INPATIENT SERVICES
Physician Training
Presented by: La Verne Jones
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The Coding Network (TCN)
Quality and Affordability
THE CODING NETWORK is committed to
provide cost effective state-of-the-industry
procedural and diagnostic coding support to
medical groups, academic practice plans,
hospitals, ambulatory surgery centers, and
billing companies throughout the United
States.
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TCN provides physician & hospital coding,
compliance reviews and training
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Avoid costly mistakes and unnecessary
audits.
Maximize your revenue.
Reduce fixed expenses.
Maintain continuity of coverage.
Safeguard OIG and CMS compliance.
Eliminate coding backlogs.
Add new specialists with confidence.
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TCN is the nation’s leading
remote coding service
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Each specialty is managed by a national coding expert,
with years of coding experience in his specialty.
Our staff of certified coders understand the subtle
differences that exist in each specialty.
All coders have years of experience coding exclusively
for their specialty.
Since our 1995 establishment, not a single physician
has ever paid a penny for recoupments, fines or
penalties for a case coded by TCN.
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TCN’s areas of expertise
PHYSICIAN CODING
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Ambulatory Surgery Centers
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Anesthesiology
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Cardiac Catheterization
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Colorectal Surgery
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Emergency Medicine
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Evaluation and Management
Services
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Gastroenterology
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General Surgery
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Gynecology and Gynecologic
Oncology
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Interventionional Radiology
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Neurosurgery
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Ophthalmology
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Orthopedics
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Otolaryngology – Head and Neck
Surgery
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Pain Management
1/15/2009
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Pathology – Surgical and Anatomic
Pediatric Surgery
Plastic and Reconstructive Surgery
Radiology
Surgical Oncology
Transplant Surgery
Trauma and Burn
Urology
Vascular Surgery
FACILITY CODING
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Ambulatory Surgical Centers
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Emergency Medicine
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Radiology
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Inpatient Records
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Outpatient Ambulatory Coding
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When TCN codes for you
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Provide coverage for absent coders due to illness, vacation or
family leave.
Eliminate backlogs and/or bottlenecks.
Reduce exposure to denials, recoupments and audits.
Optimize revenue.
Stay on top of coding changes.
Comply with all laws and regulations.
Receive coding "helpline" access.
Receive documentation training.
Access to certified experienced coders.
Cut overhead by eliminating salaries and benefits.
Curtail fixed expenses.
Errors and omissions insured.
Receive prompt turnaround.
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Coding compliance reviews
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The OIG recommends periodic independent
reviews to evaluate your coding for accuracy.
TCN’s coding specialist examines a sample
of your coded medical records to validate the
procedural and diagnostic coding.
Proper modifier usage and other compliance
issues are evaluated and reported.
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Physician and staff training
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Physician and staff training on site at your
facility.
Extensive physician-specific training to assist
in the proper documentation of patient care.
All courses are specialty specific and include
a syllabus for each participant.
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LA VERNE JONES CCP, CPC
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30 years of experience in practice
management settings
13 years as facilitator of procedural and
diagnostic coding
13 years experience as practice management
consultant of HCFA policies
7 years experience as Compliance Officer
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Course Agenda
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Components of E&M Services
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History
 Examination
 Medical Decision-Making
 Time
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Inpatient Categories of Service and
Documentation Requirements
Teaching Physician Guidelines
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Let’s get started!
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How to use the course workbooks.
Lecture – please follow along with the
overheads.
Resources & Follow-Up
Questions – Please ask me!
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INPATIENT SERVICES
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EVALUATION AND MANAGEMENT SERVICES
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KEY COMPONENTS FOR SELECTION OF LEVEL
OF SERVICE
Three (3) key components:
History
Examination
Physician Training
Presented by: La Verne Jones
Medical Decision-Making
Key components drive the decision for level of service
unless a visit consists predominantly of counseling or
coordination of care.
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KEY COMPONENT #1: HISTORY
The extent of history of present illness, review of
systems and past family and/or social history obtained
and documented is dependent upon clinical judgment
and the nature of presenting problem(s).
 History is comprised
some or all of the following
Physicianof
Training
elements: Presented by: La Verne Jones
 Chief Complaint (CC)
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History of Present Illness (HPI)

Review of Systems (ROS)

Past, Family and/or Social History (PFSH)
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 There are four (4) types of history: Problem Focused,
Expanded Problem Focused, Detailed and Comprehensive. To qualify for a given type of history, all three
(3) criteria of HPI, ROS and PFSH must be met or
exceeded.
TYPES OF HISTORY
HPI
ROS
PFSH
PROBLEM FOCUSED
Brief
N/A
N/A
Problem
N/A
1-3
EXPANDED PROBLEM
FOCUSED
Brief
Pertinent
1-3
DETAILED
COMPREHENSIVE
1
Extended
Extended
4+
2-9
Extended
Complete
4+
1
2-3
10
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DOCUMENTATION GUIDELINES FOR HISTORY: REVIEW
OF SYSTEMS AND PAST FAMILY SOCIAL HISTORY
 A Review of Systems and/or Past, Family and/or Social History obtained
during an earlier encounter does not need to be re-recorded if there is
evidence that the physician reviewed and updated the previous
information. This may occur when a physician updates his own record,
or in an institutional setting, or group practice where many physicians
share a common record.
 The review and/or update may be documented by describing any new
ROS/PFSH information or noting there has been no change in the
information. The date and location of earlier ROS/PFSH should be
noted.
 Documentation of Review of Systems and/or Past, Family Social History
by University Hospital System or Christus Santa Rosa staff cannot be
counted toward the provider’s E&M level.
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DOCUMENTATION GUIDELINES FOR HISTORY: REVIEW
OF SYSTEMS AND PAST FAMILY SOCIAL HISTORY
 If the physician is unable to obtain a history from the patient or other
source, the record should describe the patient’s condition/
circumstances which precludes obtaining history, i.e., patient
unconscious, patient intubated.
 Physicians cannot use “all other systems are negative” as a completion
statement for Review of Systems.
 Medical students can document in the record but attendings can only
count their documentation of ROS and PFSH. The faculty attending
must re-perform or re-document any other work that the medical student
has performed.
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KEY COMPONTENT #2: EXAMINATION
There are four (4) types of examinations.
Problem Focused Exam
– 1 body area or organ system
Expanded Problem Focused Exam
– Limited exam of affected
area + 2-7 body areas or
organ systems
–
Detailed Exam
Ex: AA0X3, CTAB, Abdomen
ND/NT
– Document 3 or more elements of
exam of affected area + 2-7
body areas or organ systems
–
Comprehensive Exam
Ex: AA0X3, CTAB, Abdomen
ND/NT, +BS, no HSM
– 8 or more organ systems
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1995 EXAMINATION DOCUMENTATION
GUIDELINES
Body Areas:
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Head, including the face
Neck
Chest, including the breasts and axillae
Abdomen
Genitalia, groin, buttocks
Back
Each extremity
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Organ Systems:
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Constitutional
Eyes
Ears, Nose, Mouth, and Throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
Neurologic
Psychiatric
Hematologic/Lymphatic/Immunologic
Endocrine system (thyroid)
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DOCUMENTATION GUIDELINES FOR EXAMINATION
 Specific abnormal and relevant negative findings of the examination
should be documented. A notation of “abnormal” or “positive” without
elaboration is insufficient.
 Abnormal or unexpected findings of the examination of
asymptomatic body area(s) or organ system(s) should be described.
any
 A brief statement or notation indicating “negative” or “normal” is
sufficient to document normal findings related to unaffected area(s) or
asymptomatic organ system(s).
 When pelvic or rectal exam for an adult is deferred, document the reason.
 The exam is real time. One cannot indicate “no change in exam from
previous encounter.”
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KEY COMPONENT #3: COMPLEXITY OF MEDICAL
DECISION-MAKING
Medical decision-making refers to the complexity of establishing a
diagnosis and/or selecting a management option. The complexity of
the assessment and plan of care for a patient is measured by:
 number of possible diagnoses and/or management options
 amount and complexity of medical records, diagnostic tests and
other data to be obtained, reviewed and analyzed
 risk of significant complications, morbidity and mortality
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KEY COMPONENT #3: COMPLEXITY OF MEDICAL
DECISION-MAKING
There are four (4) types of medical decisionmaking. To qualify for a given type of medical
decision-making, two of the three elements in
the table must be either met or exceeded.
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ELEMENTS
Amount and/or
complexity of data
obtained, reviewed,
and analyzed
Risk of complications
and/or morbidity or
mortality
Type of Decision
Making
Minimal (1)
Minimal or none (1)
Minimal (1)
Straightforward
Limited (2)
Limited (2)
Low (2)
Low Complexity
Multiple (3)
Multiple (3)
Moderate (3)
Moderate
Complexity
Extensive (>4)
Extensive (>4)
High
High Complexity
Number of
diagnoses or
management
options
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MEDICAL DECISION-MAKING BOX A.1:
DIAGNOSES EXAMPLE
MEDICAL DECISION MAKING
Number
of
Diagnose
s
A “problem” is defined as definitive diagnosis or, for undiagnosed
problems, a related group of presenting symptoms and/or clinical
findings.
Each
new
or
and/or
treatment
confirmation
established
plan
is
problem
evident
for
with
which
the
or
without
diagnosis
diagnostic
Per
Problem
1 Point
3
CKD, HTN, DM
Each new or established problem for which the diagnosis and/or treatment plan is not evident.
2 plausible differential diagnoses, comorbidities or complications
(not counted as separate problems) clearly stated and supported by
information in record: requiring diagnostic evaluation or
confirmation
Per
Problem
2 Points
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MEDICAL DECISION-MAKING BOX A:
DIAGNOSES EXAMPLE
3 plausible differential diagnoses, comorbidities or complications
(not counted as separate problems) clearly stated and supported by
information in record: requiring diagnostic evaluation or
confirmation
Per Problem
3 Points
4 or more plausible differential diagnoses, comorbidities or
complications (not counted as separate problems) clearly stated and
supported by information in record: requiring diagnostic evaluation
or confirmation
Per Problem
4 Points
Total Diagnoses (Box A1) If total is greater than total points for box
A2, use in box D.
3
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MEDICAL DECISION-MAKING BOX A.2:
MANAGEMENT OPTIONS
Important Note:
These tables are not all inclusive. The entries are examples of
commonly prescribed treatments and the point values are illustrative of their intended
quantifications. Many other treatments exist and should be counted when documented.
Points
Do not count as treatment option’s notations such as: Continue “same” therapy or
“no change” in therapy (including drug management) if specified therapy is not
described (record does not document what the current therapy is nor that the
physician reviewed it.
0
Drug management, per problem. Includes “same” therapy or
“no change” in therapy if specified therapy is described
(i.e., record documents what the current therapy is and that
the physician reviewed it). Dose changes for current medications
are not required; however, the record must reflect conscious
decision-making to make no dose changes in order to count for
coding purposes.
1
> 3 new or current
medications per
problem
≤ 3 new or current
medications per
problem
2
Open or percutaneous therapeutic cardiac, surgical or radiological procedure; minor or
major
1
Physical, occupational or speech therapy or other manipulation
1
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MEDICAL DECISION-MAKING BOX A.2:
MANAGEMENT OPTIONS
Closed treatment for fracture or dislocation
1
IV fluid or fluid component replacement, or establish IV access when record is clear
that such involved physician decision-making and was not standard facility “protocol”
1
Complex insulin prescription (SC or combo of SC/IV), hyperalimentation, insulin
drip or other complex IV admix prescription
2
Conservative measures such as rest, ice/heat, specific diet, etc.
1
Radiation therapy
1
Joint, body cavity, soft tissue, etc. injection/aspiration
1
Patient education regarding self or home care
1
Decision to admit to hospital
1
Discuss case with other physician
1
Other-specify
1
Total Management Points: If total is greater than total for Box A1, use in Box D.
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MEDICAL DECISION-MAKING BOX A.2:
MANAGEMENT OPTIONS
 Drug Management
 “Continue present management” but don’t document what current med
regimen is = 0 points
 PER Problem: Document current regimen and decision to continue or
modify:
•
•
1-3 meds for the problem = 1 point
4 or more meds for the problem = 2 points
 Performing or deciding to perform major or minor surgical procedure = 1
point
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MEDICAL DECISION-MAKING BOX A.2:
MANAGEMENT OPTIONS
 IV meds order (not just IV saline) = 1 point
 Complex insulin Rx or other IV admix Rx = 1 point
 Injection/aspiration = 1 point
 Dietary counseling or conservative measures (ice, bandages, rest) = 1
point
 Counseling on home/self care techniques (example: glucose monitoring)
= 1 point
 Discuss cases w/other physician (not resident or fellow) = 1 point
 Admit patient = 1 point
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MEDICAL DECISION-MAKING BOX A.2:
 Remember that Box A is the number of diagnoses OR management
options
-
Use the one (A.1 or A.2) with the highest score.
 Maximum score for either diagnoses or management options is 4 points.
 If you reach 4 points, stop and move onto Box B.
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MEDICAL DECISION-MAKING BOX B:
DATA REVIEWED OR ORDERED
Table B Data Reviewed or Ordered
Point Value
Order and/or review medically reasonable and necessary clinical
laboratory procedures.
Note: Count laboratory panels as one procedure.
1–3 procedures
Order and/or review medically reasonable and necessary diagnostic
imaging studies in Radiology section of CPT.
1–3
procedures
>4
procedures
1
2
Order and/or review medically reasonable and necessary diagnostic
procedures in Medicine section of CPT.
1–3
procedures
>4
procedures
1
2
>4
procedures
1
2
Discuss test results with performing physician.
1
Discuss case with other physician(s) involved in patient’s care or consult
another physician (i.e., true consultation meaning seeking opinion or advice
of another physician regarding the patient’s care). This does not include
referring patient to another physician for future care.
1
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MEDICAL DECISION-MAKING BOX B:
DATA REVIEWED OR ORDERED
Order and/or review old records. Record type and source must be
noted. Review of old records must be reasonable and necessary based
on the nature of the patient’s condition. Practice/facility protocoldriven record ordering does not require physician work. Thus should
not be considered when coding E/M services. Perfunctory notation of
old record ordering/review solely for coding purposes is inappropriate
and counting such is not permitted.
Order/review
without
Summary
Order/review
and
summarize
1
2
Independent visualization and interpretation of an image, EKG or
laboratory specimen not reported for separate payment.
Note: Each visualization and interpretation is allowed one point.
1
Review of significant physiologic monitoring or testing data not
reported for separate payment (e.g., prolonged or serial cardiac
monitoring data not qualifying for payment as rhythm
electrocardiograms).
1
Total points for Box B. Bring results to box D.
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MEDICAL DECISION-MAKING BOX B

For ordering and/or reviewing medically reasonable and necessary
lab tests:
 1 lab panel = 1 procedure (Example: Chem 7)
 1 to 3 procedures = 1 point
 4 or more procedures = 2 points

For ordering and/or reviewing medically reasonable and necessary
radiology tests:
 1 to 3 procedures = 1 point
 4 or more procedures = 2 points
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For ordering and/or reviewing medically reasonable and necessary
medical tests:
 Medical tests: EKGs, treadmills, sleep studies, PFTs, EEGs, EMGs
 1 to 3 procedures = 1 point
 4 or more procedures = 2 points
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MEDICAL DECISION-MAKING BOX B
 Discussing case (during encounter) w/other
physician managing patient’s care (PCP) or ordering
a consult (referral doesn’t count) = 1 point
 Discussing test results w/ performing physician
(during encounter) = 1 point
 Old Records:
 Ordering records (document type and source) = 1 point
 Reviewing records (document summary of review
findings) = 2 points
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MEDICAL DECISION-MAKING BOX B:

Document review of significant physiologic monitoring or test
data not separately coded/billed for payment (home glucose
or BP logs) = 1 point

Independently visualizing and interpreting a radiology image,
EKG or lab specimen not separately coded/billed for payment
(visualizing and documenting your own interpretation of a
chest x-ray already viewed and reported by the radiologist) =
1 point per visualization and interpretation

Note: Can’t double-count (e.g. take a point for reviewing
chest x-ray under radiology and take a point for
independently visualizing and interpreting same chest x-ray)
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TABLE OF RISK: BOX C: Use highest level of risk
on Table.
Level of
Risk
Presenting of Problem(s)
Minimal
•
Low
•
One self-limited or minor
problem (e.g., cold, insect
bite, venipuncture tinea
corporis)
Two or more self-limited or
minor problems
• One stable chronic illness
(e.g., well controlled hypertension, non-insulin dependent diabetes, cataract,
BPH)
• Acute uncomplicated illness
or injury (e.g., cystitis, allergic
rhinitis, simple sprain)
Diagnostic Procedure(s)
Ordered
Management Options
Selected
Laboratory tests requiring
• Chest x-rays
• EKG/EEG
• Urinalysis
• Ultrasound
(e.g., echocardiography)
• KOH prep
•
•
•
•
Rest
Gargles
Elastic Bandages
Superficial Dressings
•
•
•
•
•
•
•
Over-the-counter drugs
Minor surgery with no
identified risk factors
Physical therapy
Occupational therapy
IV fluids without additives
•
•
•
•
Physiologic tests not under
stress (e.g., pulmonary
function tests)
Non-cardiovascular imaging
studies with contrast
(e.g., barium enema)
Superficial needle biopsies
Clinical laboratory tests
requiring arterial puncture
Skin biopsies
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TABLE OF RISK: BOX C
Level of
Risk
Moderate
Presenting of Problem(s)
•
One or more chronic
illnesses with mild exacerbation, progression, or side
effects of treatment
• Two or more stable chronic
illnesses
• Undiagnosed new problem
with uncertain prognosis
(e.g., lump in breast)
• Acute illness with systemic
symptoms (e.g.,
pyelonephritis, pneumonitis,
colitis)
Diagnostic Procedure(s)
Ordered
•
•
•
•
•
Physiologic tests under
stress (e.g., cardiac stress
test, fetal contraction stress
test)
Diagnostic endoscopies with
no identified risk factors
Deep needle or incisional biopsy
Cardiovascular imaging studies
with contrast and no identified
risk factors (e.g., arteriogram,
cardiac catheterization)
Obtain fluid from body cavity
(e.g., lumbar puncture,
thoracentesis, culdocentesis)
Management Options
Selected
•
•
•
•
•
•
Minor surgery with
identified risk factors
Elective major surgery
(open, percutaneous or
endoscopic) with no
identified risk factors
Prescription drug
management
Therapeutic nuclear
medicine
IV fluids with additives
Closed treatment of
fracture or dislocation
without manipulation
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TABLE OF RISK: BOX C
Level of
Risk
High
Presenting of Problem(s)
• One or more chronic
illnesses with severe exacerbation, progression, or side
effects of treatment
• Acute or chronic illnesses or
injuries that pose a threat to
life or bodily function (e.g.,
multiple trauma, acute MI,
pulmonary embolus, severe
respiratory distress, progressive severe rheumatoid
arthritis, psychiatric illness
with potential threat to self or
others, peritonitis, acute renal
failure
An abrupt change in neurologic status (e.g., seizure,
TIA, weakness, sensory loss)
Diagnostic Procedure(s)
Ordered
•
Cardiovascular imaging
studies with contrast with
identified risk factors
• Cardiac electrophysiological
tests
• Diagnostic endoscopies with
identified risk factors
• Discography
Management Options
Selected
• Elective major surgery
(open, percutaneous or
endoscopic) with identified
risk factors
• 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
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Final Assignment of Medical Decision Making Type
Line A – Use Total Diagnosis Points or the Total Management
Option Points from Section A (Tables A.1 and A.2).
Line B – Use Total Points from Section B (Table B).
Line C – Use highest level of risk from Section C (Table C).
Choose final Type of Medical Decision Making.
Final Type
Requires 2 of the 3 MDM Components below be met or
exceeded.
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TABLE D FINAL ASSIGNMENT OF MEDICAL
DECISION-MAKING TYPE
Number of
diagnoses or
management
options
1 point - Minimal
2 points Limited
Amount and
complexity of
data reviewed
or order
≤ 1 point
None-Minimal
2 points Limited
3 points Multiple
4 points Extensive
Minimal
Low
Moderate
High
Straightforward
Low
Complexity
Moderate
Complexity
High
Complexity
Risk
Type of
medical decisionmaking
3 points
Multiple
4 points Extensive
Final Medical Decision-Making requires 2 of 3 components met or exceeded.
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WHEN TO USE TIME BASED CODING
 In an inpatient setting, when more than 50% of the total visit time by
the teaching physician is counseling and/or coordinating the patient’s
care, the time used to code must be provided at the patient’s bedside
and/or on the patient’s hospital floor or unit.
 When coding based on time, the teaching physician may not:
 Add time spent by the resident in the absence of teaching physician to
face-to-face time with the patient by the teaching physician with or
without the resident present.
 Count time counseling or coordinating the patient’s care after leaving
the patient’s floor or after beginning to care for another patient.
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WHEN TO USE TIME BASED CODING
 In addition to documenting history and/or physical exam provided, the
documentation should include:
 Total visit time and time spent counseling and coordinating care, and,
 Description of the medical decision making and counseling discussion
and/or activities coordinated.
 Example of documenting support for coding based on time based:
 “I spent a total of 45 of 60 minutes on the floor coordinating Mr.
Brown’s care and in discussion with Mr. Brown regarding his newly
diagnosed lung cancer, prognosis and treatment options. We discussed
side effects of medication. We also discussed the possibility of a
clinical trial. I have requested that Dr. Jones visit Mr. Brown to discuss
the clinical trial.” (99253 Consult)
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CASE 1: HISTORY
 16 year old white male with osteosarcoma presents for
admission for scheduled chemotherapy. First diagnosed in
L proximal tibia in July 2008. Had increasing pain (7/10)
prior to surgical intervention in July. Has been tolerating
treatments – no mucositis, nausea or vomiting, ROS, MSK
as per HPI, no decreased ROM. No abnormal weight loss,
vision, respiratory, cardiovascular, GI, GU, endocrine
normal. FMHx negative for cancer; PMHx, T&A age 2, L
tibial intervention July 08. Maintaining B average in school,
lives with parents and sibling.
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CASE 1: HISTORY LEVELING
 Chief Complaint
 New Patient
 Est. Patient
 Consultation
History
HPI (History of Present Illness)
√ Location √ Duration
Mod Factors
Timing Context
√
Quality
√
Severity

Brief (1-3 elements)
Associated signs/symptoms
ROS (Review of Symptoms
√ Constitutional
ENMT
√ Musculo
√ GU
Integ
√ Card/vac
√ Resp
Neuro
 Endo
√ GI
 Eyes
 Hem/Lymph
Psych
 Allergic/Immunologic
PFSH (Past medical, Family and Social History)
√ Past (patient’s illness, operation, injuries & treatments)
√ Family (review of medical events in pt’s family incl. hereditary
disease placing patient at risk
√ Social (age appropriate review of past and current activities)
Complete PFSH:
2 Hx areas: a) established patient office visit, domiciliary care;
home care, b) Emergency dept visit, and c) Subsequent
nursing
facility care,
3 Hx areas: a) New patients – office visit; domiciliary care, home care,
b) consultations, c) initial hospital care; d) hospital observation; and e)
comprehensive nursing facility assessments.

None

Pertinent
to
problem
(1 system)

Extended
2-9 system
including
1 pertinent

Pertinent

None
Problem
Focused
(FP)

Extended
4 or more
elements
(1 History area)
Expanded
Problem
Focused
(EPF)
Detailed (D)

Complete
10 or more
systems
including
pertinent

Complete
New or Consult
3 history areas
Established: 2
history areas
Comprehensive
(C)
Final level of history requires 3 components
above meet or exceed the same level
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CASE 1: EXAM
 Temp 98, pulse 86, RR 20-24, BP 123/60. Head normal;
eyes PERRLA, mouth, teeth, throat normal; neck and
thyroid normal; normal heart rhythm, s1, s2; lungs normal;
abdomen, liver, spleen normal; lymph nodes normal; upper
and lower extremities normal ROM; + alopecia, + well
healed L tibia scar.
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Body Areas:
√Head
(w/face)
Chest
w/Brest
& Axilla
√ Neck

Abdomen

Genitourinary
/groin
/buttocks
(thyroid)

Back
(w/spine)

1 body
area or
system

limited
exam of
affected
area
+ 2-7 body
or systems

Expanded
exam (3
elements
of affected
area + 2-7
additional
body areas
or systems
Problem
Focused
Expanded
Problem
Focused
Detailed

8 or more
organ systems
(can include
thyroid)
Each
Extremity
Organ Systems:
Consti
tional
√ Eyes
√ Ears,
nose
mouth,
throat
1/15/2009
√ Skin
√ Resp
√ Cardio
√ GI
GU
Neuro
√ Muscu
√ Heme
/Lymp
/Imm
Psyc
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Comprehensive
32
If vital signs are taken by UHS/CSR staff, they
cannot be counted as constitutional exam.
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CASE 1: MEDICAL DECISION-MAKING
 Hb/Hct 15/42, platelet 376, WBC 10.6, Glu
258, Ca+ 11.5, MTX level 820
 Assessment: Osteosarcoma L proximal tibia;
proceed with chemotherapy; re-evaluation per
prn orders.
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CASE 1: MEDICAL DECISION-MAKING
Box A.1:
# Diagnoses = 2(osteosarcoma, admission for
chemotherapy), Limited; Box A.2: # mgmt options = 1, Minimal( Use
box A.1 since score is higher than box A.2.)
Box B: Labs = 2 points due to more than four labs, Limited
Box C: Nature of presenting problem = high diagnostic tests ordered
= minimal; management options selected = high, High
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Number of
diagnoses or
1 point management
Minimal
options
Amount and
complexity of
≤ 1 point
data reviewed or Non-Minimal
order
Risk of
complication
Minimal
and/or
morbidity or
mortality
Type of
MDM
Straightforward
2 points
Limited
3 points
Multiple
4 points
Extensive
2 points
Limited
3 points
Multiple
≥ 4 points
Extensive
Low
Moderate
High
Low
Complexity
Moderate
Complexity
High
Complexity
2 of 3 of the above components are met or exceeded.
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CASE 1: FINAL LEVELING
Initial Inpatient Admission: History, Exam, and Medical Decision-Making must meet or exceed
the same level in order to assign a specific code (3 out of 3 same level or higher
1/15/2009
Code
History
Exam
MDM
99221
D
D
S or L
Average
Time
30
99222
C
C
M
50
99223
C
C
H
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36
CATEGORIES AND SUBCATEGORIES OF E&M SERVICES
Hospital
Observation
Discharge Services
99217
Hospital
Observation
Discharge Services
99218 - 99220
Hospital Inpatient
Services
99221 – 99223 –
Initial Hospital
Care
99231 – 99233 –
Subsequent
Hospital Care
99234 – 99236 –
Observation or
Inpatient Care
Services including
Admission and
Discharge
99238 – 99239 –
Hospital Discharge
Services
Consultations
99241 – 99245 –
Office Consultations
99251 – 99255 – Initial
Inpatient
Consultations
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CATEGORIES AND SUBCATEGORIES OF E&M SERVICES
Prolonged
Services
99356 – 99357
With Direct
Patient Contact
Critical Care
Services
99291 – 99292–
Adult
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Newborn Care
Service
99460-99463
Critical Care
Service
Delivery/Birthing Room
Attendance and
Resuscitation Services
99464-99465
99499
Unlisted E&M Service
Pediatric Critical
Care Transport
99466-99467
Initial Neonatal and
Pediatric Critical Care
99468-99476
Initial and Continuing
Intensive Care Services
99477-99480
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CATEGORY: Consultation
GENERAL
Service provided by a physician or qualified nonphysician practitioner
whose opinion or advice regarding evaluation and/or management of a
specific problem is requested by another physician or other appropriate
source. (Excludes residents, fellows and interns) due to the consultant’s
expertise in a specific medical area beyond the requesting provider’s
knowledge.
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Four (4) Requirements for Using Consult Codes
 A request for a consultation from an appropriate source and the
need for consultation (i.e., the reason for the consultation
service) shall be documented by the consultant in the patient’s
medical record and included in the requesting physician or
qualified NPP’s plan of care in the medical record.
 The consultant’s opinion and any services performed or ordered
must also be documented in the patient’s medical record.
(Render service)
 After the consultation is provided, the consultant shall prepare a
written report of his findings and recommendations, which shall
be provided to the requesting physician to use in the
management of and/or decision making for the patient.
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 Note: A request to take care of the problem is a
referral and should be coded with subsequent
hospital care codes 99231-99233.
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 Intent is to return the patient to the requesting provider
for ongoing care of the problem.
 During the service, the consultant may perform or
order diagnostic tests or initiate a treatment plan,
including performing emergent procedures.
 Additional follow up visits after the initial inpatient
consultation are billed using the subsequent hospital
care codes (99231-99233).
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INPATIENT CONSULTATIONS: 99251 - 99255
 For new or established hospital inpatients, residents of
nursing facilities or patients in a partial hospital setting.
 One initial consult per consultant per patient admit.
 Subsequent services during the same admission are
reported using subsequent hospital care codes (9923199233) or subsequent nursing facility care codes (9930799310), including services to complete the initial
consultation, monitor progress, revise recommendations,
or address a new problem.
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ACCEPTABLE CONSULT PHRASES
The patient is seen in consultation at the request of Dr. Welby for
evaluation of abdominal pain.
Dr. Ben Casey has requested consultation on Jane Doe for preoperative clearance.
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UNACCEPTABLE CONSULT PHRASES
The patient was referred by Dr. John Smith for treatment of
diabetes.
Thank you for referring Betty Brown to me for management of
her shortness of breath.
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EXAMPLE DISPOSITION BOXES ON EXAM TEMPLATES
Return to Requesting M.D. with recommendations and treatment
options
Return to Requesting M.D.’s care after completion of additional
diagnostic testing with final recommendations.
Return to Requesting M.D.’s care after evaluation of trial of
therapeutic regimen.
Will follow for GI problems in parallel with PCP if PCP agrees.
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INPATIENT CONSULTATIONS
1/15/2009
CPT
99251
PF PF SF
HPI
1-3
ROS
0
PFSH
0
EXAM
1 BA/OS
MDM
Straightforwar
d
99252
EPF EPF
SF
1-3
1
0
2-7
BA/OS
Straightforwar
d
99253
DDL
4+
2-9
1
2-7
BA/OS
Low
99254
CCM
4+
10+
3
8+
OS
Moderate
99255
CCH
4+
10+
3
8+
OS
High
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66
Observation or Inpatient Hospital Care
(Including Admission and Discharge Services)
Codes 99234-99236 are used by a provider to report observation or inpatient hospital care
services provided to patients admitted and discharged on the same date of service.
Code
History
Exam
Medical Decision
Making
99234
Detailed or Comp
Detailed or Comp
Straightforward or
low
Usually problem(s) requiring admission are of
low severity
99235
Comprehensive
Comprehensive
Moderate
Usually problem(s) requiring admission are of
moderate severity
99236
Comprehensive
Comprehensive
High
Usually problem(s) requiring admission are of
high severity
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Comments
67
Observation or Inpatient Hospital Care
(Including Admission and Discharge Services)
Notes:
 When performed on the same date as the
admission, all other outpatient services provided
by the physician in conjunction with that
admission are considered part of the initial
hospital or observation care.
 CPT does not indicate time parameters for the
encounter.
However, CMS (Medicare) has
specific time guidelines. Note discussion on
Medicare and Carelink.
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Observation or Inpatient Hospital Care –
Medicare and CareLink
Codes 99234-99236 are used by a provider to report:
 Admitting and discharging a patient on the same
calendar day for >8 hours but <24 hours, or
 Placing a patient under observation and
discharging the patient on the same calendar
date for >8 hours but <24 hours
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Observation or Inpatient Hospital Care –
Medicare and CareLink
Code
History
Exam
Medical
Decision
Making
99234
Detailed or
comprehensive
Detailed or
comprehensive
Straightforwa
rd or low
Usually problem(s) requiring admission
are of low severity
99235
Comp
Comp
Moderate
Usually problem(s) requiring admission
are of moderate severity
99236
Comp
Comp
High
Usually problem(s) requiring admission
are of high severity
Comments
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Observation or Inpatient Hospital Care –
Medicare and CareLink
Notes:
 In addition to meeting the documentation
requirements for history, exam and medical
decision-making, documentation in the medical
record should include:
 Statement that the stay for observation care or
inpatient hospital care involved eight hours, but less
than 24 hours.
 Admission and discharge notes written by the billing
provider.
 Personal documentation by the billing provider
indicating presence and face-to-face services were
provided.
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Hospital Observation Services
Admit to
Observation
Status*
Initial observation
care:
Codes 99218,
99219 or 99220
Admission & discharged
on same calendar date:
*Code 99234, 99235 or
99236
Subsequent visit by
admitting physician or
visit by another
provider
Code 99212, 99213,
99214, or 99215
Then use
discharge code
99217
Outpatient
consultation: Code
99241, 99242,
99243, 99244, or
99245
Then admit as
inpatient:
Code 9922199223)
Notes:
Prior to observation, patient may have been evaluated at another site of service (e.g. outpatient hospital,
office, emergency department, or nursing facility).
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Hospital Observation Services – Medicare and CareLink
In Observation < 8 hours and
discharged same calendar date:
Code 99218, 99219 or 99220
Admit to
Observation
Status
In Observation > 8 hours but
< 24 hours and discharged
same calendar date:
Code 99234, 99235 or 99236
(see slide 15)
In Observation > 24 hours:
Code 99218, 99219 or 99220
In Observation > 48 hours:
Code 99218, 99219 or 99220
then 99212-99215
When discharged, use
observation care
discharge day
management: Code
99217
If admitted, use initial
hospital visit:
Code 99221, 99222 or
99223
Notes:
Prior to observation, patient may have been evaluated at another site of service
(e.g., outpatient hospital, office, emergency department, or nursing facility).
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Hospital Observation Services
These codes are used to report a patient placed under observation and include initiation of
observation status, supervision of care, and periodic assessments.
Code
99218-99220
99217
99218-99220 +
99212-99215 +
99217
99218-99220 +
99212-99215 +
99221-99223
Type
Initial Observation Care
Initial Observation Care
+
Established Patient, Office or
other Outpatient Visit
+
Observation Care Discharge
Services
Initial Observation Care
+
Established Patient, Office
or other Outpatient Visit
+
Initial Hospital Visit
+
Observation Care Discharge
Services
1/15/2009
Duration of
Service
1st calendar day - placed
under observation
+
2nd calendar day - discharged
1st calendar day - placed under
observation
+
2nd calendar day - subsequent
service
+
3rd calendar day - discharged
1st calendar day - placed
under observation
+
2nd calendar day subsequent service
+
3rd calendar day - admitted
to inpatient status
Comments
Code both services
Code all services
Code all services
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74
Hospital Observation Services
Notes:
 Billed only by the physician who admitted the patient
to observation and was responsible for the patient
during his/her stay.
 All other providers should bill the outpatient E/M codes
that describe their participation in the patient’s care
(i.e., office and other outpatient service codes or
outpatient consultation codes)
1/15/2009
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75
Hospital Observation Services – Medicare and CareLink
1/15/2009
Code
99218-99220
99234-99236
99218-99220 +
99217
99218-99220 +
99212-99215 +
99217
99218-99220 +
99212-99215 +
99221-99223
Type
Initial Observation
Care
Observation or
Inpatient Care
Services
(Including Same
Day Admission and
Discharge)
Initial
Observation
Care
+
Observation
Care
Discharge
Services
Initial
Observation
Care
+
Established
Patient, Office
or other
Outpatient Visit
+
Observation
Care Discharge
Services
Initial Observation
Care
+
Established Patient,
Office or other
Outpatient Visit
+
Initial Hospital
Visit
Duration
of Service
Placed under
observation with
discharge on different
calendar date
or
Under observation <8
hours and discharged
on same calendar date
Placed under
observation and
discharged on same
calendar date
for >8 hours but
<24 hours
>48 hours:
1st calendar
day - placed
under
observation
+
2nd calendar
day discharged
>48 hours:
1st calendar day
- placed under
observation
+
2nd calendar
day subsequent
service
+
3rd calendar
day - discharged
>48 hours:
1st calendar day placed under
observation
+
2nd calendar day subsequent service
+
3rd calendar day –
admitted to
inpatient status
Comments
Do not also code a
discharge day service if
observation was <8
hours
Code both
services
Code all
services
Code all services
Do not also code a
discharge day
service
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76
HOSPITAL OBSERVATION SERVICES – MEDICARE AND
CARELINK
Notes:
Billed only by the physician who admitted the patient to
observation and was responsible for the patient during
his/her stay.
All other providers should bill the outpatient E/M codes
that describe their participation in the patient’s care (i.e.,
office and other outpatient service codes or outpatient
consultation codes).
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Initial Hospital Observation Services
History, exam, and medical decision-making must meet or exceed the same level in order to
assign a specific code (i.e., 3 out of 3 same level or higher).
1/15/2009
Code
History
Exam
Medical Decision Making
Comments
99218
Detailed or
Comprehensive
Detailed or
Comprehensive
Straightforward or low
Usually problem(s)
requiring admission to
observation status are of
low severity
99219
Comprehensive
Comprehensive
Moderate
Usually problem(s)
requiring admission to
observation status are of
moderate severity
99220
Comprehensive
Comprehensive
High
Usually problem(s)
requiring admission to
observation status are of
high severity
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Hospital Observation Services
Notes:




The descriptors for these codes include the phrase “per day”,
meaning care for the day.
Select a code that reflects all services provided during the
date of the service.
The observation record for the patient must contain dated and
timed physician’s admitting orders regarding the care the
patient is to receive while in observation, and progress notes
prepared by the physician while the patient was in observation
status. This information is in addition to any record prepared
as a result of an emergency department, outpatient clinic, or
nursing facility encounter.
In rare instances when a patient is held in observation status
for more than two calendar dates, the physician must code
subsequent services before the discharge date using
outpatient/office visit codes (99212-99215).
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Observation Care Discharge Services
Code 99217 is used to report discharge services of a
patient in observation status.
History
99217
Observation care discharge day
management
Comments
Face-to-face time between
attending and the patient
the
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Observation Care Discharge Services
Notes:




Notes:
Billed only by the physician who was responsible for observation care during this
stay.
Discharge service is billed on the date of the actual visit by the provider .
Includes:






Final patient exam
Discussion of the hospital stay
Instructions for continuing care
Preparation of discharge records, prescriptions, and referral forms
All other providers performing a final visit should use outpatient/office visit codes
(99212-99215).
Do not bill the hospital observation discharge management code (99217) if
patient was


Admitted to inpatient status, use codes 99221-99223.
Placed under observation and discharged on the same calendar date, use codes
99234-99236.
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Hospital Observation During A Global Surgical Period


The global surgical fee includes payment for hospital observation
(codes 99217, 99218, 99219, 99220, 99234, 99235 and 99236)
services unless specific requirements are met.
Observation services may be paid in addition to the global surgical fee
only if both of the following requirements are met:
 The hospital observation service meets the criteria needed to
justify billing it with modifiers:
 24 - Unrelated E/M service by the same physician during a
post-operative period
 25 - Significant, separately identifiable E/M service by the
same physician on the same day of a procedure or other
service
 57 - Decision for major surgery
 The hospital observation service furnished by the surgeon meets
all the criteria for the hospital observation code billed.
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How to Use Observation Codes - Examples
9/18
9/18
Medicare & CareLink
Admitted to Observation by
Provider A on 9/18 at 1AM;
seen and discharged by
Provider A at 7 AM on 9/18
99234-99236
(Provider A)
99218-99220
(Provider A)
Admitted to Observation by
Provider A on 9/18 at 1AM;
seen and discharged by
Provider A at 9/18 4PM
99234-99236
(Provider A)
99234-99236
(Provider A)
Date
1/15/2009
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9/19
9/20
83
How to Use Observation Codes - Examples
Admitted to Observation by Provider
A on 9/18 at 1AM; seen by Provider
B 9/18 at 3 PM; seen and discharged
on 9/19 at 7 AM by Provider A
Note: Provider A is from a different
specialty than
Provider B and the service was not a
consultation.
1/15/2009
99218-99220
(Provider A)
99212-99215
(Provider B)
99218-99220
(Provider A)
99212-99215
(Provider B)
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99217
(Provider A)
84
How to Use Observation Codes - Examples
Admitted to Observation by Provider
A on 9/18 at 1AM; seen by Provider
A on 9/19; and, seen and discharged
by Provider A on 9/20
99218-99220
(Provider A)
99218-99220
(Provider A)
99212-99215
(Provider A)
99217
(Provider A)
Admitted to Observation by Provider
A on 9/18 at 1AM; seen by Provider
A on 9/19; and, admitted by Provider
A to inpatient status 9/20
99218-99220
(Provider A)
99218-99220
(Provider A)
99212-99215
(Provider A)
99221-99223
(Provider A)
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85
CATEGORY: Hospital Inpatient Services
GENERAL
 Care provided to patient admitted to hospital facility.
 Four (4) subcategories of Hospital Inpatient Services:
 Initial Hospital Care (99221 - 99223)
 Subsequent Hospital Care (99231 - 99233)
 Observation or Inpatient Care Services (Including
Admission and Discharge) (99234-99236)
 Hospital Discharge Services (99238 - 99239)
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INITIAL HOSPITAL CARE: 99221 – 99223
 There is no distinction between new or established
patients.
 Used only by one admitting physician per admission.
 All E&M services provided on the same day are included
in initial hospital care and cannot be billed separately.
 Frequently disallowed as part of the global surgery
package if performed on the day before or the day of a
surgical procedure.
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99221
Det/Comp
Det/Comp
SF/Low
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HPI 4+
ROS: 2-9 Systems
PFSH: 1
Exam: 2-7
MDM: Low
99222
Comp
Comp
Mod
HPI: 4+
ROS: 10 + Systems
PFSH: 3
Exam: 8+ Systems
MDM: Moderate
99223
Comp
Comp
High
HPI: 4+
ROS: 10+ Systems
PPSH: 3
Exam: 8+ Systems
MDM: High
Physicians that participate in the care of a patient but are not the admitting physician of
record should bill the inpatient evaluation and management services codes that describe
their participation in the patient’s care (i.e., subsequent hospital visit or inpatient
consultation).
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CODING A HOSPITAL ADMISSION THAT OCCURS IN THE
COURSE OF AN OFFICE VISIT
E/M office visit
code
Admitted patient to the hospital via the office and
didn’t see patient in the hospital on the same date
Initial hospital care
code
Admitted patient to the hospital via the office and
saw patient in the hospital on the same date
E/M office visit
Code + Initial
Hospital care code
Admitted patient to the hospital via the office and
saw patient in the hospital on the following date
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SUBSEQUENT HOSPITAL CARE: 99231 - 99233
 Physicians can only bill one hospital code per day to encompass all visits for
the patient on a given day.
 In a hospital inpatient situation involving one physician covering for another,
if physician A sees the patient in the morning and physician B, who is
covering for A, sees the same patient in the evening, physician B is typically
not paid separately for the second visit. The hospital visit descriptors include
the phrase “per day” meaning care for the day.
 If the physicians are each responsible for a different aspect of the patient’s
care, both visits are paid if the physicians are in different specialties and the
visits are billed with different diagnoses.
 There are circumstances where concurrent care may be billed by physicians
of the same specialty.
 Review of medical record, diagnostic studies and changes in the patient’s
status (changes in history, physical condition and response to management)
since last assessment by the physician.
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 The acuity of the patient’s condition is a key factor in selection
of the level of hospital visit. CPT describes the patient’s
condition at each level of service as follows.
 99231 – usually the patient is stable, recovering or improving.
 99232 – usually the patient is responding inadequately to
therapy or has developed a minor complication.
 99233 – usually the patient is unstable or has developed a
significant complication or a significant new problem.
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99231
PF
PF
SF/Low
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HPI: 1-3
ROS: None
PFSH: None
Exam: 1 BA/System
MDM: Low
99232
EPF
EPF
Mod
HPI: 1-3
ROS: 1- System
PFSH: None
Exam: 2-7 BA/System
MDM: Moderate
99233
D
D
High
HPI: 4+
ROS: 2-9 System
PPSH: None
Exam: 2-7 BA/System
MDM: High
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OBSERVATION OR INPATIENT CARE SERVICES (INCLUDING
ADMISSION AND DISCHARGE SERVICES (99234-99236)
 Used to report observation or inpatient hospital care services provided to
patients admitted and discharged on the same date.
99234
Det/Comp
Det/Comp
SF/Low
HPI 4+
ROS: 2-9 Systems
PFSH: 1
Exam: 2-7 BA/Systems
MDM: Low
99235
C
C
Mod
HPI: 4+
ROS: 10 + Systems
PFSH: 3
Exam: 8+ Systems
MDM: Moderate
99236
C
C
High
HPI: 4+
ROS: 10+ Systems
PPSH: 3
Exam: 8+ Systems
MDM: High
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HOSPITAL DISCHARGE SERVICES: 99238 – 99239
 Includes final exam of patient, discussion of hospital stay,
instructions for continuing care to all relevant care givers and
preparation of discharge records, prescriptions and referral forms
 Less than 30 minutes or greater than 30 minutes. Document the
time spent for appropriate code selection.
 Only the attending of record can discharge the patient. There
may only be one hospital discharge service per patient per
hospital stay.
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CATEGORY: Prolonged Services
PROLONGED SERVICES: 99356– 99357
 Used to report prolonged services involving direct (face-toface) patient contact beyond the usual E&M services in the
outpatient or inpatient setting.
 CPT 99356-57 are used in addition to the designated E&M
service at any level and any other physician services provided
at the same session.
 Time based codes. Time does not have to be continuous.
However, the total duration of time must be considered.
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CATEGORY: Prolonged Services
 Prolonged services codes can be billed only if the total duration
of all physician or qualified NPP direct face-to-face service
(including the visit) equals or exceeds the threshold time for the
evaluation and management service the physician or qualified
NPP provided (typical/average time associated with the CPT
E/M code plus 30 minutes).
 Time spent reviewing charts or discussion of a patient with
house medical staff and not with direct face-to-face contact
with the patient or waiting for end of a therapy, or for use of
facilities cannot be billed as prolonged services.
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CATEGORY: Prolonged Services
 Resident/Fellow time does not count.
 The medically necessary reason for prolonged
encounter must be documented as well as the total
time spent with patient or in review/communication.
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 The medical record must be appropriately and sufficiently
documented by the physician or qualified NPP to show that
the physician or qualified NPP personally furnished the
direct face-to-face time with the patient specified in the
CPT code definitions.
 The start and end times of the visit shall be documented in
the medical record along with the date of service.
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Do not report prolonged service if it is less than 30 minutes.
 Codes 99356-99357 are used to report the total duration of
unit time spent by a physician on a given date providing
prolonged service to a patient.
 Code 99356 is used to report the first hour of prolonged
service on a given date.
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 Code 99357 is used to report each additional 30 minutes
beyond the first hour. This code may also be used to report
the final 15-30 minutes of prolonged service on a given date.
Prolonged service of less than 15 minutes beyond the first
hour or less than 15 minutes beyond the final 30 minutes is not
reported separately.
 The use of the time based add-on codes requires that the
primary E&M service have a typical or specified time published
in the CPT book.
 Use CPT 99356 in conjunction with 99221-99233, 9925199255, 99304-99310, 90822 and 90829.
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The following table illustrates the correct reporting of prolonged
physician service with direct patient contact in the office setting:
Total Duration of Prolonged Service
Code(s)
Less than 30 minutes
(less than ½ hour)
Not reported separately.
30 – 74 minutes
(½ hr. – 1 hr. 14 min.)
99356 X 1
75 – 104 minutes
(1 hr. 15 min. – 1 hr. 44 min.)
99356 X 1 AND 99357 X 1
105 – 134 minutes
(1 hr. 45 min. – 2 hr. 14 min.)
99356 X 1 AND 99357 X 2
135 – 164 minutes
(2 hr. 15 min. – 2 hr. 44 min.)
99356 X 1 AND 99357 X 3
165 – 194 minutes
(2 hr. 45 min. – 3 hr. 14 min.)
99356 X 1 AND 99357 X 4
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 In those E&M services in which the code level is selected
based on time (counseling and coordination of care),
prolonged services can only be reported with the highest
code level in that family of codes as the companion code.
In the inpatient setting, prolonged service codes can only
be assigned with a level three initial encounter(99223) or
subsequent encounter(99233) or a level five consultation
(99255).
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CLINICAL EXAMPLE:
 A 34 year old primigravida presents to hospital in early labor.
Admission history and physical reveals severe preeclampsia.
Physician supervised management for preeclampsia, IV magnesium
initiation and maintenance, labor augmentation with pitocin, and
close maternal-fetal monitoring. Physician face-to-face involvement
includes 40 minutes of continuous bedside care until the patient is
stable, then is intermittent over several hours until the delivery.
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PROLONGED SERVICES:
Threshold Time for Prolonged visit Codes 99356 and/or 99357 billed
with Inpatient Setting Codes.
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Code
Typical Time for Code
Threshold Time to Bill
codes 99356 &
Threshold Time to Bill
99357
Code 99356
99252
40
70
115
99253
55
85
130
99254
80
110
155
99255
110
140
185
99304
25
55
100
99305
35
65
110
99306
45
75
120
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Code
Typical Time for Code
Threshold Time to Bill
codes 99356 &
Threshold Time to Bill
99357
Code 99356
99307
10
40
85
99309
25
55
100
99310
35
65
110
99318
30
60
105
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SELECT THE APPROPRIATE CODE BASED
UPON THE TYPE OF HISTORY, EXAM AND
MEDICAL DECISION-MAKING RENDERED
AND DOCUMENTED. CONSIDER THE
IMPACT OF TIME AS APPROPRIATE.
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CHOOSING EVALUATION AND MANAGEMENT CODES
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
Identify the category of service.

Identify the subcategory of service.

Determine the extent of history obtained.

Determine the extent of examination performed.

Determine the complexity of medical decision-making.

Determine the approximate amount of intra-service time if
counseling or coordination of care is greater than 50%.
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INITIAL VISITS
Require all 3 key components (History, Exam and Medical Decision-Making).
First time encounters include:



Hospital observation services
Initial hospital visits
Initial office and inpatient consults
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SUBSEQUENT VISITS
Require 2 of the 3 key components (History, Exam and Medical
Decision-Making).
Subsequent encounters include:
 Subsequent hospital visits
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INPATIENT E&M CODES
HOSPITAL OBSERVATION
KEY COMPONENTS
OUTPATIENT
E&M CODES
HISTORY
EXAM
MEDICAL
DECISION
PROBLEM
TIME
OBSERVATION CARE DISCHARGE DAY MANAGEMENT
99217
99218
DET-COM
DET-COM
STRT-LOW
LOW
99219
COMPRE
COMPRE
MODERATE
MODERATE
99220
COMPRE
COMPRE
HIGH
MOD-HIGH
3 of 3 Key Components must be met for initial visit
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INPATIENT E&M CODES
HOSPITAL ADMISSIONS
KEY COMPONENTS
INPATIENT
E&M CODES
HISTORY
EXAM
MEDICAL
DECISION
PROBLEM
TIME
99221
DET-COM
DET-COM
COMPRE
LOW
30
99222
COMPRE
COMPRE
MODERATE
MODERATE
50
99223
COMPRE
COMPRE
HIGH
MOD-HIGH
70
3 of 3 Key Components must be met for initial visits
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INPATIENT E&M CODES
OBSERVATION OR ADMIT WITH SAME DAY DISHARGE
KEY COMPONENTS
INPATIENT
E&M CODES
HISTORY
EXAM
MEDICAL
DECISION
PROBLEM
99234
DET-COM
DET-COM
DET-COMP
STRT-LOW
992352
COMPRE
COMPRE
COMPRE
MODERATE
99236
COMPRE
COMPRE
COMPRE
HIGH
TIME
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INPATIENT E&M CODES
HOSPITAL VISITS
KEY COMPONENTS
INPATIENT
E&M CODES
EXAM
MEDICAL
DECISION
HISTORY
PROBLEM
TIME
99231
FOCUSED
FOCUSED
STRT-LOW
STABLE
15
99232
EXP/FOC
EXP/FOC
MODERATE
MINOR CMP
25
99233
DETAILED
DETAILED
HIGH
UNSTABLE
35
99238
99239
HOSPITAL DISCHARGE DAY MANAGENENT LESS THAN 30 MIN.
HOSPITAL DISCHARGE DAY MANAGEMENT GREATER THAN 30 MIN.
2 of 3 Key Components must be met for subsequent visits
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INPATIENT E&M CODES CONTINUATION
INPATIENT CONSULTATIONS
KEY COMPONENTS
INPATIENT
E&M CODES
HISTORY
EXAM
MEDICAL
DECISION
PROBLEM
TIME
99251
FOCUSED
FOCUSED
STRTFWD
MINOR
20
99252
EXP/FOC
EXP/FOC
STRTFWD
LOW-MOD
40
99253
DETAILED
DETAILED
LOW
MODERATE
55
99254
COMPRE
COMPRE
MODERATE
MOD-HIGH
80
99255
COMPRE
COMPRE
HIGH
MOD-HIGH
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3 of 3 Key Components must be met for initial visits
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MEDICAL NECESSISTY
 The CMS Manual, publication 100-4, Chapter 12, 30.6.1 – Selection
of Level of Evaluation and Management Service states the following:
 “Medical necessity of a service is the overarching criterion for
payment in addition to the individual requirements of a CPT
code.
 It would not be medically necessary or appropriate to bill a
higher level of evaluation and management service when a
lower level of service is warranted.
 The volume of documentation should not be the primary
influence upon which a specific level of service is billed.
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MEDICAL NECESSISTY
 Documentation should support the level of service reported.
The service should be documented during, or as soon as
practicable after it is provided in order to maintain an accurate
medical record .
 Instruct physicians to select the code for the service based
upon the content of the service.
 The duration of the visit is an ancillary factor and does not
control the level of the service to be billed unless more than 50
percent of the face-to-face time (for non-inpatient services) is
spent providing counseling or coordination of care.”
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MEDICAL NECESSISTY
 Medically Necessary Services are services required to:
 Diagnose or prevent an illness, injury or condition
 Treat an illness, injury, or condition
 Keep condition from getting worse
 Lessen pain or severity of condition
 Help improve condition
 Restore lost skills (rehabilitation)
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MEDICAL NECESSISTY
 Medically Necessary Services:
 Are consistent with diagnosis;
 Meet accepted standards of good medical practice;
 Can be safely provided.
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DIAGNOSTIC CODING
 ICD codes describe the reason a service (CPT code) was provided.
 List the primary diagnosis, condition, problem or other reason for the
medical service or procedure.
 List secondary diagnoses that impact the medical decisionmaking
for the encounter.
 Exclude diagnoses that relate to the patient’s previous medical
condition or problem and have no bearing on the patient’s present
problem.
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DIAGNOSTIC CODING
 Assign all codes to the highest level of specificity (4th or 5th digits).
 Code signs and symptoms if a definitive diagnosis has not been
determined.
 Do not code probable, possible or suspected conditions as definitive
diagnoses.
 Be specific in describing the condition, illness or disease of the
patient. (e.g., renal failure vs. chronic kidney disease, Stage III).
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DIAGNOSTIC CODING
 Distinguish between acute and chronic conditions.
 Identify how injuries occur by using E codes.
 Use V codes to indicate why a service was rendered when there is
no complaint, i.e. routine physical, well baby care, aftercare
following surgery, need for prophylactic vaccination, etc.
 Avoid unspecified codes when there is a more specific code to
describe the patient’s illness, condition or injury.
 Diagnoses may be taken from the final assessment or chief
complaint.
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DIAGNOSES
 New or established problems
 Addressed during the visit
•
Qualify the diagnosis (e.g., acute severe, chronic, mild, moderate,
etc.).
 Co-morbid conditions include conditions that coexist at the time of the visit
and influence, require, or affect patient care or treatment.
 CPT – Comorbidities/underlying diseases, in and of themselves, are not
considered in selecting a level of E/M service unless their presence
significantly increases the complexity of the medical decision-making.
 Documentation needs to demonstrate that the comorbidity was a
significant influence.
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DIAGNOSES
Example:
•
•
Assessment 1) CKD – continue present management, 2)
Anemia X
Assessment 1) CKD – continue present management, 2)
Anemia secondary to CKD – continue present management
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DIAGNOSES
 Possible code series to consider in addition to co-morbid
conditions or complications.






History of cancer (V10)
Personal medical history (V11-V15)
Family history (V15-V19)
Condition influencing health status (V40-V41)
Tissue Transplant or artificial device (V42-V44)
Post-procedural status (V45)
 Must be supported by documentation in the current note.
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LINKING DIAGNOSIS CODES
Assessment
Codes
1.
1. 493.02
Childhood asthma w/
acute exacerbation
2. 477.9
2. Allergic rhinitis
1. 493.02
E/M Service Established
Procedures:
 Bronchodilation
Responsiveness
spirometry as in 94010,
pre and postbronchodilator
administration
99232-25
94060
2. 477.9
493.02
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MEDICAL RECORD DOCUMENTATION
Complete Documentation
Correct Medical Coding
Appropriate Reimbursement
The critical factor in determining the level of care:
Not what you did….but what you documented!
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E&M MODIFIERS
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MODIFIERS
Modifiers are two-digit additions to CPT codes to
indicate that a performed service or procedure has
been altered by a specific circumstance but not
changed in its definition or code. Some modifiers
impact reimbursement while others simply convey
information.
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EVALUATION AND MANAGEMENT MODIFIERS
- 24
Unrelated Evaluation and Management Service by the Same
Physician During a Postoperative Period.
 Used to indicate that an E&M service performed during the
postoperative period is unrelated to the original procedure.
 The diagnosis for the E&M service must support the fact
that the service was unrelated.
 If the service is unrelated, Medicare will pay for the E&M
service with the 24 modifier.
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- 25
Significant, Separately Identifiable Evaluation and Management Service by
the Same Physician on the Same Day of the Procedure or Other Service.
 Reflects that the day of a minor surgical procedure, the patient’s
condition required a significant, separately identifiable E&M service
above and beyond the other service provided or beyond the usual
operative and postoperative care associated with the procedure that
was performed.
 The term “separately identifiable service” means an additional service
that is not part of the surgery or procedure. The E&M service must
require additional history, exam, knowledge, skill, work, time, and risk
above and beyond that of the surgery or procedure and its pre- and
post-procedure components. Moreover, the E&M service should be
able to stand alone from the same-day procedure.
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 Generally used with established patient visits.
 A significant, separately identifiable E&M service is defined or
substantiated by documentation that satisfies the relevant criteria
for the respective E&M service to be reported. .
 The E & M service may be prompted by the symptom or condition
for which the procedure and/or service was provided. Different
diagnoses are not required for reporting of the E & M service on
the same date.
 Initial consultations and additional procedures may be reported
without the use of modifier 25.
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- 32
Mandated Services
 Used to identify mandated consultation and/or related
services (e.g., PRO, third party payer, governmental,
legislative, or regulatory requirement).
 Generally allowed at 100% since the service is mandated .
 Used with second surgical opinions
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- 57
Decision for Surgery
 Indicates initial decision to perform major surgery the same
day or next day of the E&M service.
 Removes service, normally consultative, from the global
surgical package.
 Codes with this modifier are reimbursed separately by the
carrier.
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OTHER MODIFIERS
- 22
Increased Procedural Services
 When the work required to provide a service is substantially
greater than typically required, modifier 22 may be added to
the usual procedure code.
 Documentation must support the additional work and the
reason for it (i.e., increased intensity, time, technical
difficulty of procedure, or severity of patient’s condition,
physical and mental effort required).
 This modifier should not be appended to an E&M Service.
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OTHER MODIFIERS
- 26
- GC
Professional component or interpretation of a
diagnostic test or study
Service performed in part by a resident under
direction of a teaching physician
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EVALUATION AND MANAGEMENT SERVICES
WITH PROCEDURES
 Any specifically identifiable procedure (i.e., identified with a specific CPT
code) performed on or subsequent to the date of initial or subsequent
Evaluation and Management Services should be reported separately.
 The physician may need to indicate that on the day a procedure or service
identified by a CPT code was performed, the patient's condition required a
significant separately identifiable E/M service above and beyond other
services provided or beyond the usual preservice and postservice care
associated with the procedure that was performed. The E/M service may be
caused or prompted by the symptoms or condition for which the procedure
and/or service was provided. This circumstance may be reported by adding
the modifier -25 to the appropriate level of E/M service. As such, different
diagnoses are not required for reporting of the procedure and the E/M
services on the same date.
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PERFORMANCE AND/OR INTERPRETATION
OF DIAGNOSTIC TESTS
 The actual performance and/or interpretation of
diagnostic tests/studies ordered during a patient
encounter are not included in the levels of E/M services.
Physician performance of diagnostic tests/studies for
which specific CPT codes are available may be
reported separately, in addition to the appropriate E/M
code.
 Results are the technical components of a service.
Testing leads to results; results lead to interpretation.
Reports are the work product of the interpretation of
numerous test results.
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PERFORMANCE AND/OR INTERPRETATION
OF DIAGNOSTIC TESTS
 The physician’s interpretation of the results of
diagnostic tests/studies (i.e., professional component)
with preparation of a separate distinctly identifiable
signed written report may also be reported separately,
using the appropriate CPT code with the modifier -26
appended.
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DOCUMENTATION EXAMPLES
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SAMPLE DOCUMENTATION - 99222
Level II Initial Hospital Care
This 42-year old diabetic female Hispanic patient is admitted today with
four-day history of fever, chills, harsh cough productive of moderate
amounts of greenish and foul-smelling sputum, shortness of breath at
rest and general malaise. Onset of symptoms occurred rather
suddenly, though the patient admits to a mild dry cough for several
weeks, changing to a productive cough over the last four days. Denies
rhinorrhea or nasal congestion. Patient fainted today after walking up a
flight of steps; says she “could not find my breath and then got dizzy.”
Feeling weak and just “really sick.” Temperature taken at home last
night 102 degrees. Had TB as a child in her native country in South
America. Was apparently treated successfully at that time without
sequelae. No history of asthma.
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ROS:
Head: no complaints except for recent dizziness. Ears: no
complaints. Eyes: wears glasses. Last exam five years
ago in her native country. Nose: denies rhinitis, as above.
Throat: extremely sore secondary to deep cough. Resp:
Cough, SOB as above.
Breasts:
has never had
mammograms; denies history of nodule/mass. Cardio:
patient is hypertensive, controlled with Monopril 20 mg/day.
Takes her Bp every other day at local drug store. GI: no
NVD. Appetite diminished. GU: no complaints. Last Pap
some years ago - normal. Musculoskeletal: admits to
general arthralgias with onset of fever. No history of
arthritis. Neuro: without complaint. Endo: patient is
diabetic; controlled on daily Glucophage 1500 mg/day. Last
glucose level taken at home a few days ago by home
glucometer. Patient doesn’t remember the result. Admits to
being less than compliant in taking the med and monitoring
the blood glucose.
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PMH: Hypertension and diabetes for years. No major
surgeries. Usual childhood illnesses.
Immunizations: unknown. Allergy: severely allergic
to penicillins: hives , no anaphylaxis.
FH: Noncontributory to this illness. Mother was
nonhypertensive; nondiabetic. Never knew her
father and therefore history is unavailable. Three
siblings, alive and well.
SH: No smoking or drinking. Doesn’t exercise.
Married with two children.
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O:
General: febrile-appearing female, short with barrel-shaped chest, lying supine in bed. T:
101.6; P: 72; R: 30, shallow, guarded. Bp: 132/82. Head: normocephalic. No lesions,
signs of trauma or fall. Eyes: PERRLA. Sclerae sl. yellow. Ears: Canals clear. TM’s
WNL. Nose: mucosa pale. No exudates. Turbinates sl. Congested. Septum deviated to
left. Throat: posteropharyngeal wall erythematous. Tonsils small, red without exudates.
Tongue geographic, thick. Dentition poor. Gold fillings throughout. Neck: +3 anterior
cervical lymphadenopathy. Thyroid not palpable. Chest auscultation reveals LUL clear;
LLL with high-pitched rales. RUL nonaudible; RML and RLL some wheezing. Chest
percussion reveals dull sounds over RML/RLL but tinny sounds over RUL. Breasts:
WNL. No mass or tenderness. Areolae WNL: No discharge. Cardio: Normal S1,S2.
No murmur or rub. Abdomen: no hepato-or splenomegaly. Some tenderness over
epigastrium. BS active. GU: deferred. Rectal: deferred. Skin: Dry; no petechiae or
purpura. Extremities: Warm. No pedal edema. Pulses +2 in upper/lower extremities.
No digital clubbing. No CVA tenderness. Neuro: no focal deficits. DTRs +2 upper
extremities; +1 lower extremities.
STAT portable chest x-ray ordered. Laboratory tests ordered: SMA-12 including CBC
w/diff. STAT ABG. Blood glucose; Hg Alc; UA; sputum culture/sensitivity, and gram stain,
AFB x 3. Oximetry reported 90 percent.
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A:
1.
2.
3.
4.
5.
Community acquired pneumonia of LUL. Probably bacterial.
R/O pneumothorax.
R/O atypical pneumonitis.
NIDDM.
HTN.
P:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Patient admitted today to Medical Service ward.
Await chest x-ray/ labs.
Obtain Pulmonary consult.
Begin IV antibiotics – Erythromycin 500 mg q. 6 h.
Begin Tylenol for fever.
1500 cal/day ADA diet.
Finger sticks before meals.
Lispro insulin before meals.
Hold Glucophage for now.
Resp. isolation.
Nasal oxygen 2 liters by nasal cannula.
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Addendum:
Patient now reports she thinks she has
visited the ER here about eight months ago
for lower respiratory infection, at which time
she underwent chest x-ray. Old films to be
pulled for comparative review.
(Multisystem-Primary Care Physician)
St. Anthony’s Guide to
Evaluation and Management
Coding and Documentation
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SAMPLE DOCUMENTATION - 99231
Level I Subsequent Hospital Visit
The patient was admitted three days ago with bleeding gastric
ulcer, now stable. Since admission, she has received three units
of packed RBCs; hematocrit 29.9, hemoglobin 9.2. Tolerating
clear liquids well. She is on H2 blocker, Sucralfate and antacids.
No GI complaints at this time. NG tube was removed. Stools
remain melanotic.
Blood pressure, pulse, respirations are stable; temperature
normal. Abdominal exam is basically unchanged from yesterday.
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AMENDED CHART NOTES
It is not unlawful to amend a physician’s chart notes to add
inadvertently omitted information. Amendments should be made
as follows:

Don’t revise a closed note, one that’s already been signed and
dated by the physician. Don’t replace an original note with
new notes.
Instead, add the extra information as an
amendment or addendum.
 Identify the amendment as an amendment of “late
entry.”
 Have the physician sign the amendment and date it.
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AMENDED CHART NOTES
 Date it with the date the amendment is made, not the
date of the original note. Otherwise, you risk fraud
allegations for misrepresentation.
 Obviously, amend a note only when the additional work
actually was performed and was medically justified.
Avoid adding elements to raise the level of service.
 Make amendments to notes within a reasonable
timeframe. It is questionable whether a physician
remembers details of a patient’s care weeks later.
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TEACHING PHYSICIAN
GUIDELINES
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MEDICARE TP ATTESTATION REQUIREMENT





The 11/22/02 revisions to the regulations provide that for E&M
services, the TP does not have to duplicate any resident
documentation.
The TP must be present during the key portions of the service and
personally document his or her presence.
The resident note alone, the TP note alone or a combination of the
two may be used to support the level of service billed.
Documentation by a resident of the presence and participation of
the TP is not sufficient.
Documentation may be dictated and typed, hand-written or a
computer statement initiated by the TP.
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TEACHING PHYSICIAN ATTESTATION FOR E/M SERVICES

The attending physician who bills for evaluation and management (E&M)
services in the teaching setting must, at a minimum, personally document:
 His or her participation in the management of the patient; and
 That he or she performed the service or was physically present during
the critical or key portion(s) of the service performed by the resident
(the resident’s certification that the attending physician was present is
not sufficient)
 You have to include some of your history, exam, assessment, and
plan – merely stating “reviewed and agree” is no longer enough

When properly attested, the resident’s documentation and the faculty’s
documentation are both considered in determining the E/M level.
 Use your attestation to augment/supplement what the resident
documented.
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MEDICARE’S EXAMPLES OF ACCEPTABLE TP NOTES
CMS’ examples of minimally acceptable documentation:

Admitting Note: “I performed a history and physical examination of the
patient and discussed his management with the resident. I reviewed
the resident’s note and agree with the documented findings and plan of
care.”

Follow-up Visit: “I saw and evaluated the patient. I agree with the
findings and the plan of care as documented in the resident’s note.” or
“I saw and examined the patient. I agree with the resident’s note
except the heart murmur is louder, so I will obtain an echo to evaluate.”

Initial or Follow-up Visit: “I was present with resident during the history
and exam. I discussed the case with the resident and agree with the
findings and plan as documented in the resident’s note.

Follow-up Visit: “I saw the patient with the resident and agree with the
resident’s findings and plan.
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MEDICARE’S EXAMPLES OF UNACCEPTABLE TP NOTES
 “Agree with above.” followed by legible countersignature or
identity;
 “Rounded, Reviewed, Agree.” followed by legible countersignature
or identity;
 “Discussed with resident. Agree.” followed by legible
countersignature or identity;
 “Seen and agree.” followed by legible countersignature or identity;
 “Patient seen and evaluated.” followed by legible countersignature
or identity; and
 “A legible countersignature or identity alone.

The preceding six and similar statements don’t make it possible to
determine whether the TP was present, evaluated the patient, and/or
had any involvement with the plan of care.
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MEDICARE’S SUPERVISION GUIDELINES FOR
PROCEDURES PERFORMED WITH RESIDENTS
 Minor procedures of <5 minutes: Must be present
the entire time
 Endoscopies (other than surgical operations):
TP must be present for entire viewing including
insertion and removal
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DOCUMENTATION GUIDELINES FOR MINOR PROCEDURES
 Procedure name
 Names of the teaching physician and assistants
 Pre-operative and post-operative diagnoses, if
different
 Description of the procedure
 Post-operative instructions
 Anesthetic agent, if any
 Additional information to support the procedure
performed
 Legible signature(s)
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DOCUMENTATION GUIDELINES FOR MINOR PROCEDURES
 Attestation for minor procedures:
 Present for entire procedure.
 Presence demonstrated by personal note.
 “I was present for the entire bone biopsy performed
by Dr. Resident.”
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MEDICARE SUPERVISION GUIDELINES
FOR SPECIFIC PROCEDURES
 Time-based procedures billed on TP time only
 Critical care
 Hospital discharge day management
 Prolonged services
 Care plan oversight
 E&M counseling/coordination of care
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MEDICARE SUPERVISION GUIDELINES
FOR SPECIFIC PROCEDURES
 Specific complex or high-risk procedures require
continual personal TP supervision
 Interventional radiologic/cardiology codes
 Cardiac cath, stress tests, transesophageal ECG
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KEY POINTS FOR DOCUMENTING INPATIENT SERVICE
 Must be legible.
 SOAP note must include a chief complaint, ie,
follow-up for gastroenteritis
 Document time for admissions, discharges, critical
care, time-based coding, and start/stop times for
prolonged services.
 Resident (if applicable) and faculty must sign.
 Faculty attestation must show active participation
(“Reviewed and agree won’t do it – your
documentation needs to supplement the resident’s
note).
 Cannot use documentation notes of non-UT
Medicine auxiliary staff or mid-levels.
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COMPLETING FEE TICKET
 Select E/M level and any CPT procedure
codes.
 Select and sequence diagnoses
(Diagnoses must be sequenced.)
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COMPLETING FEE TICKET
 #1 = CC or primary reason for appointment
 Code additional diagnoses or co-morbid conditions
that coexist at the time of the service and influence,
require, or affect patient care or treatment as
supported in documentation.
 Pay attention to sequencing when providing an E/M
service and a procedure in same visit.
 Sequencing required to link diagnoses to E/M codes
and procedures performed.
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COMPLETING FEE TICKET

• Remember ICD-9 codes explain why you
performed the service
• If procedures are performed, sequencing is
critical since the correct diagnosis code must be
linked to the procedure for the procedure to be
paid.
Select modifiers

 25 modifier is checked or written next to E/M code
selected when a procedure is performed (otherwise
one of the service codes may not be paid).
Sign fee ticket (paper).
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IN CLOSING
 Avoid reckless disregard for the rules.
 Understand the rules of documentation
 Avoid using the same level code for all services of
the same type (i.e. consultations).
 Avoid down-coding which suggests lack of
understanding.
 Document all requests for consultations.
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In closing, (con’t)
 Avoid use of the word "referral" for consultations.
 Evaluate your charge documents annually.
 Never bill for services for which you were not
present.
 Audit your practice every 6 months.
 Have a mandatory education program in place for
physicians and billing staff.
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Outpatient Evaluation &. Management CPT Code Criteria
New Patient
Avg time (mins)
99201
10
CC: Required
99202
20
CC: Required
99203
30
CC: Required
99204
45
CC: Required
99205
60
CC: Required
Requires all three key
Components
HPI: 1-3
ROS: None
PFSH: None
HPI: 1-3
ROS: 1 Pertinent
PFSH: None
HPI: 4+
ROS: 2-9
PFSH: 1 Pertinent
HPI: 4+
ROS: 10+
PFSH: 3
HPI: 4+
ROS: 10+
PFSH: 3
PE: 1 BA/OS
PE: 2-7 BA/OS
PE: 2-7 BA/OS
w/detail
PE: 8+OS
PE: 8+OS
MDM:
Straightforward
MDM:
Straightforward
MDM: Low
MDM: Moderate
MDM: High
Established Patient
Avg time (mins)
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99211
5
99212
10
99213
15
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99214
25
99215
40
174
Outpatient Evaluation &. Management CPT Code Criteria
CC:
CC: Required
CC: Required
CC: Required
CC: Required
HPI:
HPI: 1-3
HPI: 1-3
HPI:4+
HPI: 4+
Requires two of the
ROS: None
ROS: None
ROS: 1
ROS: 2-9
ROS:10+
three key components
PFSH: None
PE:
PFSH: None
PE: 1 BA/OS
PFSH: 1
PE: 2-7 BA/OS
PFSH: 2-3
PE: 8+OS
MDM:
MDM:
Straightforward
MDM: Low
PFSH: 1
PE: 2-7 BA/OS
w/detail
MDM: Moderate
MDM: High
Office Consultation
New or Established
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99242
99243
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99244
99245
175
Outpatient Evaluation &. Management CPT Code Criteria
Avg time (mins)
15
30
40
60
80
CC: Required
CC: Required
CC: Required
CC: Required
CC: Required
HPI: 1-3
HPI: 1-3
HPI:4+
HPI: 4+
HPI: 4+
Requires all three key
ROS: None
ROS: 1 Pertinent
ROS:2-9
ROS: 10+
ROS: 10+
components
PFSH: None
PFSH: None
PFSH: 1 Pertinent
PFSH: 3
PFSH: 3
PE: 1 BA/OS
PE: 2-7 BA/OS
PE: 2-7 BA/OS
w/detail
PE: 8+OS
PE: +OS
MDM:
Straightforward
MDM:
Straightforward
MDM: Low
MDM: Moderate
MDM: High
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176
Hospital Inpatient Services Evaluation & Management CPT Code Criteria
Initial Hospital
Care
Avg time (mins)
Requires all three
key
components
99221
30
CC: Required
HPI: 4+
ROS: 2-9
PFSH: 1
PE: 2-7 BA/OS
w/detail
MDM: Low
99222
50
CC: Required
HPI:4+
ROS: 10+
PFSH:3
PE:8+OS
MDM: Moderate
99223
70
CC: Required
HPI:4+
ROS: 10+
PFSH: 3
PE: 8+OS
MDM: High
Subsequent
Hospital Care
99231
99232
99233
Avg time (mins)
15
25
35
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Hospital Inpatient Services Evaluation & Management CPT Code Criteria
CC: Required
HPI: 1-3
ROS: None
Requires two of the PFSH: None
PE: 1 BA/OS
three key
MDM: Low
components
Initial Inpatient
Consultation
Avg time (mins)
Requires all three
key
components
99251
20
CC: Required
HPI: 1-3
ROS: None
PFSH: None
PE: 1 BA/OS
MDM:
Straightforward
CC: Required
HPI: 1-3
ROS: 1 Pertinent
PFSH: None
PE: 2-7 BA/OS
MDM: Moderate
CC: Required
HPI:4+
ROS: 2-9
PFSH: None
PE: 2-7 BA/ OS /
detail
MDM: High
99252
99253
99254
55
CC: Required
HPI:4+
ROS: 2-9
PFSH: 1
Pertinent
PE: 2-7 BA/ OS
w/detail MDM:
Low
80
CC: Required
HPI:4+
ROS:10+
PFSH:3
PE:8+OS
MDM: Moderate
40
CC: Required
HPI: 1-3
ROS: 1 Pertinent
PFSH: None
PE: 2-7 BA/OS
MDM:
Straightforward
99255
110
CC: Required
HPI:4+
ROS:10+
PFSH:3
PE::8+OS
MDM: High
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History Components
HPI: History of Present Illness
 Location
 Quality
 Severity
 Duration
 Timing
 Past medications, illnesses, injuries, operations, hospitalization, allergies,
 Context
immunizations status
 Modifying Factors
 Family health status and dx of family members or cause of death
 Associated signs/symptoms  Social marital status, current employment/occupational, environment, drugs, alcohol
and tobacco use, sexual history
ROS: Review of Systems
 Constitutional
 Eyes
 ENMT
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PFSH: Past, family & Social History
2 ROS documented, remainder “all other systems negative” = complete ROS
 Respiratory
 Gastrointestinal
 Genitourinary
 Musculoskeletal
 Integumentary
 Neurological
 Psychiatric
 Endocrine
 Hematologic/Lymphatic
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 Allergic/Immunologic
 Cardiovascular
179
Examination Components
BA: Body Area
 Abdomen
 Back, Spine
 Chest, Breasts
 Each Extremity
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OS: Organ System
 GU/groin/pelvic/buttocks
 Head & Face
 Neck
 Constitutional systems
 Cardiovascular
 Ears Nose Mouth Throat
 Eyes
 Gastrointestinal
 Genitourinary
 Hematologic/Lymphatic/Immunologic
 Integumentary (skin and breast)
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 Musculoskeletal
 Neurological
 Psychiatric
 Respiratory
180
Risk of Complications and/or Morbidity or Mortality
Level of
Risk
Category I
Presenting Problems
Minimal  One self-limited or minor
(1)
problem, e.g.
Cold, insect bite, tinea corporis
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Category II
Diagnostic Procedure(s)
 Laboratory tests requiring
venipuncture
 Chest X-rays
 EKG/EEG
 Urinalysis
 Ultrasound, e.g., echocardiography
 KOH prep
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Category III
Management Options
Selected
 Rest
 Gargles
 Elastic bandages
 Superficial dressings
181
Risk of Complications and/or Morbidity or Mortality
Low
(2)
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 Two or more self-limited or minor
problems
 One stable chronic illness, e.g.,
well controlled
Hypertension or non-insulin
dependent
diabetes, cataract, BPH
 Acute uncomplicated illness or
injury.
e.g., cystitis, allergic rhinitis,
simple sprain
 Physiologic tests not under stress, e.g.
pulmonary function tests
 Non-cardiovascular imaging studies
with contrast,
e.g., barium enema
 Superficial needle biopsies
 Clinical laboratory tests requiring
arterial puncture
 Skin biopsies
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 Over the counter drugs
 Minor surgery with no identified risk
factors
 Physical therapy
 Occupational therapy
 IV fluids without additives
182
Risk of Complications and/or Morbidity or Mortality
Moderate  One or more chronic illnesses with  Physiologic tests under stress, e.g.
(3)
mild exacerbation, progression
stress test
or side effects of treatment
 Diagnostic endoscopies with no
 Two or more stable chronic
identified risk factors
illnesses
 Deep needle or incisional biopsy
 Undiagnosed new problem with
 Cardiovascular imaging studies with
uncertain
prognosis, e.g., lump
contrast and no
in breast
identified risk factors, e.g. arteriogram,
 Acute illness with systemic
cardiac
symptoms,
catheterization
e.g., pyelonephritis, pneumonitis,  Obtain fluid from body cavity, e.g.
colitis
lumbar puncture,
 Acute complicated injury, e.g.,
thoracentesis, culdocentesis
head injury with
brief loss of consciousness
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 Minor surgery with identified risk
factors
 Elective major surgery (open,
percutaneous or
endoscopic)
 Prescription drug management
 Therapeutic nuclear medicine
 IV fluids additives
 Closed treatment of fracture or
dislocation without
manipulation
183
Risk of Complications and/or Morbidity or Mortality
High
(4)
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 One or more chronic illnesses with  Cardiovascular imaging studies with
severe
contrast with identified risk factors
exacerbation, progression or side  Cardiac electrophysiological tests
effects of treatment
 Diagnostic endoscopies with identified
 Acute or chronic illnesses or
risk factors
injuries that pose a
 Discography
threat to life or bodily function,
e.g., multiple
trauma, acute MI, pulmonary
embolus, severe
respiratory distress, progressive
severe rheumatoid arthritis,
psychiatric illness with potential
threat to self or others,
peritonitis, acute renal failure
 An abrupt change in neurologic
status, e.g.,
seizure, TIA, weakness or sensory
loss
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 Elective major surgery (open,
percutaneous or
endoscopic) with identified risk
factors
 Emergency major surgery (open,
percutaneous
Or endoscopic)
 Parenteral controlled substances
 Drug therapy requiring intensive
monitoring for
toxicity
 Decision to not resuscitate or to deescalate care
because of poor prognosis
184
TrailBlazer
EVALUATION AND MANAGEMENT
Coding and Documentation Reference Guide
HEALTH ENTERPRISE, LLC
© CP7 codes, descriptions, and other data only are copyright 2007 American Medical
Association. All rights reserved. Applicable FARS/DFARS clauses apply.
1 ) HISTORY
HPI (History of Present Illness): Characterize HPI by considering either the Status of chronic conditions or the
number of elements recorded.
 1 condition
 Location
 2 conditions OR
 Severity
 3 conditions
 Timing
 Modifying factors
 Quality
 Duration
 Context
 Associated signs and symptoms
1 condition
2 conditions
3 conditions
Duration
Context
Associated signs and symptoms
HPI (History of Present Illness): Characterize HPI by considering either the Status of chronic
conditions or the number of elements recorded.
Location
Severity
Timing
Modifying factors
ROS (Review of Systems):
 Constitutional
 Ears, nose,
 Gl
 Integumentary
 Endo
(wt loss, etc.)
mouth, throat
(skin, breast)
 Eyes
 Card/vase
 GU
 Neuro
 Hem/lymph
 Musculo
 Psych
 All/immuno
Resp
Quality
PFSH (Past, Family, Social History):
 Past history (the patient's past experiences with illnesses, operations, injuries and treatments)
 Family history (a review of medical events in the patient's family, including diseases that may be hereditary or
place the patient at risk)
 Social history (an age-appropriate review of past and current activities)
"Complete PFSH:
2 history areas: a) established patients - office (outpatient) care, domiciliary care, home care;
b) emergency department; c) subsequent nursing facility care; and, d) subsequent hospital
care.
3) history areas: a) new patients - office (outpatient) care, domiciliary care, home care;
b) consultations; c) initial hospital care; d) hospital observation; and, e) initial nursing facility
care.

Status of
1-2 chronic
conditions

Status of
1-2 chronic
conditions

Status of
3 chronic
conditions

Status of
3 chronic
conditions

Brief (1-3)

Brief (1-3)

Extended
(4 or more)

Extended
(4 or more)
N/A

Pertinent to
problem (1
system)

Extended
(Pert and
others) (2-9
systems)

Complete (Pert and
all others) (10
systems)
N/A
N/A

Pertinent
(1 history
area)

"Complete
(2 or 3 history areas)
PROBLEMFOCUSED
EXP.
PROBLEM
-FOCUSED
DETAILED
COMPREHENSIVE
Final History requires all 3 components above met or exceeded
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EVALUATION AND MANAGEMENT
Coding and Documentation Reference Guide
TrailBlazer
HEALTH ENTERPRISE, LLC
© CP7 codes, descriptions, and other data only are copyright 2007 American Medical
Association. All rights reserved. Applicable FARS/DFARS clauses apply.
2) EXAMINATION
"—
CRT Exam Description
95 Guideline Requirements
Limited to affected body area or organ system
97 Guideline Requirements
CRT Type of Exam
One body area or organ system
1-5 bulleted elements
PROBLEM-FOCUSED EXAM
Affected body area or organ system and other symptomatic or
related organ systems
2-7 body areas and/or organ
systems
6-11 bulleted elements
EXPANDED PROBLEMFOCUSED EXAM
Extended exam of affected body area or organ system and other
symptomatic or related organ systems
2-7 body areas and/or organ
systems
12-17 bulleted elements for 2 or more
systems
DETAILED EXAM
8 or more body areas and/or organ
systems
18 or more bulleted elements for 9 or
more systems
General multi-system
Complete single organ system exam
Not defined
COMPREHENSIVE EXAM
See requirements for individual single
system exams
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© 2006 The Coding Network, LLC
EVALUATION AND MANAGEMENT
Coding and Documentation Reference Guide
TrailBlazer
HEALTH ENTERPRISE, LLC
© CP7 codes, descriptions, and other data only are copyright 2007 American Medical
Association. All rights reserved. Applicable FARS/DFARS clauses apply.
MEDICAL DECISION-MAKING
Instructions for Using Trailblazer’s MDM Coding Method
Coding Medical Decision-Making (MDM) begins with separately coding the three distinct components of MDM. Two of the three
components determine the final level of MDM complexity documented in a record of Evaluation and Management (E/M) service. These
components are:
1.
Number of diagnoses and/or management options.
2.
Amount and/or complexity of data reviewed or ordered.
3.
Risk of complication and/or mortality.
The TrailBlazer MDM coding method corresponds directly to the components above as follows:
•
Section A corresponds to number of diagnoses and/or management options.
•
Section B corresponds to amount and/or complexity of data reviewed or ordered,
•
Section C corresponds to risk of complication and/or mortality.
Code each component separately using respective Tables A-C, then compare results from Tables A-C to requirements in Table D to determine the overall
MDM level.
Section A
Coding Number of Diagnoses or Management Options – Use the Table A.1 and A.2 on page 2 to determine the numbers of diagnoses or management options.
Note: In all cases, the information in the clinical record (history and physical) must clearly support diagnostic impressions. Diagnostic impressions listed but not supported
elsewhere I the clinical record must be included in the problem list for coding purposes.
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