Version Date 2-4-21

Tip Sheet: Evaluation & Management Services (Excluding Office/Outpatient Services CPT codes 99202-99215 and Critical Care CPT Codes 99291-99292) :::::::::EFFECTIVE JANUARY 1, 2021

Phone: 773-834-1143 compliance@bsd.uchicago.edu

E/M Patient Types New Patient: One who has not received professional services from the physician/QHCP or another physician/QHCP of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

Established Patient: One who has received professional services from the physician/QHCP or another physician/QHCP of the exact same specialty and subspecialty who belongs to the same group practice, within the past 3 years.

Note, for Medicare E/M services, the same specialty is determined by the practitioner’s primary specialty enrollment in Medicare. Recognized Medicare specialties can be found in the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 26.

Selecting the Level of E/M Service Generally speaking, medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of the CPT code. It would not be medically necessary or appropriate to bill a higher level of E/M 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. Documentation should support the level of service reported. When selecting the level of E/M service, history, exam, and medical decision making are considered the key components. An exception to this rule is in the case of visits that consist predominantly of counseling or coordination of care; time may be used in such cases. History—Comprised of history of present illness (HPI), past medical, family, social history (PSFH), and review of systems (ROS). There are 4 recognized levels: Problem focused, Expanded problem focused, Detailed, and Comprehensive. Exam—There are 4 types of exam: Problem focused, Expanded problem focused, Detailed and Comprehensive. Medical Decision Making (MDM) —Comprised of

The number of possible diagnoses and/or management options that must be considered;

The amount and/or complexity of medical records, diagnostic tests and/or other information that must be obtained, reviewed and analyzed; and

The risk of significant complications, morbidity, and/or mortality, as well as comorbidities, associated with the patient’s presenting problem(s), the diagnostic procedure(s), and/or the possible management options.

There are 4 types of MDM: Straightforward, Low complexity, Moderate complexity and High complexity. See pages 2-4 for a detailed description of how to calculate the level of E/M service using history, exam and MDM.

Time: Time may be used to select the E/M code level when counseling* and/or coordination of care dominates (more than 50%) the service. The following time may be counted.

Face-to-face time spent in outpatient consultation services (99241-99245): This includes only the time spent by the billing provider when face-to-face with the patient and/or family. This includes the time spent performing such tasks as obtaining a history, examination, and counseling the patient.

Unit/floor time spent on inpatient consultations (99251-

99255), inpatient services (99221-99233) and observation services (99218-99220, 99224-99226, 99234-99236): This includes only the time spent by the billing provider while present on the patient’s hospital unit and at the bedside rendering services for that patient. This includes the time to establish and/or review the patient’s chart, examine the patient, write notes, and communicate with other professionals and the patient’s family.

Documentation: The note should include the time spent counseling the patient and/or coordinating patient care; and the subject matter of the counseling and/or coordination of care. Example Statement: “Total time spent was [xx] minutes. Greater than 50% was spent counseling (patient) on (summarize subject of counseling [e.g., surgical and non-surgical options for treatment of the patient’s condition.]).”

Level of Service Calculator (LOS): For outpatient consultation services, the EPIC Level of Service (LOS) calculator can suggest a consultation code. See the OCC tip sheet for instructions on how to access and use the calculator (LINK).

CMS Teaching Physician (TP) Rules: In order to receive payment for E/M services billed by TPs, the medical records must demonstrate: 1. That the TP performed the service or was physically present during

the critical or key potions of the service when performed by the resident; and

2. The TP’s participation in the management of the patient

To assist Teaching Physicians in their documentation, attestation statements for inpatient services are available at this link.

Instructions: This document describes how to select an Evaluation and Management (E/M) code for the following services:

Inpatient (99221-99223, 99231-99233) Emergency Department (99281-99285) Observation (99218-99220, 99224-99226, 99234-99236)

Outpatient Consultations (99241-99245) Inpatient Consultations (99251-99255)

For tip sheets on other types of services, see the links below: E&M Outpatient 2021 Provider Tip Sheet (CPT codes 99202-99215) (LINK) Critical Care Tip Sheet (CPT codes 99291 –99292) (LINK) COVID-19 PHE Telehealth Provider Billing Tip Sheet (LINK)

Version Date 2-4-21

Tip Sheet: Evaluation & Management Services (Excluding Office/Outpatient Services CPT codes 99202-99215 and Critical Care CPT Codes 99291- 99292) :::::::::EFFECTIVE JANUARY 1, 2021

Phone: 773-834-1143 compliance@bsd.uchicago.edu

Step 1: Calculating History

Note: A detailed or comprehensive level of care may be billed when patient history is not obtainable. Documentation would need to reflect the clinical reason that history cannot be obtained (e.g., patient unresponsive, comatose, disoriented, etc.). The medical record should also reflect any and all attempts made by the provider to elicit history from available family or significant others, from prior electronic and paper medical records, from eyewitnesses to an injury or from police and ambulance personnel.

1. HPI Elements

Brief (1-3) Brief (1-3) Extended (4 or more)

Extended (4 or more)

HPI Status of Chronic Conditions: 3 conditions N/A N/A Status of 3 chronic

conditions

Status of 3 chronic conditions

2. Review of Systems None Pertinent to

Problem (1

system)

Extended (2-9) Complete (10 or more systems, or at least 1 system with statement “all others negative”)

3. Past medical, family, social history (PFSH)

Past history (patient’s past experiences with illnesses, operations, injuries and treatments) 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)

Note: For subsequent hospital and nursing facility E/M services, only an interval history is necessary. It is unnecessary to record information about the PFSH.

None None Pertinent to Problem

(1 history area)

Complete

2 history areas:

a) Established patients-office (outpatient) care;

b) Emergency dept.

3 history areas:

a) New patients –office (outpatient) care,

b) Initial hospital care;

c) Hospital observation;

Problem Focused

Expanded Problem Focused

Detailed Comprehensive Complexity Level

Location Quality

Severity Duration

Timing Context

Modifying Factors Associated signs

and symptoms

All/immune Constitutional Eyes Ears, nose,

mouth, throat

Cardiovascular Respiratory GI GU

Musc/Skeletal Integumentary (skin,

breast) Neuro Psych

Endo Hem lymph All others negative

Step 2: Calculating Examination: Choose either the 1995 or 1997 Rules, but not both.

1995 Rules

One body area or system 2-4 areas or systems 5-7 areas or systems 8 or more systems only

1997 Rules

Exams have been defined for general multi-system

and the following single organ systems: cardio,

ENMT, Eyes, GU, Hem/Lymph/Imm, Musk, Neuro,

psych, Resp, Skin

1-5 bullets (1 or more body

areas or systems)

6 bullets (1 or more body

areas or systems)

12 bullets in 2 or more body

areas/systems or 2 bullets in 6

or more body areas or systems

(except eye and psych exams

which are 9 bullets)

2 bullets in 9 or more body

areas or systems; or

complete single organ

system

Type of Exam Problem Focused Expanded Problem Focused Detailed Comprehensive

Body Areas: Head, including

face Neck Chest, including

breast and axillae Abdomen Genitalia, groin,

buttocks Back Each extremity

Organ systems: Constitutional (e.g.,

vitals, gen app) Eyes Ears, nose, mouth

throat Cardio Resp GI GU Musc Skin Neuro Psych Hem/Lymph/Imm

Version Date 2-4-21

Tip Sheet: Evaluation & Management Services (Excluding Office/Outpatient Services CPT codes 99202-99215 and Critical Care CPT Codes 99291 -99292) :::::::::EFFECTIVE JANUARY 1, 2021

Phone: 773-834-1143 compliance@bsd.uchicago.edu

Step 3: Calculating Medical Decision Making

A. Number of Diagnoses or Treatment Options

Problem(s) Status Number Points

Self-limited or minor (stable, improved, or worsening) Max = 2 1

Est. problem (to examiner); stable, improved 1

Est. problem (to examiner); worsening 2

New problem (to examiner); no additional workup

planned

Max = 1 3

New problem (to examiner); additional workup

planned/consultation

4

Total

B. Amount and/or complexity of data reviewed Points

Review and/or order of clinical lab tests 1

Review and/or order of tests in the radiology section of CPT 1

Review and/or order of tests in the medicine section of CPT 1

Discussion of test results with performing physician 1

Decision to obtain old records and/or obtain history from someone other than

patient

1

Review and summarization of old records and/or obtaining history from someone

other than patient and/or discussion of case with another health care provider

2

Independent visualization of image, tracing or specimen itself (not simply review of

report)

2

Total

C. Risk of Complications and/or Morbidity or Mortality - This table is a guide to assign risk factors. Circle the most appropriate factor(s) in each category. The overall meas-

ure of risk is the highest level circled. Enter the level of risk identified in Table D “Final Result for Complexity”.

Risk Presenting Problem Diagnostic Procedure(s) Ordered Management Options Selected

Minimal 1 self-limited or minor problem, e.g., cold, insect bite, tinea corporis

Lab tests requiring venipuncture

Chest X-rays

EKG/EEG Urinalysis Ultrasound, e.g., echo KOH prep

Rest Gargles

Elastic bandages Superficial dressings

Low

2 or more self-limited or minor problems 1 stable chronic illness (e.g., well controlled hypertension) Noninsulin 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 test

Noncardiovascular imaging studies with contrast, e.g., barium enema

Superficial needle biopsies Clinical lab tests requiring arterial punc-

ture Skin biopsies

Over the counter drugs Minor surgery w/no identified risk factors Physical therapy Occupational therapy IV fluids without additives

Moder-

ate

1 or more chronic illness with mild exacerbation, progres-sion, or side effects of treatment

2 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 Acute complicated injury, e.g., head injury with brief loss of

consciousness

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 con-

trast and no identified risk factors, e.g., arteriogram cardiac catheter

Obtain fluid from body cavity, e.g., lumbar puncture, thoracentesis, culdocentesis

Minor surgery with identified risk factors Elective major surgery (open, percutaneous

or endoscopic with no identified risk factors) Prescription drug management (management

and/or renewal, new prescription, discontin-uation)

Therapeutic nuclear medicine IV fluids with additives Closed treatment of fracture or dislocation

without manipulation

High

1 or more chronic illnesses with severe exacerbation, pro-gression, or side effects of treatment

Acute or chronic illnesses or injuries that may pose a threat to life or bodily function, e.g., multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progres-sive 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

Cardiovascular imaging studies with con-trast with identified risk factors

Cardiac electrophysiological tests Diagnostic endoscopies with identified risk

factors Discography

Elective major surgery (open, percutaneous or endoscopic with identified risk factors)

Emergency major surgery (open, percutane-ous 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

D. Calculating MDM: Circle the corresponding values that were calculated in steps A-C. Draw a line down the column with 2 or 3 circles to find level of MDM. Otherwise,

draw a line down the column with the second circle from the left.

a. Number of diagnoses or treatment options ≤ 1 Minimal 2 Limited 3 Multiple ≥ 4 Extensive

b. Amount and/or complexity of data reviewed ≤ 1 Minimal 2 Limited 3 Multiple ≥ 4 Extensive

c. Highest Risk Minimal Low Moderate High

Straightforward Low Moderate High Level of MDM

Version Date 2-4-21

Tip Sheet: Evaluation & Management Services (Excluding Office/Outpatient Services CPT codes 99202-99215 and Critical Care CPT Codes 99291 -99292) :::::::::EFFECTIVE JANUARY 1, 2021

Phone: 773-834-1143 compliance@bsd.uchicago.edu

Step 4: Selecting E/M level- After calculating the level of history, exam and MDM for the applicable E/M service, use the table below to determine which E/M level to bill.

E/M Code Level 3 key components Time (min)

Hx Exam MDM

Emergency (99281-99285)

Note, all 3 key components must be met or exceed to qualify for a particular level of E/M service.

99281 PF PF SF N/A

99282 EPF EPF L N/A

99283 EPF EPF M N/A

99284 D D M N/A

99285 C C H N/A

Inpatient (Initial) (99221-99223)

Note, all 3 key components must be met or exceed to qualify for a particular level of E/M service.

99221 D or C D or C SF or L 30

99222 C C M 50

99223 C C H 70

Inpatient (Subsequent) (99231-99233)

Note, 2 out of 3 key components must be met or exceeded to qualify for a particular level of E/M service.

99231 PF interval PF SF or L 15

99232 EPF interval EPF M 25

99233 D D H 35

Hospital Discharge Services (99238-99239) 99238 N/A N/A N/A N/A

99239 >30

Observation (Initial) (99218-99220)

Note, all 3 key components must be met or exceed to qualify for a particular level of E/M service.

99218 D or C D or C SF or L 30

99219 C C M 50

99220 C C H 70

Observation (Subsequent) (99224-99226) 99224 PF interval PF SF or L 15

99225 EPF interval EPF M 25

99226 D interval D H 35

Observation (Discharge) when on a different day from the initiation of observation service 99217 N/A N/A N/A N/A

Observation or Inpatient Care with same day Admission and Discharge Services (99234-99236)

Note, all 3 key components must be met or exceed to qualify for a particular level of E/M service.

99234 D or C D or C SF or L 40

99235 C C M 50

99236 C C H 55

Consultation (Outpatient) (99241-99245)*

Note, all 3 key components must be met or exceed to qualify for a particular level of E/M service.

99241 PF PF SF 15

99242 EPF EPF SF 30

99243 D D L 40

99244 C C M 60

99245 C C H 80

99251 PF PF SF 20 Consultation (Inpatient) (99251-99255)*

Note, all 3 key components must be met or exceed to qualify for a particular level of E/M service. 99252 EPF EPF SF 40

99253 D D L 55

99254 C C M 80

99255 C C H 110

*Effective 1/1/10, Medicare stopped recognizing consultation CPT codes. However, they are still an AMA CPT code and recognized by non-Medicare Payors. To accommodate providers who use consultation codes, the UCMC billing system automatically cross-walks the consultation codes to the appropriate code for Medicare Payors. D** (detailed); C (comprehensive); PF (problem-focused); EPF (expanded problem-focused); SF (Straightforward); L (Low); M (moderate); H (high)

TIME: If the clinician documents total time and indicates that counseling or coordinating care dominates (more than 50%) the encounter, time may determine level of service. Documentation may refer to: prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk education and/or discussion with another health care provider.

Question Answer If all answers are “yes” you may select level based on time.

Does documentation reveal total time? Yes/ No

Does documentation describe the content of counseling or coordinating care? Yes/ No

Does documentation reveal that more than half of the time was counseling or coordinating care? Yes/ No