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Coding Patient Encounters II. EPISODE 2 Determining the “level” of the encounter. Objectives. Understand the basic rules: Physician payment rules Basic CPT and ICD coding rules Be familiar with the 3 criteria for selecting the correct EM Code. The “Art” of CPT Coding.
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Coding Patient Encounters II EPISODE 2 Determining the “level” of the encounter
Objectives • Understand the basic rules: • Physician payment rules • Basic CPT and ICD coding rules • Be familiar with the 3 criteria for selecting the correct EM Code
The “Art” of CPT Coding • First select the code based on the “feel” of the visit (not check-up) – how complex, how much time • Then validate your code using a E/M tool (E/M = evaluation and management)
The “Art” of CPT Coding • The “Feel” • 99211 = nurse visit • 99212 = easy, brief problems • 99213 = average, usual problems • 99214 = “oh no!” • 99215 = after visit you think “I just ran a marathon” • Why should you care? • > $40 difference between level 3 and 4!
99212 Typical Scenarios • Diaper rash • OM recheck and resolved • Otitis externa • Thrush
99213 Typical Scenarios • Fever and pharyngitis • UTI-cystitis • URI and Otitis • Mild LRI’s • Moderate Injury *Most acute uncomplicated problems
99214 Typical Scenarios • Chronic or Multiple problems • Headaches, abdominal pain • Fatigue, anorexia • Asthma, diabetes • School and Behavioral Problems • ADHD return visits • Acute Complicated Illnesses • Fever without focus • Influenza
99215 Typical Scenarios • Diabetes complicated by illness • Headaches with vomiting • Disabling abdominal pain • Fatigue and anorexia in adolescent • Fever without focus for more than 60 days • Initial evaluation for ADHD
The Science of Coding • Three Criteria for selecting the correct E/M Code: • History • Physical Examination • Medical Decision Making • For established patients, must have 2/3 areas at same level to qualify (3/3 for new patients)
Levels of Physical Exam Either the 1995 guidelines or 1997 guidelines may be used, but most general pediatricians use the 1995 guidelines as the 1997 guidelines were written with specialists in mind.
Criteria for Selecting the Correct EM Code • History and Physical form the 1st two of the key criteria in coding. In the next set of slides and the conclusion of the trilogy “Coding”, we will discuss medical decision making as the third component.
