office with a recurrence of bursitis in both shoulders. Examination is limited only to the shoulders in which range of motion is good and full, but he has tenderness in the subdeltoid bursa. Both shoulders were injected in the deltoid bursa with 120mg Depo-Medrol. What CPT® code(s) is/are reported for this visit?
20610-50
Rationale: For this encounter, no additional work in evaluating the patient has been performed to support an E/M service with modifier 25 that is significant and separately identifiable from the procedure. Only the procedure is billed. To perform an arthrocentesis, the physician inserts a needle through the skin and into a joint or bursa. A fluid sample may be removed from the joint or fluid may be injected for lavage or drug therapy. In the CPT® Index look for Shoulder/Arthrocentesis. You are referred to codes 20610 and 20611. Review the code description to verify accuracy. Modifier 50 Bilateral Procedure is attached because both shoulders are injected. CPT ® code 20611 is not correct because it includes ultrasound guidance with permanent recording and reporting.
Dr. Inez discharges Mr. Blancos from the pulmonary service after a bout of pneumococcal pneumonia. She spends 45 minutes at the bedside explaining to Mr. Blancos and his wife the medications and IPPB therapy she ordered. Mr. Blancos is a resident of the Shady Valley Nursing Home due to his advanced Alzheimer’s disease and will return to the nursing home after discharge. On the same day Dr. Inez re-admits Mr. Blancos to the nursing facility. She obtains a history, examination, and the medical decision making is moderate complexity.
What is/are the appropriate evaluation and management code(s) for this visit?
99239, 99305
Rationale: Hospital discharge is a time-based code. The documentation states that the provider spent 45 minutes discharging the patient. In the CPT® Index look for Hospital Services/Discharge Services. Code 99239 is for 30 minutes or more. Upon discharge the patient was readmitted to a skilled nursing facility (SNF) where he is a resident. CPT® guidelines preceding the Initial Nursing Facility Care codes state when a patient is discharged from the hospital on the same day and readmitted to a nursing facility both the discharge and readmission is reported. Documentation tells us the physician provided a medically appropriate history and exam, with a medical decision making was of moderate complexity. Our documentation shows it to be of moderate complexity, which meets the requirements of 99305.
ICU - CC: Multi-system organ failure
INTERVAL HISTORY: Patient remains intubated and sedated. Overnight events reviewed. Tolerating tube feeds. Systolic pressures have been running in the low 90s on LEVOPHED. Cultures remain negative. Kidney function has worsened, but patient remains non-oliguric.
PHYSICAL EXAM: BP 96/60, Pulse 112, Temp 100.8. Lungs have anterior rhonchi. Heart RRR with no MRGs. Abdomen is soft with positive bowel sounds. Extremities show moderate edema.
LABS: BUN 89, creatinine 2.6, HGB 10.2, WBC 22,000. ABG: 7.34/100/42 on 50% FiO2. CXR shows RLL infiltrate.
IMPRESSION
Hypoxic respiratory failure
Community acquired pneumonia
Septic shock
Non-oliguric acute renal failure
PLAN: Continue NS at 75 cc/hr. Decrease ZOSYN to 2.25 grams IV Q 6H
Follow cultures. Continue tube feeds. Titrate LEVOPHED to maintain SBP > 90
Usual labs ordered for tomorrow.
Critical care time: 35 minutes
What CPT® code(s) is/are reported?
99291
Rationale: This patient meets the definition of a critically ill patient as defined by the E/M Guidelines for Critical Care services. A critical illness is one acutely impairing one or more vital organ system with a high probability of imminent or life threatening deterioration in the patient’s condition. The physician documents 35 minutes of critical care time. Critical care for 35 minutes is reported with 99291.
When tissue glue is only used to close a wound involving the epidermis layer how is it reported according to CPT® guidelines?
A simple closure
Rationale: The Guidelines for Repair (Closure) include tissue adhesive along with sutures and staples, either singly or in combination with each other can be reported with the repair codes. In this case the tissue glue (adhesive) is a one-layer closure and can be reported with a simple repair code. Wound closure utilizing adhesive strips as the sole repair material is coded using the appropriate E/M code.
According to the AMA E/M Guidelines, what level of MDM is given for the Amount and/or Complexity of Data to be Reviewed and Analyzed when 3 X-rays are ordered and 3 unique labs are ordered?
Moderate
Rationale: The ordering of three unique test satisfies category 1 under the table for the amount an or complexity of data to be reviewed and analyzed for a moderate.
An established patient presents to the clinic today for a follow-up of his pneumonia. He was hospitalized for 6 days on IV antibiotics. He was placed back on Singulair and has been doing well with his breathing since then. An expanded problem focused exam was performed. The provider reviewed the CBC from the hospital and personally viewed and interpreted a recent chest X-ray that shows the right lung with infiltrates. The patient was told to continue antibiotics for another two weeks to 20 days, and the prescription Keteck was replaced with Zithromax. Patient is to return to the clinic in two weeks for recheck of his breathing and new follow up X-ray. What CPT® code is reported?
99214
Rationale: The patient was seen in the clinic which is an outpatient service. MDM is moderate for acute illness with systemic symptoms (Moderate number/complexity of problems addressed. [The pneumonia is still being treated and is considered as acute]), review of lab test, independent interpretation of radiology test, and new order of a follow up X-ray (Moderate amount and/or complexity of data)Prescription drug management (Moderate risk). Code 99214 is the appropriate code for this visit.
A provider makes a home care visit to a 63-year-old hemiplegic patient who has been experiencing insomnia for the last two weeks. The patient has been home bound for the last year. The last visit from this provider was four months ago to manage his DM. The physician performs medically appropriate history and examination and low MDM. The provider speaks with the spouse about the possibility of placing the patient in a nursing facility. What CPT® code is reported?
99348
Rationale: According to CPT® E/M guidelines, Home Services codes (99341-99353) are used to report evaluation and management services provided in a private residence. This is an established patient to the provider. The provider performed medically appropriate history exam and low MDM selecting code 99348.
A 37-year-old female is seen in the clinic for follow-up of lower extremity swelling.
HPI: Patient is here today for follow-up of bilateral lower extremity swelling. The swelling responded to hydrochlorothiazide.
DATA REVIEW: I reviewed her lab and echocardiogram. The patient does have moderate pulmonary hypertension.
Exam: Patient is in no acute distress.
ASSESSMENT:
1. Bilateral lower extremity swelling. This has resolved with diuretics; it may be secondary to problem #2.
2. Pulmonary hypertension: Etiology is not clear at this time, will work up and possibly refer to a pulmonologist. Will start patient on Warfarin 2.0 dosage.
PLAN: Will evaluate the pulmonary hypertension. Patient will be scheduled for a sleep study.
99214
Rationale: This is a follow-up visit indicating an established patient seen in the clinic. In the CPT® Index look for Established Patient/Office Visit. The code range to select from is 99211-99215. Pulmonary hypertension can be a serious condition. Number and Complexity of Problems Addressed at the Encounter is based on the unclear etiology, this is a chronic and progressive disease (Moderate). Because this is a follow up patient and a follow up condition, and there is no indication the labs and echocardiogram were ordered by another provider, there is no credit given for these. The provider orders one unique test (the sleep study), making this minimal for the amount and complexity of data to be reviewed and analyzed. Further study (additional testing) is needed to determine the cause of the pulmonary hypertension. There is a moderate risk involved for starting the patient on Warfarin (prescription drug management). The overall MDM is moderate for the visit.
A provider admits Mrs. Smith to the hospital. She is there for five days. The provider sees her each day she’s in the hospital. What subcategory of E/M codes would be used for days two, three and four?
Subsequent Hospital Care
Rationale: Codes from the Subsequent Hospital Care subcategory would be used for days two, three and four. The code for the first day would be from the Initial Hospital Care subcategory. Day five could be reported with either subsequent hospital care or hospital care discharge depending on the role of the provider.
A 90-year-old female was admitted this morning from observation status for chest pain to r/o angina. A cardiologist performs a history and exam. Her chest pain has been relieved with the nitroglycerin drip given before admission and she would like to go home. Doctor has written prescriptions to add to her regimen. He had given her Isosorbide, and she is tolerating it well. After 10hrs of observation, he will go ahead and send her home. We will follow up with her in a week. Patient was admitted and discharged on the same date of service.
What CPT® code is reported?
99235
Rationale: This patient was admitted and discharged on the same date of service from observation status. According to CPT® guidelines for Observation or Inpatient Care Services (Including Admission and Discharge Services), services for a patient admitted and discharged on the same date of service is reported by one code. For a patient admitted and discharged from observation or inpatient status on the same date, codes 99234-99236 is reported as appropriate.” The provider performed a moderate MDM (undiagnosed new problem with uncertain prognosis, none for amount and/or complexity of data, and moderate risk). The correct code is 99235.
A 5-year-old is brought to the Emergency Department by ambulance, He had been found floating in a pool for an unknown amount of time. EMS started CPR which was continued by the ED provider along with endotracheal intubation and placement of a CVC. The ER provider spent 1 hour with the critically ill patient. The ED provider makes a notation the 1 hour does not include the time for the other separate billable services. What CPT® codes are reported?
92950, 99291-25, 36556, 31500
Rationale: ED provider documents an amount of time spent with this critical patient. According to CPT® guidelines: “The critical care codes 99291 and 99292 are used to report the total duration of time spent by a provider providing critical care services to a critically ill or critically injured patient. Time spent with individual patient is recorded in the patient’s record.” According to CPT® guidelines: “Services such as endotracheal intubation (31500) and cardiopulmonary resuscitation (92950) are not included in the critical care codes. Therefore, they can be coded separately in addition to critical care services if the critical care is a significant, separately identifiable service, and is reported with modifier -25. The time spent performing these other services, for example endotracheal intubation, is excluded from the determination of the time spent providing critical care.” In the CPT® Index look for Cardiopulmonary Resuscitation (CPR). You are referred to 92950. Review code to verify accuracy. In the CPT® Index look for Catheterization/Central. You are referred to 36555-36566. 36556 is the correct code because the patient is 5 years of age and there is no indication the CVC was tunneled. In the CPT® Index look for Intubation/Endotracheal Tube. You are referred to 31500. Review code to verify accuracy.
A PCP transfers a patient to a cardiologist for management of the patient’s congestive heart failure. The cardiologist examines the patient, discusses treatment options and schedules a stress test for this new patient. A report is sent to the PCP detailing the findings of the office visit, results of the stress test and intent to manage and treat the congestive heart failure. An E/M code would be selected from what subcategory for the cardiologist?
New patient office visit
Rationale: The PCP transferred the patient to the cardiologist to manage/treat the congestive heart failure. The cardiologist accepted the transfer of care of the patient and sent a letter to the PCP with findings of the first visit and stress test. This would be coded as a new patient because the cardiologist accepted the patient and is taking over the care of a specific problem.
Referring to the MDM table which level is reported for a diagnosis that is an acute uncomplicated illness or injury?
Low
An acute uncomplicated illness or Injury will be a low level under the column Number and Complexity of Problems Addressed at the Encounter indicated on the MDM table.
Mary is referred to a general surgeon for treatment of a left breast mass. The surgeon reviews the visit records from Mary’s primary care provider and the results of a previous ultrasound. He orders a left breast MRI and schedules a follow-up appointment with Mary to go over treatment options. He calls the primary care provider to discuss his visit with Mary and possible options. Based on this information, what is the level for Amount and/or Complexity of Data to be Reviewed and Analyzed?
Extensive
Rationale: For an extensive level, any combination of 3 of the following must be met from Category 1: 1) Review of prior external notes; 2) Review results of a unique test; 3) order a unique test; 4) Assessment requiring an independent historian(s). Three of the four requirements were met: review of prior notes from PCP; review of ultrasound; ordering of MRI.
A 60-year-old woman is seeking help to quit smoking. She makes an appointment to see Dr. Lung for an initial visit. The patient has a constant cough due to smoking and some shortness of breath. No night sweats, weight loss, night fever, CP, headache or dizziness. She has tried patches and nicotine gum which has not helped. Patient has been smoking for 40 years and smokes 2 packs per day. She has a family history of emphysema. A limited three system exam was performed. Dr Lung discussed in detail the pros and cons of medications used to quit smoking. Total time of 30 minutes was spent on this visit today. Prescriptions for Chantix and Tetracycline were given. The patient to follow up in 1 month. A chest X-ray and cardiac work up was ordered. Select the appropriate CPT code(s) for this visit.
99203
Rationale: Patient is coming to the provider’s office for help to quit smoking. The patient is new. The provider documents that 20 minutes of the 30-minute visit was spent counseling the patient. E/M Guidelines identify when time is considered the key or controlling factor to qualify for an E/M service. Time E/M guidelines indicate that time alone can be used to select codes 99202-99215. The correct code is 99203 based on the total time of the visit which is 30 minutes.
