View
217
Download
1
Category
Preview:
Citation preview
Rational Physician Coding for Established
Office Patients
Peter R. Jensen, MD, CPC www.EMuniversity.com
Redac
ted V
ersion
Peter R. Jensen, MD, CPC
For clinically driven E/M coding education, go to www.EMuniversity.com
Rational Physician Coding for Established Office
Patients
Goals
Learn the documentation requirements for established office patientsIdentify the “correct” level of careAvoid undercodingEnsure E/M complianceLearn to use the approved E/M “shortcuts”Keep the focus on patient care
1
Redac
ted V
ersion
$19.28$35.74$58.06$88.12$119.54
Established Office Patients
Most commonly billed CPT codes on the planet99211992992992992
5.2%
56%
49,912,657 Encounters
#2 ranked CPT code
108,985,507 Encounters
#1 ranked CPT code
CompComp99215
ng and/or
co ation of ca
W ing ba ime, no specific documentation requirements for History, Physical and MDM
the otted t AND an haltime ust have be evoted cou ling and co nation o
Coding Based on Time
2
Redac
ted V
ersion
Rational Physician Coding
RiskDataProblems
Primacy of Medical Decision-Making
MDM =
3
Redac
ted V
ersion
Determining the MDM
High Complexity
HighExtensiveExtensive
Moderate Complexity
ModerateModerateMultiple
Low Complexity
LowLimitedLimited
Straight-Forward
MinimalMinimalMinimal
Level of MDM
RiskData Reviewed
Number of Diagnoses
Need 2 out of 3 to qualify for given level of MDM
4
Redac
ted V
ersion
1.
2.
3.
His
Documentation Requirements
40HighCompComp9921525ModDetailedDetailed9921415LowEPFEPF9921310SFPFPF992125NoneNoneNone99211
TimeMDMExamHistoryE/M Code
2 out of 3 key components must qualify
5
Redac
ted V
ersion
99211
Outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal.
CPT Manual
5RequiredMDNo99211TimeMDMExamHistoryE/M Code
Secofrequcode encouReimabout
2 out of 3 key components must qualify
Ti
99211
5RequiredMDNo99211
TimeMDMExamHistoryE/M Code
6
Redac
ted V
ersion
99211
Face-to-face interaction
have to be in the office suite (“incident to”)
99211 Documentation
No specific docu
on patient care
7
Redac
ted V
ersion
99211 Examples
BP
What Does a 99211 Look Like?
After adjusting blood pressure
current medications
8
Redac
ted V
ersion
No specific documentation requirements
NANANA99211MDMExamHistoryTarget Code
99211 Documentation
99211HistoryPhysical ExamMedical Decision-Making
No specific documentation requirements
NANANA99211MDMExamHistoryTarget Code
99211
CC: BP check
Interval History: The patient is
BP were also discussed
“E/M”Substance
9
Redac
ted V
ersion
2 out of 3 key components must qualify
99212
10SFPFPF99212
TimeMDMExamHistoryE/M Code
6 – 11 from any systemsEPF
12 from any systemsDet
1 – 5 from any systemsPF
2 from EACH of NINE systemsComp
BulletsExam
None1BriefEPF
1/32 – 9ExtDet
NoneNoneBriefPF
3/310ExtComp
PFSHROSHPIHx
OR
Requires documentation of qualifying MDM plus either a problem focused history OR a problem
focused exam
Third mfrequecode fencouReimbabout
2 out of 3 key components must qualify
Time required would be 10 minutes
99212
10SFPFPF99212
TimeMDMExamHistoryE/M Code
10
Redac
ted V
ersion
What Does a 99212 Look Like?
You see an otherwise completely healthy 44 YOM with OA controlled with THgrYfo
Self limited
New problework-up pla
New problework-up pla
Establishedworsening
Established
Prob
11
Redac
ted V
ersion
High44High
Need 2 out of 3 to qualify for given level of MDM
d
ing for
gs no
•Rest•Gargles•Superficial dressings
•Laboratory tests •Chest X-rays•EKG/EEG, Echocardiogram
•One self-limited or minor problem, e.g., cold, insect bite, tinea corporis.
Minimal
Management Options
Diagnostic ProceduresPresenting ProblemsRisk
12
Redac
ted V
ersion
Target Code: 99212
40HighCompComp9921525ModDetailedDetailed9921415LowEPFEPF9921310SFPFPF992125NoneNoneNone99211
TimeMDMExamHistoryE/M Code
2 out of 3 key components must qualify
SFPFPF99212
99212
Planning out the Documentation
Are
13
Redac
ted V
ersion
1. What level of care is
documentation
asks?
Rational Physician Coding
SFPFPF99212MDMExamHistoryTarget Code
Ethical Documentation
OR2 out of 3 key components must qualify
A problem focused history requires a brief HPI and no elements of ROS or PFSH
Problem Focused History
Problem Focused Exam
14
Redac
ted V
ersion
MDM
99212 Documentation
99212Problem
MDM
CC: F/U complaints.
2 out of 3 key components must qualify
NoneNoneBriefPFPFSHROSHPIHistory
SFPFPF99212MDMExamHistoryTarget Code
level of history
History
15
Redac
ted V
ersion
CC: F/U OAIE
Physical ExamConstitutional Eyes ENMT Neck
Chest/Breasts
CV GI GULungs
Ta
Tw
•Inspect•Assess
(DOES
Exam
CC: F/U OAInterval History: No new complaints.Ex
Im1.Pl1.2.
Medical Decision-Making
9Targ
16
Redac
ted V
ersion
CC: F/U OAInterval History:
MDMExamHistoryTarget Code
Two out of Three is all you Need For established office patients, only two out of three
ending” might look.
17
Redac
ted V
ersion
CC: F/U OAInterval
2. RTC in six months
2 out of 3 key components must qualify
SFPFPF99212MDMExamHistoryTarget Code
NoneNoneBriefPFPFSHROSHPIHistory
One HPI ElementLocation
Zero Exam Bullets
Alternative Ending: 99212
Any Two will Do The example above qualifies as a 99212 based
change so this still counts as one of our quali-fying key components.
18
Redac
ted V
ersion
Third frequecode fencouReimbabout
2 out of 3 key components must qualify
Tim
99213
15LowEPFEPF99213
TimeMDMExamHistoryE/M Code
2 out of 3 key components must qualify
99213
15LowEPFEPF99213
TimeMDMExamHistoryE/M Code
6 – 11 from any systemsEPF
12 from any systemsDet
1 – 5 from any systemsPF
2 from EACH of NINE systemsComp
BulletsExam
None1BriefEPF
1/32 – 9ExtDet
NoneNoneBriefPF
3/310ExtComp
PFSHROSHPIHx
OR
Requires documentation of qualifying MDM plus either an expanded problem focused history OR an
expanded problem focused exam
19
Redac
ted V
ersion
What Does a 99213 Look Like?
The same patient returns in six months.He stcontrgolf gYou rTID, pthree
Self limited or mi
New problem, adwork-up planned
New problem, nowork-up planned
Established probworsening
Established prob
Problems
To
20
Redac
ted V
ersion
Need 2 out of 3 to qualify for given level of MDM
•Over the counter drugs•Minor surgery, with no risk factors•PT/OT
•Physiologic tests not under stress, e.g., PFTs•Non-cardiovascular imaging studies with contrast
•Two or more self-limited or minor problems•One stable chronic illness•Acute uncomplicated injury or
Low
•Rest•Gargles•Superficial dressings
•Laboratory tests •Chest X-rays•EKG/EEG, Echocardiogram
•One self-limited or minor problem, e.g., cold, insect bite, tinea corporis.
Minimal
Management Options
Diagnostic ProceduresPresenting ProblemsRisk
21
Redac
ted V
ersion
Target Code: 99213
40HighCompComp9921525ModDetailedDetailed9921415LowEPFEPF9921310SFPFPF992125NoneNoneNone99211
TimeMDMExamHistoryE/M Code
2 out of 3 key components must qualify
OR
LowEPFEPF99213MDMExamHistoryTarget Code
99213
Planning out the DocumentationTwo out of
any organ systems
Let’s go for the History First
22
Redac
ted V
ersion
CC: Knee Pain
Interval History: Bilater
for polyarticular joint pain
or myalgias
Two HPI ElementsLocation, Context
One ROSMusculoskeletal
2 out of 3 key components must qualify
LowEPFEPF99213MDMExamHistoryTarget Code
None1BriefEPFPFSHROSHPIHistory
CC: Knee PainInterval
bilateral knee effusionsImpression1. Worsening OA
Plan1. Start Motrin 800 mg TID, prn2. RTC in four months with renal profile and CBC
An EPF Exam requires AT LEAST 6 bullets from ANY organ systems
2 out of 3 key components must qualify
Constitutional Eyes ENMT Neck
Chest/Breasts
CV
Skin
Musculoskeletal
Neurologic
Psychiatric
GI GULungs
1
2
LowEPFEPF99213MDMExamHistoryTarget Code
23
Redac
ted V
ersion
CC: Knee PainInterval History: Bilateral knee pain is no longer controlled with Tylenol. His knees hurt playing golf.
ROS:
Exam:
Impressio1. Wors
Plan1. Start2. RTC
Medical Decision-Making
9921Target
CC: Knee Pain
Interval History: Bilateral knee pain is no longer controlled with Tylenol. His knees hurt playing golf.
R
Ex
Im1.
Pl1.2.
Alternative Ending
T
24
Redac
ted V
ersion
Alternative Ending: 99213CC: Knee PainInterval History:
His knees hurt playing golf.
ee stiffness and decreased n
nee effusions
Impression1. Worsening
Interval History:
MDMExamHistoryTarget Code
Alternative Ending: 99213 The example above qualifies as a 99213 based o
25
Redac
ted V
ersion
Second mfrequentlcode for tencounteReimburabout $8
2 out of 3 key components must qualify
Time required would be 25 minutes
99214
15LowEPFEPF99213
TimeMDMExamHistoryE/M Code
2 out of 3 key components must qualify
99214
25ModDetDet99214
TimeMDMExamHistoryE/M Code
6 – 11 from any systemsEPF
12 from any systemsDet
1 – 5 from any systemsPF
2 from EACH of NINE systemsComp
BulletsExam
None1BriefEPF
1/32 – 9ExtDet
NoneNoneBriefPF
3/310ExtComp
PFSHROSHPIHx
OR
Requires documentation of qualifying MDM plus either a detailed history OR a detailed exam
26
Redac
ted V
ersion
What Does a 99214 Look Like?
rns for follow-up.otrin, but he has BP of 155/80.rvasc 5 mg QD
-up visit in three
MDM Points
Self limited or minor (
New problem, additiowork-up planned
New problem, no addiwork-up planned
Established problem, worsening
Established problem,
PtsProblems/DDx PtsData Reviewed
Total
27
Redac
ted V
ersion
•Over the counter drugs•Minor surgery, with no risk factors•PT/OT•IV fluids, without
•Physiologic tests not under stress, e.g., PFTs•Non-cardiovascular imaging studies with contrast•ABG
•Two or more self-limited or minor problems•One stable chronic illness•Acute uncomplicated injury or illness, e.g., cystitis, allergic
Low
•Rest•Gargles•Superficial dressings
•Laboratory tests •Chest X-rays•EKG/EEG, Echocardiogram
•One self-limited or minor problem, e.g., cold, insect bite, tinea corporis.
Minimal
Management Options
Diagnostic ProceduresPresenting ProblemsRisk
Need 2 out of 3 to qualify for given level of MDM
28
Redac
ted V
ersion
Target Code: 99214
40HighCompComp9921525ModDetailedDetailed9921415LowEPFEPF9921310SFPFPF992125NoneNoneNone99211
TimeMDMExamHistoryE/M Code
2 out of 3 key components must qualify
OR
LowEPFEPF99213MDMExamHistoryTarget Code
99214
Planning out the DocumentationTwo out of three key co
any
organ systems
In this case, it would be impossible to obtain a detailed
29
Redac
ted V
ersion
9214Detailed HistoryDetailed ExamModerate MDM
CC: Follow-up OAInterval
MDM
Contains no elements of HPI, ROS or PFSH and therefore does not qualify for ANY level of history.
CC: Follow-up OAInterval History: No new complaints.
2 out of 3 key components must qualify
Physical ExamConstitutional Eyes ENMT Neck
Chest/Breasts
CV
Skin
Musculoskeletal
Neurologic
Psychiatric
GI GULungs
Detailed Physical Exam requires at least 12 bulletsfrom ANY organ systems
Gen: NAD, conversantVitals: 155/80, 65,
30
Redac
ted V
ersion
2 out of 3 key components must qualify
Time required would be 40 minutes
99215
40HighCompComp*99215
TimeMDMExamHistoryE/M Code
CC: Follow-up OAInterval History: No new complaints.
2 out of 3 key components must qualify
Medical Decision-Making
Gen: NAD, conversantVitals: 155/80, 65, 98.6Neck: No JVD or carotid
renal profile
Hi
M
Lo
S
RiskData PtsProb PtsMDM
ModDetDet99214MDMExamHistoryTarget Code
*In this case, clude an exte
31
Redac
ted V
ersion
2 out of 3 key components must qualify
99215
40HighCompComp*99215
TimeMDMExamHistoryE/M Code
6 – 11 from any systemsEPF
12 from any systemsDet
1 – 5 from any systemsPF
2 from EACH of NINE systemsComp
BulletsExam
None1BriefEPF
1/32 – 9ExtDet
NoneNoneBriefPF
3/310ExtComp
PFSHROSHPIHx
OR
Requires documentation of qualifying MDM plus either a comprehensive history OR a
comprehensive exam
99215: What it Takes
32
Redac
ted V
ersion
MDM Points
Self limited
New problwork-up pl
New problwork-up pl
Establisheworsening
Establishe
Pro
•Drug therapy requiring intensive monitoring for toxicity•Obtain DNR or de-escalate care
factors•Cardiac EP studies•Diagnostic endoscopies, with identified risk factors
•Onwith•Acute or chronic illness or injury, which poses a threat to life or bodily function•An abrupt change in neurological status
High
•Onexac•Tw•Ununce
Moderate
•Twmin•On•Acillnerhini
Low
•Onprobtinea
Minimal
Risk
33
Redac
ted V
ersion
Calculating the Overall MDM
Min0 - 11SF
RiskData Problems MDM Complexity
Nee
Target Code: 99215
40HighCompComp9921525ModDetailedDetailed9921415LowEPFEPF9921310SFPFPF992125NoneNoneNone99211
TimeMDMExamHistoryE/M Code
2 out of 3 key components must qualify
34
Redac
ted V
ersion
OR
HighCompComp*99215MDMExamHistoryTarget Code
99215Planning out the DocumentationTwo out of three key components requiredWe know
99215 Example
2 out of 3 key components must qualify
99215Comprehensive HistoryComprehensive ExamHigh Complexity MDM
35
Redac
ted V
ersion
CC: Chest Pain
HPI: Patient complains of intermittent chest pain, which began about three weeks ago and
2 out of 3 key components must qualify
2/310ExtendedComp*PFSHROSHPIHistory
HighCompComp*99215MDMExamHistoryTarget Code
For established office patients, only a modified co
shorthand, “All other sys-
tems reviewed and are negative.”
36
Redac
ted V
ersion
2 out of 3
• Assessment of extremity edema
37
Redac
ted V
ersion
2 out of 3 key components must qualify
Medical Decision-Making
Assessment: 1. Atypical chest pain 2. Etiology may be GI but need to rule out CAD3. Stable HTN4. Stable OA
Plan: 1. Start trial of Protonix 40 mg PO QD2. Nuclear stress test in am. 3. Continue PRN Motrin for
dimensions are needed to qualify for any given level of complexity.
38
Redac
ted V
ersion
99215
Target Code History Exam MDM 99215 Comp* Comp High
Requires two out of three qualifying key components
CC: Chest Pain
Interval History: The patient’ complains of intermittent chest pain which began about three
weeks ago and is described as burning
have moderate risk.
0.7
137 98
14
24
12 36
101 4.1
MDM Prob Pts Data Pts Risk
SF ≤ 1 ≤ 1 Min
Low 2 2 Low
Mod 3 3 Mod
High ≥ 4 ≥ 4 High
EKG shows NSR with normal axis and no diagnostic ST changes.
39
Redac
ted V
ersion
CC: Chest PainHPI: Patient complains of intermittent chest pain, which began about three weeks ago and is desPMH: Positive for OA SH: Remarkable for o
Alternative Ending
ROS: Complete ROS
Complexity MDM
HighMDM
High≥4≥4
Mod33
Low22
O ify for any given le ample qualified w O am instead of th T for this alterna-ti
40
Redac
ted V
ersion
Alternative Ending: 99215
Target Code History Exam MDM 99215 Comp* Comp High
Requires two out of three qualifying key components
CC: Chest Pain
Interval History: The patient’
only
have moderate risk.
0.7
137 98
14
24
12 36
101 4.1
MDM Prob Pts Data Pts Risk
SF ≤ 1 ≤ 1 Min
Low 2 2 Low
Mod 3 3 Mod
High ≥ 4 ≥ 4 High
EKG shows NSR with nor-mal axis and no diagnostic ST changes.
Bullets Used Constitutional • Three vital signs • General appearance Eyes • Exam of sclerae/lids • Exam of pupils/irises Musculoskeletal • Exam of spine/ribs • Exam of digits Neck • Exam of neck • Exam of thyroid Lungs • Auscultation of lungs • Assess respiratory effort CV • Auscultation of heart • Palpation of heart Abdomen • Abdominal Exam • Exam of liver/spleen Skin • Inspection of skin • Palpation of skin Psyche • Assessment of affect • Assessment of orientation (Qualifies as a comprehensive exam)
41
Redac
ted V
ersion
Is it Okay to Use Templates?
Templates are acceptable The examiner
(See the next page for our E/M University template for established office patients)
42
Redac
ted V
ersion
E/M University: For practical E/M coding education, visit us at www.EMuniversity.com
PF: 1 - 5 bullets (99212) EPF: 6 - 11 bullets (99213) Det: 12 bullets (99214) Comp: 2 bullets from EACH of NINE systems (99215)
See also dictated note from today
Comp: ≥ 4 HPI elements or status of 3 problems, plus 10 ROS plus 2 out of 3 components of PFSH—Okay to review prior PFSH to qualify (99215)
Minimal Risk Low Risk Moderate Risk High Risk
•One self limited problem (e.g., cold, insect bite)
• Two self-limited problems • One stable chronic illness • Acute uncomplicated illness
(e.g., cystitis/rhinitis) • OTC drugs
• Mild exacerbation of one chronic illness • Two stable chronic illnesses • Undiagnosed new problem • Acute illness with systemic symptoms
(e.g., pyelonephritis, colitis) • Prescription drug management
• Severe exacerbation of chronic illness • Illness with threat to life or bodily function • Abrupt change in neurological status (e.g., TIA/weakness) • Parenteral controlled substances • Decision for DNR or to de-escalate care • Drugs requiring intensive monitoring for toxicity
Constitutional: NAD, conversant, pleasant (appearance) BP HR RR T
Exam Findings & Data Reviewed
Eyes: Anicteric sclerae, moist conjunctiva, no lid-lag PERRLA fundi clear, disc margins sharp
ENMT: NC/AT oropharynx clear; no erythema/exudate normal hearing normal auditory canals/TM’s intact
Neck: Supple, FROM no thryomegaly or carotid bruits
Lungs: CTA and percussion normal respiratory effort
CV: RRR, no MRGs normal PMI No LE edema ABD: Soft, NABS, no masses no HSM no hernias
Skin: Normal temperature, tone, texture and turgor; no induration or subcutaneous nodules no rash, lesions or ulcers Psych: A & O X 3 appropriate affect intact judgment
Neuro: CNs II - XII intact no focal sensory deficits
2 out of 3 Key Components Required E/M Hx Exam MDM Time
99212 PF PF SF 10 99213 EPF EPF Low 15 99214 Det Det Mod 25 99215 Comp Comp High 40
______________________________________ Signature
Data Reviewed Pts Review and/or order clinical lab tests 1
Review and/or order radiology tests 1
Review and/or order medical test (PFTs, EKG, echo, cath)
1
Discuss test with performing MD 1
Review of image, tracing, specimen 2
Decision to obtain old records 1
Review and summa-rize old records 2
4 3 1 2 1 Problem Points
Esta
blis
hed,
stab
le
Patient: Date:
CC: Interval History:
Medications: reviewed; see today’s medication list for details (counts as ONE element of PMH). Pertinent PFSH:
Comprehensive PFSH taken during a previous encounter was re-examined and reviewed with the patient. For details, refer to the note in this chart dated:
PF: 1 -3 HPI elements or the status of 1 - 3 problems (No ROS required)(99212)
EPF: 1 - 3 HPI elements or the status of 1 - 3 problems plus at least 1 ROS (99213)
Det: ≥ 4 HPI elements or the status of 3 problems, 2 - 9 ROS plus at least 1 element of PFSH (99214)
ROS (-) Positive Findings Constitutional
Eyes
ENT
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Skin
Musculoskeletal
Psychiatric
Endocrine
Neurological
Hem/Lymphatic
Allergic/Immun
H
is
to
ry
E s t a b l i s h e d O f f i c e V i s i t
P
hy
si
ca
l
MD
M
(three vital signs)
1. 2. 3. 4. 5.
Assessment & Plan
New
, fur
ther
w/u
is p
lann
ed
New
, no
furth
er w
/u p
lann
ed
Esta
blis
hed,
not
con
trolle
d
99212
99213
99214
99215
Self-
limite
d or
min
or (m
ax 2
)
MDM Prob Pts Data Pts Risk E/M SF ≤ 1 1 Min 99212 Low 2 2 Low Mod 3 3 Mod 99214 High ≥ 4 4 High 99215
Only 2 out of 3 components required
99213
See also dictated note from today
See also dictated note from today
Redac
ted V
ersion
A “Routine Office Patient”
YoanAftprone
44
Redac
ted V
ersion
A Detailed History requires 4 HPI elements (or the status of 3 chronic problems), 2 – 9 ROS and 1 PFSH
A Detailed Exam requires a total of 12 bullets from ANY organ systemsOR
2 out of 3 key components must qualify
99214
2 out of 3 key components must qualify
How would it look using a template?
ModDetDet99214MDMExamHistoryTarget Code
History
John Doe
The patient’s HTN and
1/3PFSHROSHPIHistory
45
Redac
ted V
ersion
Physical Exam
X
130/80X
X X
NAD; conversant130/80
MDMExam
Medical Decision-Making
s with BMP, nd CBC
rent Rx
84
7
Moderate MDM
ModDetDet99214MDMTarget C
2 st qualify
46
Redac
ted V
ersion
History Physical MDM
Select the “correct” level of carePerform the documentation in a purpose-driven manner“Less is More”It’s okay to use templatesRelax and let the patient dictate the level of care
Peter R. Jensen, MD, CPC
Online and On-site Physician-to-Physician E/MCoding Education
1-888-U-EM-CODE
pjensen@emuniversity.com
Practical E/M Coding Education
www.EMuniversity.com
47
Redac
ted V
ersion
Recommended