E & M Coding Education for Orthopedics
Etransmedia
© ETRANSMEDIA TECHNOLOGY, INC
Presented by Lori McGwire, MBA, CMPE, CPC, CHCO, CHCC
PROPRIETARY AND CONFIDENTIAL
Lori M. McGwire, MBA, CPC, CHCO, CHCC, CMPE
Vice President of Physician Services, Etransmedia
About Your
Presenters
In December 2014, Lori McGwire began serving as Vice President of Physician Services for
Etransmedia when DoctorsXL became part of the Etransmedia family. Lori started
DoctorsXL in 2008. She is a member of the Renal Physicians Association, Medical Group
Management Association and American Academy of Professional Coders. She is also a Past
President of the Practice Managers Committee of the Renal Physicians Association.
1.866.725.2855
•
Certified Professional Coder
www.etransmedia.com
•
Certified Healthcare Compliance Officer
•
Certified Healthcare Compliance Consultant
•
Certified Medical Practice Executive
All Current Procedural Terminology (CPT) codes and descriptors
used in this presentation are copyright © by the American
Medical Association. All rights reserved. The information
enclosed was current and the time it was presented. Policies
change frequently; links to the source documents have been
provided within the document for your reference. This
presentation was prepared as a tool to assist providers and is
not intended to grant rights or imposed obligations.
Although every reasonable effort has been made to assure that
accuracy of the information within these pages, the ultimate
responsibility for the correct submission of claims and response
to any remittance advice lies with the provider of the services.
Etransmedia employees, agents, and staff make no
representation, warranty, or guarantee that this compilation of
this information is error free and will bear no responsibility or
liability for the results or consequences of the use of this guide.
This presentation is a general summary that explains certain
aspects of the Medicare program, but is not a legal document.
The official Medicare program provisions are contained in the
relevant laws. Regulations. And rulings.
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Carolynn Coates, CPC, CCA
Certified Coder
Carolynn works with physicians and staff as a coder liaison to ensure proper coding and
education. Carolynn frequently provides E & M and surgical audits to Etransmedia billing
and consulting clients.
•
Certified Professional Coder
•
Certified Coding Associate
PROPRIETARY AND CONFIDENTIAL
Evaluation and Management Codes
NEW
OFFICE AND PATIENT VISITS
Code (need 3 of 3)
99201
99202
99203
99204
99205
Code (need 2 of 3)
Non-Facility RVU/Avg. Time
1.08/
10 min.
1.87/
20 min.
2.71/
30 min.
4.20/
45 min.
5.28/
60 min.
Non-Facility RVU/Avg. Time
History
K
E
Y
Problem Focused
X
Expanded Problem-Focused
Problem Focused
X
Detailed
X
X
X
X
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.53/
5 min.
1.08/
10 min.
1.82/
15 min.
2.73/
25 min.
3.68/
40 min.
X
X
X
X
X
Expanded Problem-Focused
X
X
Detailed
X
X
Medical Decision Making
High Complexity
99215
Comprehensive
Problem Focused
Comprehensive
Moderate Complexity
99214
Examination
Detailed
Low Complexity
99213
Detailed
X
Expanded Problem-Focused
Straight Forward
99212
Expanded Problem-Focused
Examination
Problem Focused
99211
History
Comprehensive
C
O
M
P
O
N
E
N
T
S
ESTABLISHED
X
Comprehensive
X
Medical Decision Making
X
X
Straight Forward
X
Low Complexity
X
Moderate Complexity
X
High Complexity
PROPRIETARY AND CONFIDENTIAL
X
X
X
X
Evaluation and Management Codes
INITIAL HOSPITAL CARE/NEW OR ESTABLISHED
SUBSEQUENT HOSPITAL CARE
Code (need 3 of 3)
99221
99222
99223
Code (need 2 of 3)
99231
99232
99233
Non-Facility RVU/Avg. Time
2.61/
30 min.
3.53/
50 min.
5.18/
70 min.
Non-Facility RVU/Avg. Time
1.06/
15 min.
1.91/
25 min.
2.74/
35 min.
History
K
E
Y
History
Problem Focused
Problem Focused
Expanded Problem-Focused
Expanded Problem-Focused
Detailed
X
Comprehensive
C
O
M
P
O
N
E
N
T
S
X
X
Comprehensive
Problem Focused
Expanded Problem-Focused
Expanded Problem-Focused
X
Comprehensive
X
X
Low Complexity
High Complexity
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Comprehensive
Straight Forward
Low Complexity
X
Moderate Complexity
X
High Complexity
PROPRIETARY AND CONFIDENTIAL
99292
(30-74
min.)
(each
add. min.)
Facility RVU
5.99
2.99
Non-Facility RVU
7.16
3.23
X
* Time is used for the other E and M codes only
when counseling and coordination of care is greater
than half the time spent.
Medical Decision Making
X
99291
Code
X
Detailed
Medical Decision Making
Moderate Complexity
CRITICAL CARE (based on time)*
Examination
Problem Focused
Straight Forward
X
Detailed
Examination
Detailed
X
X
X
Evaluation and Management Codes
*CONSULT INPATIENT/NEW OR ESTABLISHED
*CONSULTATIONS (OFFICE OR OUTPATIENT)
Code (need 3 of 3)
99251
99252
99253
99254
99255
Code (need 3 of 3)
99241
99242
99243
99244
99245
Non-Facility RVU/Avg. Time
1.38/
20 min.
2.11/
40 min.
3.22/
55 min.
4.65/
80 min.
5.62/
110 min.
Non-Facility RVU/Avg. Time
1.35/
15 min.
2.54/
30 min.
3.47/
40 min.
5.14/
60 min.
6.28/
80 min.
X
X
X
X
X
X
History
K
E
Y
Problem Focused
History
X
Expanded Problem-Focused
Problem Focused
X
Detailed
Expanded Problem-Focused
X
Comprehensive
C
O
M
P
O
N
E
N
T
S
X
X
X
Comprehensive
Problem Focused
X
Detailed
X
Expanded Problem-Focused
X
Comprehensive
X
Detailed
X
X
Medical Decision Making
X
Comprehensive
Medical Decision Making
X
X
Low Complexity
Moderate Complexity
High Complexity
Straight Forward
X
Low Complexity
X
Moderate Complexity
X
High Complexity
*Consult codes are not billable under Medicare effective January 1, 2010
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X
Examination
Expanded Problem-Focused
Straight Forward
X
Detailed
Examination
Problem Focused
X
PROPRIETARY AND CONFIDENTIAL
X
X
X
Evaluation and Management Codes
DOCUMENTATION GUIDELINES
HISTORY
CC (Chief Complaint):
Reasons patient is being seen
HPI (history of present illness) elements:
PFSH (past medical, family, social history) areas:
 Past history (the patient’s past experiences with illnesses,
operations, injuries and treatment)
Location
Duration
 Modifying factors
Quality
Timing
Severity
Context
 Associated signs
and symptoms
ROS (review of systems):
 Constitutional
(weight loss, etc.)
 Eyes
 Ears, nose,
mouth, throat
 Cardiovascular
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 Respiratory
 Family history (a review of medical events in the patient’s
family, including diseases which may be hereditary or
place the patient at risk)
 Social history (an age appropriate review of past and
current activities)
 Neurological
 Gastrointestinal  Psychiatric
 Genitourinary  Endocrine
 Musculoskeletal  Hematologic/lymphatic
 Integumentary  “all other negative
(skin, breast)
PROPRIETARY AND CONFIDENTIAL
Evaluation and Management Codes
DOCUMENTATION GUIDELINES
History
Physical Exam
1997
Physical Exam
1995
HPI
ROS
PFSH
CPT
Level
Brief
None
None
Problem Focused
1-5 elements identified
by  (bullet)
affected area or
organ system
None
None
Expanded
Problem Focused
 6 elements identified
by  (bullet)
limited to affected area or
organ (2-7 systems)
Extended
Pertinent
Detailed
2-9 systems
1 history area related to
patient's problem
 2 elements identified
by  (bullet) from 6
areas/systems or 12
elements identified by a 
extended to area or organ
plus symptomatic or related
organ (2-7 systems)
Complete
Complete
Comprehensive
 2 elements identified
by  (bullet) from 9
areas/systems
Comprehensive Exam
(general multi-system [8 or
more of 12 organ systems
or all body areas])
1-3 elements
Brief
1-3 elements
Extended
 4 elements or status of
 3 chronic or inactive
conditions
Extended
 4 elements or status of
 3 chronic or inactive
conditions
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10 systems, or some
systems with statement “all
others negative”
3 New
2 of 3
Established
PROPRIETARY AND CONFIDENTIAL
(General Mulit-System
Exam)
Evaluation and Management Codes
COMPLEXITY OF MEDICAL DECISION MAKING
Type of Decision Making
Number of Diagnoses or
Management Options
Amount and/or Complexity
of Data to be Reviewed
Risk of Complications
and/or Morbidity or
Mortality
straightforward
minimal
minimal or none
minimal
low complexity
limited
limited
low
moderate complexity
multiple
moderate
moderate
high complexity
extensive
extensive
high
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PROPRIETARY AND CONFIDENTIAL
Evaluation and Management Codes
Level of Risk Presenting Problem(s)
Minimal
•
One self-limited or minor problem,
eg, cold, insect bite tinea corporis
Diagnostic Procedure(s) Ordered
Management Options Selected
•
Laboratory tests requiring
venipuncture
Chest x-rays
EKG/EEG
Urinalysis
Ultrasound, eg echocardiography
KOH prep
•
Rest
•
Gargles
•
Elastic bandages
•
Superficial dressings
Physiologic tests not under stress,
eg, pulmonary function tests
Non-cardiovascular imaging
studies with contrast, eg barium
enema
Superficial needle biopsies
Clinical laboratory tests requiring
arterial puncture
Skin biopsies
•
Over-the-counter drugs
•
Minor surgery with no identified
risk factors
•
Physical therapy
•
Occupational therapy
•
IV fluids without additives
•
•
•
•
•
Low
•
•
•
Two or more self-limited or minor
problems
One stable chronic illness, eg well
controlled hypertension or non
insulin dependent diabetes,
cataract, BPH
Acute uncomplicated illness or
injury, eg, cystitis, allergic rhinitis,
simple sprain
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•
•
•
•
•
PROPRIETARY AND CONFIDENTIAL
Evaluation and Management Codes
Level of Risk Presenting Problem(s)
Moderate
Diagnostic Procedure(s) Ordered
Management Options Selected
One or more chronic illnesses with
mild exacerbation, progression, or
side effects of treatment
•
•
Minor surgery with identified risk
factors
•
•
Two or more stable chronic
illnesses
•
Diagnostic endoscopies with no
identified risk factors
Elective major surgery (open,
percutaneous or endoscopic) with
no identified risk factors
•
Undiagnosed new problem with
uncertain prognosis, eg, lump in
breast
•
Deep needle or incisional biopsy
•
Prescription drug management
•
Cardiovascular imaging studies
with contrast and no identified risk
factors, eg, arteriogram, cardiac,
catheterization
•
Therapeutic nuclear medicine
•
IV fluids with additives
•
Closed treatment of fracture or
dislocation without manipulation
•
•
Acute illness with systemic
symptoms, eg, pyelonephritis,
pneumonitis, colitis
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•
Physiologic tests under stress, eg,
cardiac stress test, fatal
contraction stress test
Obtain fluid from body cavity, eg,
lumbar puncture, thoracentesis,
culdocentesis
PROPRIETARY AND CONFIDENTIAL
Evaluation and Management Codes
Level of Risk Presenting Problem(s)
High
•
•
•
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 of
bodily function, eg, 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, eg, seizure, TIA, weakness,
sensory loss
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Diagnostic Procedure(s) Ordered
Management Options Selected
•
Cardiovascular imagine studies
with contrast with identified risk
factors
•
Elective major surgery (open,
percutaneous or endoscopic) with
identified risk factors
•
Cardiac electrophysiological tests
•
•
Diagnostic endoscopies with
identified risk factors
Emergency major surgery (open,
percutaneous or endoscopic)
•
Parenteral controlled substances
Discography
•
Drug therapy requiring intensive
monitoring for toxicity
•
Decision not to resuscitate or to
de-escalate care because of poor
prognosis
•
PROPRIETARY AND CONFIDENTIAL
Evaluation and Management Codes
97 WORKSHEET
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PROPRIETARY AND CONFIDENTIAL
History
Chief Complaint: “Reason patient is being seen”
•
You ALWAYS need the Chief Complaint. State why you are seeing the patient. Don’t say “follow-up”. The auditor
needs to know “follow-up for…”.
•
WITHOUT A CHIEF COMPLAINT THERE IS NO ELEMENT OF HISTORY
History of Present Illness (HPI) elements:
•
Location – Where is the pain or problem?
•
Quality – Color of a mole? How something feels?
•
Severity – How bad is the pain?
•
Duration – How long have you been experiencing this pain or problem?
•
Timing – When did this pain or problem start or occur?
•
Context – Where were you and/or what were you doing when pain/problem occurred?
•
Modifying Factors – What makes the pain worse or better? What information would modify how the provider will
treat this patient?
•
Associated Sign/Symptoms – Are you experiencing any other signs or symptoms?
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PROPRIETARY AND CONFIDENTIAL
History (continued)
Review of Systems (ROS):
• Need 10 but can use 3 with added statement “All Other Systems Negative”
Past Medical, Family and Social History (PFSH):
• Need all except for follow up visits, subsequent visits in hospital, etc. For those subsequent visits, you can
ask the patient if there has been any change since their last visit and use the statement:
“PATIENT’S PAST MEDICAL, FAMILY OR SOCIAL HISTORIES WERE REVIEWED AND THERE HAS BEEN NO CHANGE
SINCE THE LAST VISIT”.
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PROPRIETARY AND CONFIDENTIAL
Physical Exam
For Comprehensive you need 9 systems with two elements mentioned in each system
Reminders/Frequent Audit Findings:
1.
Pedal Pulses – Cardiovascular System not Extremity
2.
Neck: Comment on Neck and Thyroid i.e. No Goiter
3.
Psychiatric: Very overlooked system – usually combined in the Constitutional. (Mood, judgement,
orientation)
4.
HEENT is actually 3 separate systems as it relates to coding. Eyes, Ears, and Neck – two comments in each
– three systems covered.
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PROPRIETARY AND CONFIDENTIAL
Medical Decision Making
•
Amount and/or Complexity of Data to be Reviewed
•
Number of Diagnoses or Management Options
•
Risk of Complications and/or Morbidity or Mortality
•
Type of Decision Making
The more documentation in the Assessment and Planning part of your notes, the better you will be able to
prove your case if the auditor finds you didn’t have a very high score in this area. Showing your labs, tests
and/or x-rays studied and reviewing of all medications and then the changes and planning of what that patient
now needs will help you have a very good record for the auditor to view.
If all the criteria are met in each category here, you should be able to code your visit higher and the
reimbursement is going to be much better for you.
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PROPRIETARY AND CONFIDENTIAL
Office Coding
Established Patient Criteria
• Established Patient is defined as a patient that has been seen within the past three years by a group physician. The
encounter could have been inpatient and/or outpatient.
• Example: If a patient was seen in 2012 by Dr. A, the patient returns in 2014 to see Dr. B. The patient is an
ESTABLISHED patient.
• Example: If a patient was seen in January 2012 by Dr. A and returns in February 2016 to see Dr. B, the patient is then
considered a NEW patient and is eligible for either a consultation or new patient code.
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PROPRIETARY AND CONFIDENTIAL
Chief Complaint and History of Present Illness
Chief Complaint/Reason for Consult
◦ Chief complaint must be documented. The CC is usually stated in the patients own words describing a symptom,
problem, condition, diagnosis, or reason for the encounter.
History of Present Illness
◦ The HPI is a chronological description of the development of the patient’s present illness from the first sign and/or
symptom or from previous encounter to the present.
◦ HPI elements include:
◦ Location; For example “chest” pain, sore “knee”, “abdominal” pain
◦ Quality; How it looks or feels
◦ Severity; Scale of 1 to 10
◦ Duration; Time regarding when the complaint first occurred.
◦ Timing; When or at what frequency, i.e. “intermittent”, “constant”, lasted 5 minutes
◦ Context; What the patient was doing or when does it occur
◦ Modifying factor; What makes it better or worse
◦ Associated signs and symptoms; Any associated or secondary complaints
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PROPRIETARY AND CONFIDENTIAL
Past, Medical, Family and Social History
•Past Medical History (PMH) – The patients past experience with illness, injuries and treatments
•Family History (FH) – A review of medical events in the patients family, including diseases which my be
hereditary or place the patient at risk
•Social History (SH) – an age-appropriate review of past and current activities
Important tidbit:
A PFSH 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. The review and update may be documented by;
There has been no change in the information; and noting the date and location of the earlier PFSH.
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PROPRIETARY AND CONFIDENTIAL
Review of Systems
The Review of Systems is the subjective inventory of body systems through a series of questions to identify and signs or symptoms that the patients has been
experiencing. These systems include:
• Constitutional
• Eyes
• Ears, Nose, Mouth, Throat
• Respiratory
• Cardiovascular
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Integumentary (skin, breast)
• Neurological
• Psychiatric
• Endocrine
• Hemotologic/Lymphatic
• Allery/Immunologic
20
Review of Systems Continued
An important tidbit to remember:
If a review of systems is unobtainable due to the patients condition i.e intubated, mentally challenged, then
documenting “Unable to obtain due to” the patients status, will justify as a complete ROS.
Also:
It is permissible to obtain a complete ROS for the remaining systems by documenting 3 systems, then make a
notation indicating “all other systems reviewed and are negative”. This phrase indicated that the 10 systems
were reviewed and any pertinent negative or positive findings are documented in the note.
21
Elements required for a physical examination
• Most orthopedic surgeons use the Musculoskeletal Single Specialty Examination (MSSE), which includes both a general examination and
six musculoskeletal areas: neck, back, right and left upper extremities, and right and left lower extremities.
• Each examined area should be described in the report.
• Elements to be examined:
¨ Gait ( ... ability to exercise)
¨ Palpation Digits, Nails (i.e. cyanosis, clubbing)
¨ Head/Neck: Inspect, Palp
¨ Head/Neck: Motion (+/-pain, crepit)
¨ Head/Neck: Stability (+/-lux, sublux)
¨ Head/Neck: Muscle strength & tone
¨ Spine!Rib/Pelv: Inspect, Palp
¨ Spine!Rib/Pelv: Motion
¨ Spine!Rib/Pelv: Stability
¨ Spine!Rib/Pelv: Strength and tone
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PROPRIETARY AND CONFIDENTIAL
Elements required for physical examination
¨ R.Up Extrem: Inspect, Palp
¨ R.Low Extrem: Inspect, Palp
¨ R.Up Extrem: Motion (+/-pain, crepit)
¨ R.Low Extrem: Motion (+/-pain, crepit)
¨ R.Up Extrem: Stability (+/-lux, sublux)
¨ R.Low Extrem: Stability (+/-lux, laxity)
¨ R. Up Extrem: Muscle strength & tone
¨ R.Low Extrem: Muscle strength & tone
¨ L.Up Extrem: Inspect, Palp
¨ L.Low Extrem: Inspect, Palp
¨ L.Up Extrem: Motion (+/-pain, crepit)
¨ L.Low Extrem: Motion (+/-pain, crepit)
¨ L.Up Extrem: Stability (+/-lux, sublux)
¨ L.Low Extrem: Stability (+/-lux, sublux)
¨ L.Up Extrem: Muscle strength & tone
¨ L.Low Extrem: Muscle strength & tone
23
Physical exam requirements cont...
Musculoskeletal Examination System/Body Area Elements of Examination
• Constitutional: Measurement of any three of the following seven vital signs: 1) sitting or standing blood
pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height,
7) weight (May be measured and recorded by ancillary staff do not count patient stated height and
weight) General appearance of patient (eg, development, nutrition, body habitus, deformities, attention
to grooming)
• Cardiovascular: Examination of peripheral vascular system by observation (eg, swelling, varicosities) and
palpation (eg, pulses, temperature, edema, tenderness)
• Lymphatic: Palpation of lymph nodes in neck, axillae, groin and/or other location
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PROPRIETARY AND CONFIDENTIAL
Physical exam component cont.
• Skin: Inspection and/or palpation of skin and subcutaneous tissue (eg, scars, rashes, lesions, cafe-au-lait
spots, ulcers) in four of the following six areas: 1) head and neck; 2) trunk; 3) right upper extremity; 4) left
upper extremity; 5) right lower extremity; and 6) left lower extremity.
•NOTE: For the comprehensive level, the examination of all four anatomic areas must be performed and
documented. For the three lower levels of examination, each body area is counted separately. For example,
inspection and/or palpation of the skin and subcutaneous tissue of two extremities constitutes two
elements.
• Neurological: Notation made on cranial nerves, pathological reflexes, and sensation.
• Psychiatric: Notation of Orientation to time, place, and person, mood and affect (depression, anxiety),
recent, remote memory, and judgement or insight.
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PROPRIETARY AND CONFIDENTIAL
Physical exam component cont.
Content and Documentation Requirements Level of Exam Perform and Document:
•
•
•
•
Problem Focused-One to five elements identified by a bullet.
Expanded Problem Focused-At least six elements identified by a bullet.
Detailed-At least twelve elements identified by a bullet.
Comprehensive-Perform all elements identified by a bullet
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PROPRIETARY AND CONFIDENTIAL
Medical Decision Making
Medical Decision Making is based on three sets of data:
•The number of diagnoses and management options
•The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be
obtained, reviewed, or analyzed
•Risk of complications and/or morbidity or mortality as well as comorbidities
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PROPRIETARY AND CONFIDENTIAL
Number of diagnoses or management options
For each encounter, an assessment, clinical impression, or diagnosis should be documented. These may be
documented regarding the management plans and/or further evaluation.
For a presenting problem with an established diagnosis the record should reflect whether the problem is:
A) Improved, well controlled, resolving or resolved; or
B) Inadequately controlled, worsening, or failing to change as expected
For a presenting problem with an established diagnosis, the assessment or impression may be stated in the
form of differential diagnoses or as a “possible”, “probable”, or “rule out” (R/O) diagnosis.
28
Assessment of risk of complications, morbidity, and/or mortality
o Comorbidities/underlying diseases or other factors that increase the complexity of medical decision making by
increasing the risk of complications, morbidity, and/or mortality should be documented.
o If a surgical or invasive diagnostic procedure is ordered, planned or scheduled at the time of the E/M encounter, the
type of procedure, e.g., laparoscopy, should be documented.
o If a surgical or invasive diagnostic procedure is performed at the time of the E/M encounter, the specific procedure
should be documented.
o The referral for or decision to perform a surgical or invasive diagnostic procedure on an urgent basis should be
documented or implied.
29
Counseling or coordination of care
In the case where counseling and/or coordination of care dominates (more than 50%) of the
physician/patient and/or family encounter (face to face time in the office or other or outpatient setting,
floor/unit time in the hospital or nursing facility), time is considered the key or controlling factor to qualify
for a particular level of E/M service.
If the physician elects to report the level of service based on counseling and/or coordination of care, the total
length of time of the encounter (face to face or floor time, as appropriate) should be documented and the
record should describe the counseling and/or activities to coordinate care.
30
Modifiers
25 - Significant, separately identifiable E&M service by the same physician on the same day of the procedure
or other therapeutic service which has (0-10 day global period). A separate diagnosis is not needed. This
modifier is used on the E &M service.
26 - Professional Component – Certain procedures are a combination of a physician component may be
identified by adding the modifier 26 to the usual procedure number. All diagnostic testing with a technical and
professional component done in an outpatient or inpatient setting must reflect the 26 modifier. The fiscal
intermediary (Part A Medicare) will reimburse the facility for the technical component.
59 - Distinct procedural service - The physician may need to indicate that a procedure or service was distinct or
separate from other services performed on the same day. This may represent a different session or patient
encounter, different procedure or surgery, different site, separate lesion, or separate injury. However, when
another already established modifier is appropriate, it should be used rather than modifier 59.
AI – Principal Physician of Record – Append to Admit Codes (99221 – 99223) if you are the ADMITTING
PHYSICIAN
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PROPRIETARY AND CONFIDENTIAL
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for joining Etransmedia
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