Gray Areas of E/M and Where to Find the Answers
Questions
Answers
Webinar Subscription Access Expires December 31.
How long can I access the on demand version?
You will find that in the same instructions box you utilized
to access this presentation. Subscription access expires
December 31, individual purchases will not expire for at
least two years. If you are the purchaser, you can find your
information through following these steps: 1. Go to
http://www.aapc.com & login 2. Go to Purchases/Items 3.
Click on “Webinars” tab 4. Click on “Details” next to the
webinar 5. Find the instructions box in the middle of the
page. Click on the link to the item you need (Presentation,
MP3 file, Certificate, Quiz)
Where can I ask questions after the webinar?
The online member forums, where over 100,000 AAPC
members have access to help each other with all types of
questions. *Forum Posting Instructions* 1.Login to your
online account 2.In the middle of the page you will see
“discussion forums” 3.Click on “view all” – top right hand
side 4.Select “general discussion” under “medical coding”
unless you see a topic that suits you more – 5.On the top
left side of the forum box, you will see a blue button, “new
thread” – click on that 6.Type your question and submit
7.Check back in that location for answers as you please
For an established patient, which of the 2 of 3 key
components do you recommend be used to select E/M
level?
There is not requirement by the DGs or by CPT for this. In
most cases, since the NPP will drive the medical need for
the visit, it is MDM and then one other.
Do they make any check off forms to aid in coding for
E&M?
There are many forms used by auditors that are based on
the 95 and 97 DGs. The Marshfield clinic model is the
most common
Points are given for the both type of dx (minor, new or est.
problem--and the severity or need for workup) The use of
audit forms is payer specific. Many list their criteria on
their websites.
There are many forms used by auditors that are based on
the 95 and 97 DGs. Some of the MACs publish theirs for
use by the public.
In most cases, a Comprehensive exam may be performed
for every patient but the patient /payer should not be billed
for what was not medically needed.
When using the Marshfield clinic model tool, do you give
points for diagnoses in the medical decision making are
when there is not a plan for that diagnosis?
As a former Medicare employee, we were told to use the
E&M coding sheet found at CMS website.
What should you do when you have a physician that has a
template and documents a comprehensive Physical Exam
for every patient?
How do you define baseline health?
I am not sure what you mean by baseline health. A
baseline audit is a first audit to explore the accuracy. A
follow up audit would typically follow a baseline to ensure
continued accuracy and to make sure education was
effective if it was given.
We have a provider who feels managing 3 or more chronic
problems in a 3 month follow up should be 99213. The
documentation meets a 4. Do you have any suggestions or
know of any resources to assist us? We have agreed if she
is seeing a patient for a 3 month follow up and no changes
in meds are made and the chronic problems are all stable
we will bill a level 3. If any medications are being changed
or adjusted we go with a 4. Thanks
A level 4 requires a patient with problem/s that are of a
higher level of concern. In some cases 3 chronic
conditions, by nature, will require close observation not
typically seen in a more controlled patient. The physician
is best qualified to determine if the patient is at a higher
risk or not.
We are a rural health clinic that has visiting specialist that Typically the global payment includes all post operative
come each month to see pts. Many of these do their
care unless it was split in advance.
surgeries at their "main" hospital since our hospital is CAH
and does not do surgeries. When they do their follow up at
our clinic, is this considered part of the global package?
There has been discussion going both ways since it's a
different NPI being used, etc... my main concern is my
orthopedic and my OB/GYN who delivers at another
facility and we have no part of the delivery. Any help
would be appreciated.
How do we discern and explain to providers that a
comprehensive exam is not medically needed? Many
providers (i.e., pediatrics) say a comprehensive exam is
needed because a child cannot relay symptoms, although
the final dx may be otitis media.
A physician is best qualified to determine the medical need
for an exam. The physician must understand that a medical
peer would have to agree with him/her that it was needed
based on the NPP and the MDM.
In regards to question stating that comprehensive exam
A medical peer would have to agree on an audit. As a
should not be billed if not medically necessary, how would coder, you must make sure the MD is aware of that.
you advise a physician that the exam they performed was
not medically necessary? I know I'm not an md and can't
say this wasn't necessary.
Under the 97 guidelines for the Musculoskeletal system
Yes. A simple notation of normal or negative is fine.
exam, for the bullet "Assessment of muscle strength and
tone with notation of any atrophy and abnormal
movements", would "musculoskeletal- Is there presence of
abnormal movement? No" be sufficient to receive credit for
that bullet?
My gray area is in office procedures performed with e&M., Was the E/M separately identifiable at all? I would need to
i.e. nasal endoscopy for chronic sinusitis. Physician states take a look at the document to better respond.
in order to better view as the reason. I am thinking they
need to state why they were unable to adequately visualize
what they needed with a mirror. Should they also state
"performed to examine the ostia or middle meatus" or
anterior rhinoscopy with decongestion of the nasal
membrane does not provide an adequate evaluation .
FYI - Palmetto GBA no longer has the MAC contract for
That must be very recent news! Thank you for sharing. I
Hawaii (including Guam), No & So California and Nevada. had not yet heard.
Work is transitioning to Noridian Healthcare Solutions
(formerly Noridian Administrative Services) in Fargo, ND
Do you have a resource with clinical examples of when
critical care is supported?
I use the CPT and CMS guidelines and the policies of the
practice, particularly with peds.
We started EMR in April, and I often see where a patient
Dx codes are the symptoms unless a definitive Dx is
comes in for say two things like a headache and a leg rash. documented
In the exam and ROS the provider mentions both but for
the final assessment they only give me one of the diagnosis
and not the other. They say to just use the symptoms, I say
they need to amend the note...who's right?
For the Rural Health question, so it doesn't matter if it is
separate facility site for the surgery and separate follow up
site, it would follow under the global because of the
provider?
Would you please write out the explanation of the 4x4
model?
Continuing the Rural Health...for the OB provider, since we
don't do the delivery how do we get paid then for all the
prenatal visits up to the surgery if most of the insurances do
a lump payment with the surgery and prenatal visits being
all inclusive?
yes. The global fee includes post op follow up.
I have a provider that is seeing patients to "review labs"
that he ordered. He then documents a comprehensive
examination. Do you have any resources I could point to
that show that the presenting problem/issue should guide
the level of exam conducted?
Yes, the CPT in the E/M section under the instructional
notes on the NPP Nature of the Presenting problem.
The 4 x 4 is the need to exam 4 items in 4 organ systems.
You can read more on the Novitas website
The delivery in this case should be billed with the delivery
code and antepartum and post op OB is separately coded by
the different providers
We have many physicians that document follow up as a cc. Yes. It is not necessary to document a separate CC. The
They give no further detail on what they are following up reason for the visit, however, must be readily reflected in
until you get to the present illness. Is this acceptable?
the note. CC, ROS and PFSH may be listed as separate
elements of history, or
they may be included in the description of the history of the
present illness
Is it no true that even if the medical decision making is a
Yes. The documentation requirements for a new patient
level 4, if the physician documents a level 3 history he must require you to default to the lowest key component
code a level 3 or if they forget 1 element in the exam which documented.
brings the documentation down to a level 3, - we must code
a level 3.
Can you point to written validation of what supports a
further "Workup"?
I like your tip about having a medical peer agreeing about
the exam compenent. Do you have any tips for a payor
trying to decide if a comprehensive exam was medically
necessary based on documentation alone?
When and if WNL acceptable in the ROS
Work-up is a clinical term, not a coding term, that implies a
problem must be further evaluated before a final diagnosis
and/or plan can be made.
Most payers have a CMO or other Medical Director on
staff who would be typically be available to ask questions
of.
The patient's positive responses and pertinent negatives for
the system related to the problem should be documented in
the ROS. WNL is typically seen with elements of Exam,
which is also allowed.
When counting the number of diagnosis do you take
everything in the note as a whole? Ex/ removed a lesion
and treating a rash. Correct to use the entire note for this
total.
For the purpose of E/M coding, you should count the
diagnoses recorded in the record to #of Dx and Tx options-which are sometimes symptoms and differentials. The note
might be poorly written---if you are unsure if a symptom
should be included: query the Dr.
In our EMR/EHR the chief complaint is set up so that the
nurse enters this when she is doing the nursing assessment.
I have argued that it has to be enter under/by the physician.
Am I being over picky?
The ROS and/or PFSH may be recorded by ancillary staff
or on a form completed by the patient. To document that
the physician reviewed the information, there must be a
notation supplementing or confirming the information
recorded by others. Typically the HPI is thought to be
required by the provider directly.
If a patient has multiple co-morbidities such as DM and are
being treated at a Wound clinic but they have 1 non healing
ulcer is there a way to calculate the new problem as a value
of 4 with # of dx and management options if there is no
additional workup planned? I am referring to the "New
problem, no addtl workup planned" where the # of
Occurrences you can count is 1 x value of 3. I hope this
makes sense. Thanks
A new final diagnosis counts typically as 3 points. The
additional diagnoses considered (such as the documented
DM) would count as 1 additional point for a total of 4
points (unless documented as not well controlled ...and then
the DM would count as 2 for a total of 5)
Yes lets say the visit is separately identifiable. I'm focusing The medical record must support the need to do the
on the medical necessity for the nasal endoscopy. I feel
procedure ---if documentation is weak, it might be
they need to state why the felt it necessary to move from a challenged in an audit.
mirror exam to a endoscopy. I feel that just stating "to
better visualize" may not be enough. Your thoughts?
What I just heard you say is if a rx is wrote for that
encounter it's a level 4?
How many points would you recommend to assign for a
cancer patient on chemotherapy seen in clinic for regular
followup. No mentioning of worsening or improving, but
the patient is on ongoing treatment.
Would it be reasonable for a physician to do a complete
ROS and PFSH if the patient has not been seen in over 6
months even if they are coming in for a check up or would
1 year or more be more reasonable. Lets say for something
like diagnosis of laryngeal reflux
A medication that requires a prescription and medical
management is classified on the CMS Table of Risk as
"moderate"
Without documentation of specific exacerbation, chronic
conditions are 1 point each.
Only a physician can comment on the medical need. If you
are concerned, discuss with the physician the need for
him/her to be confident a peer would agree with them. This
is the best way to avoid a problem if audited.
If a provider writes, "no family history on file", and patient Yes, Unless it was unobtainable from the patient.
is clearly 99223, does the charge drop to 99221, even
though all other documentation supports 99223?
Would you please comment on if immunizations are
considered Rx drug management? Also, what about when
provider "prescribes" a drug that is also OTC. Thanks!
FDA defines prescription drugs. OTC drugs are not
prescribed by the Dr but are obtainable directly to the
public from the manufacture.
If the patient comes in with headache and leg rash, but
provider only assess or documented headache with in
impression do you need to list sign and symptom? Why is
that necessary for the final charge if the provider did not
address?
For the purpose of E/M coding, you should count the
diagnoses recorded in the record to #of Dx and Tx options-which are sometimes symptoms and differentials. The note
might be poorly written---if you are unsure if a symptom
should be included: query the Dr.
How many points would you recommend to assign in Table This is 1 point. If other diagnoses are documented, such as
A of MDM (Number of Diagnoisis and Treatment Options) weight loss, they would be counted, too.
for a cancer patient on chemotherapy seen in clinic for
regular followup. No mentioning of worsening or
improving, but the patient is on ongoing treatment.
In regards to the situation when a patient is unable to give a I have not found this to be the case withy WPS. However
history....Our MAC (WPS) indicates that we may not give they do state the physician should document the reason the
comprehensive credit in these situations.
patient is unable to provide history and document his/her
efforts to obtain history from other sources. This could
include family members, other medical personnel,
obtaining old medical records (if available) and using
information contained therein to document some of the
history components (past medical, family, social).
For 99231-99233, when a CC or reason for visit is not
stated, can you assume the assessment as being the reason
for the visit?
What about a medical genetics provider using time based
billing for most visits due to the nature of counseling on
testing, results, implications for life etc...thanks!
No. The reason for the visit must be reflected in the note.
What does NPP stand for in reference to "The CPT on the
NPP"? Thanks
NPP is the Nature of the Presenting Problem
Time is not typically the key indicator for E/M codes.
Other codes may be more appropriate. Time is reserved for
the case where a patient visit unusually took longer due to
(usually) a new diagnosis where there are a lot of questions
and the physicians schedule is thrown off by the
unexpected time involved.
Please send a link for the scale of 1-5 pain
http://livewithchronicpain.com/wpcontent/uploads/2011/10/painmeasurementscale.jpg
For a resolving problem focused established patient visit,
with comprehensive history, comprehensive exam, and only
2 of 3 key components required, what of the 2 of 3 would
you recommend??
We shouldn't use "med refills" or "review labs" as chief
complaint right? I have seen this lately.
If a patient states that they have no known drug allergies do
you count this under ROS or past medical history?
In most cases, it is MDM and then one of the other two
With regards to the exam, do the providers need to
document an element of each ENT in order to count this
system, or is one element of ENT sufficient? Ex:
Patient is pregnant with diabetes, and insulin needs
adjustments due to unstable blood surgar on her glucose
log. Would this fall under moderate because there is a
change in Rx management? Thank you.
If a physician lists previous labs on the EHR system for
office visits, should credit be given for reviewing the same
result on different visits?
I am reading increasing numbers of resources that indicate
routine use of the same E/M code is a red flag. Do you find
that there might be some specialties that for new patient
visits, would consistently see level 4 visits?
This is sparse but in of itself not a precluder for a level of
service.
It depends on the context. If the question relates to
symptoms or past history. Different payers interpret this
differently.
One is enough to give credit for the organ system.
This qualifies for a moderate level of Overall Risk
Not usually unless they are summarized and medically
necessary
There are typically bell curves with the majority of codes
resting over the 3 or 4 based on the specialty. The correct
code is based on the unique patient encounter.
Can we share this handout with fellow coders, or is it only Yes
for my personal use?
Response to the question regarding est pt with comp hx
This should be considered per your policies. CMS takes
comp pe and the mdm...the mdm is not typically counted. not position. However, if MDM is not supported---the
nothing from medicare states you should use mdm. mdm claim is questionable for medical need.
could end up lower than what the presenting problem could
represent, which might require comp hx and comp pe to
evaluate.
We have many physicians who are under the assumption
that if they treat an acute pharyngitis or otitis media with
prescription drug medication and they do a detailed ENT
exam, they can code a 99214 if it was a new problem to the
examiner. We are concerned about medical necessity for
coding a 99214 vs a 99213. What is your opinion?
A level 4 requires a patient with problem/s that are of a
higher level of concern. Some cases. by nature, will require
close observation not typically seen in a more controlled
patient. The physician is best qualified to determine the
need for a more extended exam. The need to follow up
with the patient is typically a key indicator for medical
necessity required by a level 4. If you need to see the
patient sooner than routine you are usually in line with a
level 4.
What is the time frame for "new problem to the examiner"
in medical decision making? If a child was seen for
pharyngitis a year ago, and now comes in with the same
diagnosis, would this be considered a new problem because
of the lapse in time?
The "new" reference is to the MD …not the patient. It is
the first time the physician sees the problem. A recurrence
of a resolved problem a year later is typically a new
problem.