Evaluation and Management Coding and Medicare Part B - PowerPoint PPT Presentation

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Evaluation and Management Coding and Medicare Part B

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Medical record documentation is required for reporting pertinent findings, facts ... year old patient with painless swelling of the thigh with lytic lesion by xray ... – PowerPoint PPT presentation

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Title: Evaluation and Management Coding and Medicare Part B


1
Evaluation and Management Coding and Medicare
Part B
  • Rachel Mitchell, CPC-H
  • Applied Medical Systems, Inc.
  • August 26, 2003

2
What 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.

3
General principles of documentation
  • Medical record should be complete and legible.
  • Documentation should include
  • Chief complaint
  • Exam and diagnostic test results
  • Assessment
  • Plan

4
Components of EM visits
  • History
  • Exam
  • Medical decision making
  • Counseling and/or coordination of care

5
Continued.
  • Rationale of ordering diagnostic testing
  • Past and present diagnoses and/or conditions.
  • Health risk factors
  • Progress with regards to treatment

6
Elements of HPI
  • Location
  • Quality
  • Severity
  • Duration
  • Timing
  • Context
  • Modifying factors
  • Associated signs and symptoms

7
Elements of ROS
  • Constitutional
  • Eyes
  • Ears, nose, throat, mouth
  • Respiratory
  • Gastrointestinal
  • Genitourinary
  • Musculoskeletal
  • Integumentary (skin and/or breast)
  • Neurological
  • Psychiatric
  • Endocrine
  • Hematologic/Lymphatic
  • Allergic/Immunologic

8
Past/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.

9
Physical 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

10
Body 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

11
Medical Decision Making
  • Diagnoses/Management Options
  • Amount/Complexity of Data
  • Risk of Complication

12
Table 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.

13
Level 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.

14
Evaluation and Management Codes
15
99253 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

16
Clinical 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.

17
99254 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

18
Clinical 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.

19
99255 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

20
Clinical 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.

21
99301 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)

22
99311 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)

23
99331 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.

24
99261 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.

25
Clinical 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.

26
99262 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.

27
Clinical Example
  • Follow-up with a 51 year old male for test
    results from initial consult of the etiology of
    postop hyponatremia following TURP procedure.

28
99263 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.

29
Clinical Example
  • Follow-up of 62 year old male who was initially
    evaluated for pansinusitis now with sudden onset
    of proptosis.

30
99344 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.

31
99345 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.

32
99348 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

33
99356 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.

34
ICD9CM 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

35
CMS-1500 a.k.a HCFA-1500
36
(No Transcript)
37
Patient 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

38
Patient 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

39
Treatment 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

40
Treatment 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

41
Provider 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

42
Place 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

43
Type of Service Codes
  • 01 Medical Care
  • 02 Surgery
  • 03 Consultation

44
Part 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.

45
Websites 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

46
Physician Billing Software Websites
  • www.medisoft.com
  • www.a4healthsystems.com
  • www.perfectpracticemd.com
  • www.pmsi.com
  • www.misyshealth.com
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