Evaluation and Management Strategies For Success

1. Evaluation and ManagementStrategies For Success American Academy of Professional Coders Woodland Hills California Chapter Meeting July 2010

2. Part TwoFundamentals of Coding Evaluation and Management Services Presented by: Elizabeth McAllister, CPC, CPC-H, CPC-I, CEMC

3. KEY COMPONENTS History Examination Medical Decision Making Counseling Coordination of Care Nature of Presenting Problem Time* Evaluation & ManagementComponents

4. History Four Elements The selection of the level of history obtained will depend on the following factors: • Chief Complaint • History of Present Illness • Review of Systems • Past, Family & Social History

5. Eight Elements Location Quality Severity Duration Timing Context Modifying Factors Associated Signs & Symptoms Brief and Extended HPIs are distinguished by the amount of detail needed to accurately characterize the clinical problem(s). History of Present IllnessHPI

6. ROSCMS/AMA Systems • Constitutional Symptoms • Eyes • Ears, Nose, Mouth & Throat • Cardiovascular • Respiratory • Gastrointestinal • Genitourinary • Musculoskeletal • Integumentatry System • Neurological • Psychiatric • Endocrine • Hematologic/Lymphatic • Allergic/Immunologic

7. Past (Medical) Family and/or Social History (PFSH) • Past History - Review of patient’s previous illness, injuries, hospitalization, current medications, allergies, immunization status. • Family History – Review of patient’s family health status or cause of death of parents, siblings, children. Also includes a review of any diseases that may be hereditary, that may put patient at risk. • Social – Review of current activities, may include alcohol, tobacco use, marital status, occupation, sexual history.

8. Problem Focused -- a limited examination of the affected body area or organ system. Expanded Problem Focused -- a limited examination of the affected body area or organ system and other symptomatic or related organ system(s). Detailed -- an extended examination of the affected body area(s) and other symptomatic or related organ system(s). Comprehensive -- a general multi-system examination or complete examination of a single organ system. Evaluation and ManagementExamination - Four Levels

9. Examination For purposes of examination, the following body areas are recognized: • Head, including the face • Neck • Chest, including breasts and axillae • Abdomen • Genitalia, groin, buttocks • Back, including spine • Each extremity

10. Examination The following organ systems are recognized: • Constitutional (e.g., vital signs, general appearance) • Eyes • Ears, nose, mouth and throat • Cardiovascular • Respiratory • Gastrointestinal • Genitourinary • Musculoskeletal • Skin • Neurologic • Psychiatric • Hematologic/lymphatic/immunologic

11. Straightforward is the lowest level of Medical Decision-Making.  It is impossible not to qualify for it.  Low Complexity Medical Decision-Makingrequires only slightly more intellectual energy than straightforward MDM.  The degree of risk remains quite low and corresponds to a patient with one chronic illness which is completely stable.  If there is an acute problem, it should be an uncomplicated clinical issue such as allergic rhinitis, cystitis or a sprained ankle. Medical Decision MakingLevels

12. Detailed Complexity Medical Decision-Making describes a patient with one chronic illness with a mild exacerbation or two stable chronic illnesses would satisfy the risk requirement for this level of medical decision-making. Medical Decision MakingLevels

13. Medical Decision MakingLevels • High Complexity Medical Decision-Makingtruly is complex.  Either the patient is quite ill or the physician must review a significant amount of primary data. • The patient would need to have a severe exacerbation of a chronic problem or an acute illness which threatens life or bodily function to qualify for this level of risk. 

14. Observation ServicesCPT Code Range 99217 - 99220 • Observation codes are used to identify evaluation and management services delivered to a patient for a condition that isn’t serious enough for admission into the hospital, but the patient is not well enough to go home. • Only the physician who admitted the patient to observation and was responsible for care during the stay may submit the hospital observation codes. • Observation codes may not be utilized for post-op recovery • These services are a perennial favorite on the OIG Work plan

15. Observation Services • Medicare Reimbursement Guidelines • The patient must be admitted to observation status for a minimum of 8 hours. • Observation services paid for the following conditions: • Congestive Heart Failure • Asthma • Chest Pain

16. Initial Observation Care 99218 – 99220 3 of 3 Key Components Required Includes initiation of observation status Supervision of the care plan Performance of Periodic Reassessments Observation Care Discharge 99220 Reports all services on day of discharge. Observation Services

17. Observation Codes Admission/Discharge on Different Dates of Service(3 out of 3 Key Components Required)

18. Initial Observation Care 99234 – 99236 3 of 3 Key Components Required Includes all evaluation and management services provided by the admitting physician related to the initiation of “observation” status. ObservationAdmission & Discharge on Same Date of Service

19. Observation Codes Admission and Discharge on Same Date of Service(3 out of 3 Key Components Required)

20. Coding Flow Services Rendered by Same Physician

21. Initial Inpatient Hospital Care(3 of 3 Key Components Required) • Evaluation and Management Services provided on the same day, in different sites that are related to the inpatient admission should not be reported separately.

22. Subsequent Inpatient Hospital Care(2 of 3 Key Components Required) • Includes review of medical record, diagnostic test results, and changes in the patient’s status since last visit.

23. Inpatient Discharge Management • Report the total duration of time spent by a physician for the final discharge of patient. Time does not need to be continuous.

24. Includes: Final Examination Discussion of Hospital stay Instructions for continuing care Preparation of discharge records Prescriptions and Referral Forms 99238 Discharge Management 30 Minutes or Less 99239 Discharge Management More than thirty Minutes Inpatient Discharge Management

25. Face-to-face (office and other outpatient visits) – Defined as only that time that the physician spends face-to-face with the patient and/or family. Work spent pre/post encounter involved in such activities as reviewing records and tests, arranging further tests and treatment, communicating further with other professionals and the patient through either written reports of telephone contact. Unit/floor time (hospital observation and other inpatient care) includes the time that the physician is present on the patient’s hospital unit and a the bedside rendering services for the patient. This includes the time in which the physician established and/or reviews the patient’s chart, examines the patient, writes notes and communicates with other professionals and the patient’s family. Time

26. Office Consultation(3 of 3 Key Components Required)

27. Emergency Department Services 99281 - 99285 • An Emergency Department is a hospital based facility that is open 24 hours a day for the purpose of providing unscheduled services to patients who present for immediate medical attention. • The Emergency Department services do not distinguish between new and established patients. • Time is not a factor in code selection.

28. Emergency Department Services(3 of 3 Key Components Required)

29. Critical Care • Critical Care is provided to a critically ill or injured patient during a life threatening medical crisis or trauma requiring immediate intervention and life saving measures. • Critical Care can be provided in any location. • Care by the physician is constant, but does not need to be continuous. • Time includes floor time, consulting with other medical staff and documentation in medical record. • Codes are patient age sensitive.

30. Critical Care • 99291 – 99292 Critical Care Patients are 24 months and older • For neonates and pediatric critical care see code range 99471 - 99476

31. Critical Care Codes 99291 Used to report the first 30-74 minutes of critical care on a given date. Less than 30 minutes should be reported with an E & M code. Coded only once per day. Physician must devote entire to time to the patient (cannot be seeing other patients at the same time). +99292 Reports each additional 30 minutes beyond the first 74 minutes. Can be reported for the final 15 minutes (other 15 minute increments are not reported)

32. Critical Care 99291 - 99292Bundled Codes – Not Separately Reported Elizabeth McAllister, CPC, CPC-H, EMS Elizabeth McAllister, CPC, CPC-H, EMS 32 32

33. Critical CareTime Includes • Patient care at bedside • Review of test results on unit or floor • Discussion of patient care • Documentation of critical care including patient’s condition • Documentation of Time

34. Physical attendance and direct face-to-face care during the inter facility transport of a critically ill or injured patient are time (and age) based codes. The time begins when the physician assumes primary responsibility of the patient at the referring hospital and concludes when the receiving hospital accepts responsibility for the patient. Codes are reported in thirty minute increments 99466, +99467 24 months of age or younger 99291, +99292 older than 24 months Critical Care – Transport Coding

35. Newborn Care • Code 99460: Initial Evaluation of the normal newborn infant. Hospital or birthing room. Includes initiation of diagnostic and treatment programs, and preparation of hospital records. • Code 99461: Normal Newborn Care outside the hospital or birthing room. Includesphysical examination and conference with parents. • Code 99462: Subsequent Hospital care (per day), evaluation and management of a normal newborn • Code 99463: Evaluatin and management of a normal newborn that is delivered and discharged on the same date of service.

36. Newborn Care • 99464 Attendance at Delivery and initial stabilization of the newborn. • 99465 Delivery/Birthing room resuscitation, (provision of positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output.

37. 99468 – 99476 Initial and Subsequent inpatient neonatal critical care 99477 Initial hospital care, per day for the evaluation and management of neonate 28 days or less who requires intensive observation, frequent interventions and other intensive care services. 99478 – 99480 Subsequent intensive care, per day, evaluation and management recovering low and very low birth weight infant Pediatric and Newborn Care

38. Preventive Care Services Code Range 99381-99397 Used to code for routine examinations or asymptomatic patients of all ages Examinations are age appropriate Divided into new and established patients Age & Gender Specific • Counseling/Anticipatory guidance/Risk factor reduction interventions • Documentation Requirements • Comprehensive History & Exam • History does not contain a CC or HPI • Does require a complete ROS • Not synonymous with the comprehensive requirements of an E/M service Preventive Medicine Services Do Not Have Medical Decision Making.

39. Preventive MedicineNew Patient Examination • 99381 Initial exam - infant age 1 and under • 99382 Initial exam - ages 1-4 • 99383 Initial exam - ages 5-11 • 99384 Initial exam - ages 12-17 • 99385 Initial exam - ages 18-39 • 99386 Initial exam - ages 40-64 • 99387 Initial exam - age 65 years and over

40. Evaluation & ManagementCategories & Sub-Categories Prolonged Services With Direct Patient Contact 99354 - 99357 Without Direct Patient Contact 99358 - 99359 Standby Services99360 Anticoagulant Management99363 - 99364 Medical Team Conferences99366 – 99368 Care Plan Oversight99374 - 99380

41. Preventive MedicineCounseling Service • Individual: New or Established Patient: • 99401 Preventive Medicine Counseling - 15 minutes • 99402 Preventive Medicine Counseling - 30 minutes • 99403 Preventive Medicine Counseling - 45 minutes • 99404 Preventive Medicine Counseling - 60 minutes • Group Counseling and or Risk Factor Reduction • 99411 Approximately 30 minute session • 99412 Approximately 60 minute session

42. Evaluation & ManagementCategories & Sub-Categories Nursing Facility Services 99304 - 99318 Domiciliary, Rest Home 99324 - 99337 Oversight Services 99339 - 99340 Home Services 99341 - 99350

43. Coding resources • AAPC website • CMS – Medical Learning Network • Associates and colleagues