Title: Evaluation and Management Coding and Medicare Part B
1Evaluation and Management Coding and Medicare
Part B
- Rachel Mitchell, CPC-H
- Applied Medical Systems, Inc.
- August 26, 2003
2What is documentation and why is it
important?
- Medical record documentation is required for
reporting pertinent findings, facts and
observations about a patients health history.
The medical record documents patient care showing
the chronology of treatment, communication
between physicians, quality of care and
collection of data.
3General principles of documentation
- Medical record should be complete and legible.
- Documentation should include
- Chief complaint
- Exam and diagnostic test results
- Assessment
- Plan
4Components of EM visits
- History
- Exam
- Medical decision making
- Counseling and/or coordination of care
5Continued.
- Rationale of ordering diagnostic testing
- Past and present diagnoses and/or conditions.
- Health risk factors
- Progress with regards to treatment
6Elements of HPI
- Location
- Quality
- Severity
- Duration
- Timing
- Context
- Modifying factors
- Associated signs and symptoms
7Elements of ROS
- Constitutional
- Eyes
- Ears, nose, throat, mouth
- Respiratory
- Gastrointestinal
- Genitourinary
- Musculoskeletal
- Integumentary (skin and/or breast)
- Neurological
- Psychiatric
- Endocrine
- Hematologic/Lymphatic
- Allergic/Immunologic
8Past/Family/Social History
- Past History the patients history of
illnesses, operations, injuries, treatments,
medications. - Family History a review of medical events in
the patients family, including diseases which
may be hereditary or place the patient at risk. - Social History an age appropriate review of
past and current activities. Ex marital status
sexual history tobacco, alcohol, and drug use
history job/career status.
9Physical Exam
- Problem Focused
- Limited exam of affected area/system (1 body area
or system) - Expanded Problem Focused
- Affected area/organ system other symptomatic or
related systems (2 to 7 systems) - Detailed
- Extended exam of affected area other
symptomatic or related organ systems (2 to 7
systems) - Comprehensive
- General multi-system exam (8 or more systems)
- or complete exam of a single organ system
10Body Areas vs. Organ Systems
- BODY AREAS
- Head, incl. Face
- Neck
- Chest, incl. Breasts axillae
- Abdomen
- Genitalia, groin, buttocks
- Back, incl. Spine
- Each extremity
- ORGAN SYSTEMS
- Constitutional (vitals general appearance)
- Eyes
- ENT, mouth
- Cardiovascular
- Respiratory
- Gastrointestinal
- Genitourinary
- Musculoskeletal
- Skin
- Neurologic
- Psychiatric
- Hematologic/Lymphatic/Immunologic
11Medical Decision Making
- Diagnoses/Management Options
- Amount/Complexity of Data
- Risk of Complication
12Table of Risk Examples
- Presenting Problem
- Minimal One self-limited or minor problem.
- Low Two or more minor problems, one stable
chronic illness, acute uncomplicated illness. - Moderate Chronic illness with exacerbation, two
of more stable chronic illnesses, undiagnosed new
problem with uncertain prognosis, acute illness
with systemic pneumonitis, acute complicated
injury - High Chronic illness with severe exacerbation,
acute or chronic illness that poses threat to
life, abrupt change in neurologic status.
13Level of Service (contd)
- Time matters!
- You may code the level based only on time if more
than 50 of the visit is spent counseling the pt.
The total time must be recorded as well as a
statement that more than 50 of the visit was
counseling.
14Evaluation and Management Codes
1599253 Initial Inpatient Consult
- New or established
- Requires detailed history and exam (extended exam
of 7 organ systems/body areas) - Low complexity medical decision making
- Presenting problem of moderate severity
- 55 minutes of bedside or floor time
16Clinical Examples
- Requested by internal medicine 45 year old
male with 12 day history of incapacitating gout,
unable to walk now, not improved by bed rest. - Requested by internal medicine, for treatment
recommendations for patient admitted with
persistent inability to walk following soft
tissue injury to knee.
1799254 Initial Inpatient Consult
- New or established
- Required comprehensive history and exam (general
multisystem exam of 8 or more systems OR complete
exam of single organ system). - Moderate complexity medical decision making.
- Presenting problem of moderate or high severity.
- 80 minutes of bedside or floor time
18Clinical example
- Consult request for a 13 year old patient with
painless swelling of the thigh with lytic lesion
by xray - Or
- Consult request for a 65 year old 72 hour
status post mitral valve replacement who develops
acute respiratory distress syndrome.
1999255 Initial Inpatient Consult
- New or established
- Required comprehensive history and exam (general
multisystem exam of 8 or more systems OR complete
exam of single organ system). - High complexity medical decision making.
- Presenting problem of high severity.
- 110 minutes of bedside or floor time
20Clinical Example
- Consult request for a 74 year old male with
chest pain and massive GI bleed. - Or
- Consult request for a patient with multiple
failed back surgeries continuing to have low back
and neck pain.
2199301 99303 Nursing Facility Visits
- All three codes are assessment codes for new or
established patients - 99301 is used annually for the recertification of
the care plan. (30 minutes) - 99302 is used when a patient incurs a permanent
change in physical condition and the care plan
requires a revision. (40 minutes) - 99303 is used to establish the medical care plan
for a new admission to the nursing facility. (50
minutes)
2299311 99313 Subsequent Nursing Facility Care
- New or established patients
- Daily care visits
- 99311 is used when a patient is stable,
recovering or improving. (15 minutes) - 99312 is used when a patient is responding
inadequately to therapy or has developed a minor
complication. (25 minutes) - 99313 is used when a patient has a serious
problem, but is not required to be admitted to a
hospital. (35 minutes)
2399331 Domiciliary Care
- Established visit requiring problem focused
history, problem focused exam and low complexity
medical decision making. - Patient is usually stable, recovering or
improving. - This code can be used when patients are residents
of nursing facilities, assisted living and
retirement communities.
2499261 Follow-up Inpatient Consult
- Established visit requiring problem focused
history, problem focused exam and low complexity
medical decision making. (2 of 3 components) - Patient is stable, recovering or improving.
- Physician typically spends 10 minutes at bedside
or on the unit.
25Clinical Examples
- Follow-up with a 75 year old female who urinary
incontinence to review results of a diagnostic
test the day of initial consult. - Or
- Follow-up with a 94 year old male nursing home
resident for re-evaluation of hemorrhoids
following conservative treatment on initial
consult.
2699262 Follow-up Inpatient Consult
- Established visit requiring expanded problem
focused history, exam and moderate complexity
medical decision making. (2 of 3 components) - Patient is responding inadequately to therapy or
has developed a minor complication. - Physician typically spends 20 minutes at bedside
or on the unit.
27Clinical Example
- Follow-up with a 51 year old male for test
results from initial consult of the etiology of
postop hyponatremia following TURP procedure.
2899263 Follow-up Inpatient Consult
- Established visit requiring detailed history,
exam and high complexity medical decision making.
(2 of 3 components) - Patient is unstable or has developed significant
complication or new problem. - Physician typically spends 30 minutes at bedside
or on the unit.
29Clinical Example
- Follow-up of 62 year old male who was initially
evaluated for pansinusitis now with sudden onset
of proptosis.
3099344 Home Services
- New patient visit which requires a comprehensive
history, exam and moderate medical decision
making. - Presenting problems are usually of high severity.
- Physician typically spends 60 minutes face to
face with the patient and/or family.
3199345 Home Services
- New patient visit requiring comprehensive
history, exam and high complexity medical
decision making. - Patient is unstable or has developed a
significant new problem requiring immediate
physician attention. - Physician typically spends 75 minutes face to
face with the patient and/or family.
3299348 Home Services
- Established visit requiring expanded problem
focused history, exam and low complexity medical
decision making. (2 of 3 components) - Presenting problem(s) are of low to moderate
complexity. - Physicians typically spend 25 minutes face to
face with patient and/or family
3399356 Prolonged Services
- Physician services within the inpatient setting
that requires direct patient contact. First
hour. - This CPT is to be listed in addition to the
evaluation and management service.
34ICD9CM Coding
- Medical necessity is an important factor.
- Can code from signs and symptoms.
- Will no longer use Volume 3.
- Utilize the Medicare Local Medical Review
Policies website. - Code to the highest specificity
35CMS-1500 a.k.a HCFA-1500
36(No Transcript)
37Patient Information
- Block 1 Type of Insurance Indicator
- Block 1a Insured ID
- Block 2 Patient Name
- Block 3 Patients DOB
- Block 4 Policy Holder
- Block 5 Patient Address
- Block 6 Relationship to the Insured
- Block 7 Policy Holders Address
38Patient Information Continued
- Block 8 Patient Status
- Block 9 Medigap Info
- Block 10 Accident Indicator
- Block 11 Primary to Medicare Insurance
- Block 12 Patient Authorization
- Block 13 Insured Authorization
- Block 14 Illness Date
- Block 15 (not required by Medicare
- Block 16 Unable to Work Date
39Treatment Information
- Block 17 Referring Physician
- Block17a UPIN
- Block 18 Hospitalization Dates
- Block 19 Local Use
- Block 20 Outside Lab
- Block 21 Diagnosis Codes
- Block 22 Medicaid Resubmission Code (not required
by Medicare) - Block 23 Authorization
40Treatment Information Continued
- Block 24d CPTs and Modifiers
- Block 24e Diagnosis Code Reference
- Block 24f Charges
- Block 24g Units/Days
- Block 24h, i and j not required by Medicare
- Block 27k Provider Number (individual)
- Block 24b Place of Service
- Block 24c Type of Service
- Block 24a Treatment Date
41Provider Information
- Block 29 Amount Paid
- Block 30 Balance Due (not required by Medicare)
- Block 31 Physician Signature and Printed Name
- Block 32 Services Rendered Name and Address
- Block 33 Physician Billing Address
- Block 25 Provider Tax ID
- Block 26 Patient Account Number
- Block 27 Accept Assignment Indicator
- Block 28 Total Charges
42Place of Service Codes
- 11 Office
- 12 Home
- 13 Assisted Living Facility
- 21 Inpatient Hospital
- 22 Outpatient Hospital
- 23 Emergency Room
- 31 Skilled Nursing Facility
- 32 Nursing Facility
- 33 Custodial Care Facility
- 34 Hospice
- 51 Inpatient Psychiatric Facility
- 72 Rural Health Clinic
43Type of Service Codes
- 01 Medical Care
- 02 Surgery
- 03 Consultation
44Part B Billing
- Billed on a HCFA-1500 (CMS-1500)
- Does not require revenue codes
- Provides payment for physician and outpatient
hospital services as well as medical equipment. - 100 per year calendar deductible
- Sent to a carrier in Nashville, Tennessee
- Primary diagnosis code is the main code
recognized. - Providers can choose whether or not to
participate.
45Websites for Claim Filing,etc.
- www.payerpath.com
- www.easyhcfa.com
- www.ezclaim.com
- www.softlookup.com
- www.justclaims.com
- www.hcfaware.com
- www.claimsbpo.com
- ICD9CM look-up
- www.flashcode.com
- www.unicormed.com
- Medicare Local Medical
- Review Policies
- www.lmrp.net
46Physician Billing Software Websites
- www.medisoft.com
- www.a4healthsystems.com
- www.perfectpracticemd.com
- www.pmsi.com
- www.misyshealth.com