CONSULTATION REFRESHER

Transcription

1 BLAST CONSULTATION REFRESHER We have had many requests from clients recently asking how to correctly code Medicare consultations utilizing the new CMS requirements. Attached is a mini refresher course on everything you need to know concerning Evaluation & Management (E&M) consultation coding. Should you have any further questions, please contact Software Support. NOTE: Beginning 2010 Medicare Consults do not use: Office/outpatient change to Inpatient change to , for & use & Not recognized by most Medicare Advantage Contractors, i.e., BEL, H65, T65, UA!, etc. For Medicare Advantage Contractors, i.e., PART C information, contact Software Support. RESOURCES: CMS 1995 Documentation Guidelines CMS 1997 Documentation Guidelines MC Claims Processing manual, pub , chapter 12 Section 30.6 Evaluation and Management Service Codes - General (Codes )

2 CONSULT DOCUMENT: Lower-level inpatient consult codes (99251 and 99252) aren t directly comparable to a Level 1 initial hospital care code (99221) therefore no exact crosswalk (no arrows guiding you). The consult codes require only a: problem-focused History and expanded problem-focused Exam while must have a detailed or comprehensive History and Exam. To qualify for the (admit/initial inpatient) code the provider would have to beef up their HISTORY and EXAM or to play it safe use and respectively. TIME RULE: Special circumstances that override key components: - For coding purposes, face-to-face time for office/outpatient visits or consult services is defined as only that time that the physician spends face-to-face with the patient and/or family - When greater than 50% of the face-to-face time is spent in counseling or coordination of care, time may be considered in selecting the code level for the encounter - The time ranges associated with consultations and other inpatient services do not match and should be reviewed before selecting a level for the encounter DOCUMENTATION NEEDED: Per July 2006 MCB Pinnacle o Progress/clinical notes for the date of service requested o Name of beneficiary and date of service documented on all notes o Provider orders, if applicable o If documenting based on counseling or coordination of care, include: - total time, amount or percent of time involved in counseling or coordination of care - description of the discussion/care involved o When billed on the same date as a procedure, documentation that the E&M service is for a separate condition, unrelated to the procedure performed and affix appropriate modifier. o Legible signature of the billing provider RESOURCES: CMS 1995 Documentation Guidelines CMS 1997 Documentation Guidelines MC Claims Processing manual, pub , chapter 12 Section Evaluation and Management Service Codes - General (Codes )

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5 OTHER INFORMATION from recent seminars: documentation specifics:

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7 If Coding by TIME: 2010 HCPCS adds AI modifier for principal physician of record (the real Admitting Provider) If the 2010 HCPCS code list is any indicator, the new modifier the attending physician of record is supposed to apply to initial inpatient hospital care ( ) claims next year is AI (principal physician of record).

8 Consult Outpatient (9924x) and Inpatient (9925x), Need 3 of 3 992(4/5)1 PF PF SF 15/20 992(4/5)2 EPF EPF SF 30/40 992(4/5)3 Detailed Detailed Low 40/50 992(4/5)4 Comprehensive Comprehensive Moderate 55/80 992(4/5)5 Comprehensive Comprehensive High 80/110 New Patient (Office), Need 3 of PF PF SF EPF EPF SF Detailed Detailed Low Comprehensive Comprehensive Moderate Comprehensive Comprehensive High 80 Established (Office), Need 2 of Minimal/Nurse Visit Physician Presence Required PF PF SF EPF EPF Low Detailed Detailed Moderate Comprehensive Comprehensive High 40 Initial Observation Care, Need 3 of Detailed Detailed SF/Low N/A Comprehensive Comprehensive Moderate N/A Comprehensive Comprehensive High N/A E/M Documentation Requirements f inal exam; care inst ruct ions, discharge records code can only be used if the discharge is different than the admission to observation status date Hospital Admission, Need 3 of Detailed Detailed SF/Low Comprehensive Comprehensive Moderate Comprehensive Comprehensive High 70 Hospital Progress Note, Need 2 of PF PF SF/Low EPF EPF Moderate Comprehensive Comprehensive High 35 Hospital Discharge, Need 2 of 3 f inal exam; care inst ruct ions, code can only be used if the discharge is different <30 discharge records than the admission to hospital date f inal exam; care inst ruct ions, code can only be used if the discharge is different N/A >30 discharge records than the admission to hospital date *Time When using time as the controlling factor to determine the level of care, you must spend the entire allotted time face-to-face with the patient AND at least half of that time must have been devoted to counseling and/or coordination of care. Time spent must be documented. CPT codes and descriptions are copyrighted to the American M edical Association

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10 From Health Care Quality Consultants, 2007 E&M Pocket Guide

11 TO DETERMINE APPROPRIATE LEVEL OF CARE I. HISTORY Problem Focused - HPI 1 (1-3 elements) Detailed - HPI 4 (4 or more elements) (PF) ROS 0 PSFH 0 (D) ROS 2 (2-9 systems) PSFH 1(1 history area) Expanded Problem - HPI 1 (1-3 elements) (EF) Focused - ROS 1 (1 system) PSFH 0 Comprehensive - HPI 4 (4 or more elements); (C) ROS 10 (10 or more systems) PSFH 2 (2 or 3 history areas) II. EXAMINATION Problem focused (PF) limited to affected body area or organ system (1 body area of system) Expanded problem focused (EF) Affected body area or organ system and other symptomatic or related organ system (additional systems up to 7) Detailed (D) Extended exam of affected area and other area or symptomatic or related organ system (additional systems up to total of 7) Comprehensive (C) General multi-system exam (8 or more) or complete exam of a single organ system III. MEDICAL DECISION # RX: DIAGNOSIS: Circle One in Each of These Three Columns Number of Diagnosis or Management Options Amount and/or Complexity of Data To Be Reviewed Risk of Complications and/or Morbidity or Mortality Straightforward (SF) Minimal or None Minimal or None Minimal 1. Low Complexity (LC) Limited (2) Limited (2) Low 2. Moderate Complexity (MC) Multiple (3) Multiple (3) Moderate 3. High Complexity (HC) Extensive (4 or more) Extensive (4 or more) High 4. Two Out of Three of the Elements Required IV. TIME (Use time to code only when counseling is more than 50% of the total visit time. Documentation must include what topics were counseled.) Total Visit Time: Total Counseling Time: Physician s Signature NEW PATIENTS* (New patient defined as not seen in 3 yrs) * Requires 3 of the 3 components CPT Time History Exam Medical Decision HPI 1; ROS 0; PSFH 0 PF Problem Focused PF Straight Forward SF HPI 1; ROS 1; PSFH 0 EF Expanded PF EF Straight Forward SF HPI 4; ROS 2; PSFH 1 D Detailed D Low Complexity LC HPI 4; ROS 10; PSFH 3 C Comprehensive C Mod Complexity MC HPI 4; ROS 10; PSFH 3 C Comprehensive C High Complexity HC ESTABLISHED PATIENTS* * Requires only 2 of the 3 components CPT Time History Exam Medical Decision No Doctor Involved HPI 1; ROS 0; PSFH 0 PF Problem Focused PF Straight Forward SF HPI 4; ROS 1; PSFH 1 EF Expanded PF EF Low Complexity LC HPI 4; ROS 2; PSFH 1 D Detailed D Mod Complexity MC HPI 4; ROS 10; PSFH 2 C Comprehensive C High Complexity HC SUBSEQUENT HOSPITAL CARE* * Requires only 2 of the 3 components CPT Time History Exam Medical Decision HPI 1; ROS 0; PSFH 0 PF Problem Focused PF Straight Fwd/Low Comp SF/LC HPI 1; ROS 1; PSFH 0 EF Expanded PF EF Moderate Complexity MC HPI 4; ROS 2; PSFH 1 D Detailed D High Complexity HC CONSULTS / INITIAL HOSPITAL VISIT* * Requires 3 of the 3 components CPT Outpt / Inpt Time History Exam Medical Decision * 99241/* /20 HPI 1; ROS 0; PSFH 0 PF Problem Focused PF Straight Forward SF * 99242/* /40 HPI 1; ROS 1; PSFH 0 EF Expanded PF EF Straight Forward SF * 99243/* /55 HPI 4; ROS 2; PSFH 1 D Detailed D Low Complexity LC * 99244/* /80 HPI 4; ROS 10; PSFH 3 C Comprehensive C Mod Complexity MC * 99245/* /110 HPI 4; ROS 10; PSFH 3 C Comprehensive C High Complexity HC HPI 4; ROS 2-9; PSFH 1 D Detailed D Straight Fwd/Low Comp SF/LC HPI 4; ROS 10; PSFH 3 C Comprehensive C Moderate Complexity MC HPI 4; ROS 10; PSFH 3 C Comprehensive C High Complexity HC * NOTE: For 2010 Medicare Consult codes not used: Office/outpatient change to Inpatient change to , as supported by documentation, change to Not recognized by most Medicare Advantage Contractors, i.e., BEL, H65, T65, etc. * NOTE: Nursing Facilities, i.e., NF or SNF, CPT codes use the same crosswalk for consultation codes, i.e., to 99221, to 99222, and to NOTE: True admitting physician to add modifier AI to codes Lower-level inpatient consult codes ( ) aren t directly comparable to a Level 1 initial hospital care code (99221) therefore no exact crosswalk (no arrows guiding you). The consult codes require only a problem-focused History and expanded problem-focused Exam while must have a detailed or comprehensive History and Exam. To qualify for the (admit/initial inpatient) code the provider would have to beef up their HISTORY and EXAM; or to play it safe use and respectively.

12 I HISTORY II - EXAM III - MEDICAL DECISION MAKING Circle column to right corresponding to number of systems reviewed HPI (History of Present Illness) PF EF D C Context Duration Location Modifying Factor Brief Brief Ext Ext Quality Severity Assoc Signs/Symptoms Timing ROS (Review of Systems) Comp Allergic/Immunologic Cardiovascular Constitutional (wt loss,etc.) Ears/Nose/Mouth/Throat Pertinent 10 Extd None to with Endocrine Eyes Gastrointestinal Genitourinary 2-9 all others Hematologic/Lymphatic Integumentary problem (Skin, Breast) Musculoskeletal Neurological stated as Psychiatric Respiratory All Others Negative negative PFSH (Past Medical, Family and Social History) Past Medical History (Patients past experiences with illness, operations, injuries, and treatments) Family History (Review of medical events in the patients family, including diseases which may be hereditary or place the patient at risk) Social History (Age appropriate review of past and current activities) New Patient New Patient defined as not seen in 3 yrs Established Patient Est Pt/ER None None Pertinent to problem Comp 2-3 New Pt/Consult/ Admit None None = Complete PFSH includes 2 history areas for established patients office outpatient care, domiciliary care, home care, emergency department, and subsequent nursing facility care. = Complete PFSH includes 3 history areas for new patients office outpatient care, domiciliary care, home care, consultations, initial hospital care, hospital observation, and comprehensive nursing facility assessments. Body Areas PF EF D C Abdomen Back (Spine, etc.) Chest (Breast, Axillae, etc.) Each Extremity Head (face, etc.) Genitalia/Groin Neck (URE, ULE, LRE, LLE) Organ Systems Constitutional (3) Cardiovascular Ears/Nose/Mouth/Throat Eyes Gastrointestinal Genitourinary Hem/Lymph/Imm Musculoskeletal Neurological Psychiatric Respiratory Skin = Refer to 1997 E&M Documentation Guidelines for details on reporting 1 organ system or 1 organ system in detail Number of Diagnoses or Management Options (Number x Points = Results) Number Points Results Self-limited or minor (stable, improved or worsening) (Max 2) 1 Established problem (to examiner) (stable, improved) 1 Established problem (to examiner) (worsening) 2 New Problem (to examiner), no additional workup planned (Max 1) 3 New Problem (to examiner), additional workup planned 4 Total: (circle result in line A below, Complexity of Decision Making) A Amount and/or Complexity of Data to be Reviewed 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 2 than patient and/or discussion of case with another health care provider Independent visualization of image, tracing or specimen itself (no simply review of record) 2 Total: (circle result in line B below, Complexity of Decision Making) B Risk of Complications and/or Morbidity or Mortality (circle risk level in line C below, Complexity of Decision Making) C Presenting Problem Diagnostic Procedure Ordered Management Options Selected Risk Level One self-limited or minor problem (cold, insect bite, etc.) Two or more self-limited or minor problems One stable chronic illness Acute uncomplicated illness or injury One or more chronic illness with mild exacerbation, progression, or side effects of treatment Two or more stable chronic illnesses Undiagnosed new problem with uncertain prognosis Acute illness with systemic systems Acute complicated injury One or more chronic illness with severe exacerbation, progression, or side effects of treatment Acute or chronic illnesses or injuries that may pose a threat to life or bodily function Abrupt change in neurologic status Laboratory tests requiring venipuncture Chest X-rays EKG/EEG KOH prep Urinalysis Ultrasound (echo, etc.) Physiologic tests not under stress Non-cardiovascular imaging studies with contrast Superficial needle biopsies Clinical laboratories tests requiring arterial puncture Skin biopsies Physiologic tests under stress Diagnostic endoscopies with no identified risk factors Deep needle or incisional biopsy Cardiovascular imaging studies with contrast and no identified risk factors Obtain fluid from body cavity Cardiovascular imaging studies with contrast with identified risk factors Cardiac electrophysiological tests Diagnostic endoscopies with identified risk factors Discography Rest Gargles Elastic bandages Superficial dressings Over-the-counter drugs Minor surgery with no identified risk factors Physical therapy Occupational therapy IV fluids without additives Minor surgery with identified risk factors Elective major surgery (open percutaneous or endoscopic) with no identified risk factors Prescription drug management Therapeutic nuclear medicine IV fluids with additives Closed treatment of fracture or dislocation without manipulation Elective major surgery (open, percutaneous or endoscopic) with identified risk factors Emergency major surgery (open, percutaneous 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 8 or 1 organ system complete Minimal Low Moderate Complexity of Medical Decision Making (2 of 3 required, copy answers from above) A - Number of Diagnoses or Management Options 1 Minimal 2 Limited 3 Multiple 4 Extensive B - Amount and/or Complexity of Data to be Reviewed 1 Minimal 2 Limited 3 Multiple 4 Extensive C - Risk of Complications and/or Morbidity or Mortality Minimal Low Moderate High Type of Decision Making (column with 2 of 3 circled): Straight Forward Low Complexity Moderate Complexity High Complexity High