The evaluation-and-management (E/M) codes in the 1992 CPT Book are entirely new. All

Transcription

1 Printed in Plastic Surgery News - February 1992 Don't kill the messenger New evaluation/management codes announced By Raymond Janevicius, MD The evaluation-and-management (E/M) codes in the 1992 CPT Book are entirely new. All previous E/M or "visit" codes have been deleted and replaced with ones that have more specific definitions and clearer applications. Read the specific explanations on pages one-through-44 very carefully. Although the guidelines will appear extremely confusing at first, step-by-step application will result in accurate use of these new codes. As you apply the codes to clinical situations, you will find that the new system is quite logical, since there is a tight internal consistency between the codes and their use. This month's CPT Corner will discuss the applications of the new E/M codes to plastic surgery. Use the accompanying tables to help you code patient visits. The E/M codes (new and established patient encounters; inpatient services; in and outpatient consultations; and emergency, nursing-home and home-care services) are each made up of seven components three so-called key components and four contributory ones. The three key components that must be used to determine the level of service are: history examination, and medical decision making Four types of history and four types of examination are described, each with specific characteristics of their own (see Tables I and II). For example, a "problem-focused history" must include the chief complaint and the history of the present illness. A "detailed examination" must include an extended evaluation of the affected body area and other symptomatic or related organ systems. The four types of medical decision making are described as straightforward, low complexity, moderate complexity and high complexity (Table III). The type of medical decision making used is determined by three considerations: the number of diagnosis or management options the amount and/or complexity of data to be reviewed, and

2 the risk of complications and/or morbidity/mortality associated with the presenting problems, the diagnostic procedures, and/or the management options. Two of the three criteria in Table III must be met or exceeded to define the type of decision making. To understand this process, consult this table while reading the following examples: If the number of diagnostic and management options is "limited," the amount and complexity of data to be reviewed is "limited," and the risk of complications is"low," the type of medical decision making is of "low complexity." If the number of diagnosis or management options is "limited," the amount of data to be reviewed is "moderate," and the risk of complications is "moderate," then the type of decision making is of "moderate complexity"-- since two out of the three requirements for this category are met. Defining the type of medical decision making is probably the most confusing part of determining the level of service. Practice using Table III with your own clinical examples. Each of these three key components--history, examination and medical decision making--must be described to define new patient encounters. Two of the three components must be described to define established patient encounters. Use the grid in Table V to determine the level of service. For example, if you perform an expanded problem-focused history and an expanded, problemfocused examination during a new patient encounter--and if you determine that the type of medical decision making is straightforward--then use code (new patient, level II). If you perform a detailed history and a detailed examination on an established patient, but the medical decision making is of low complexity, you use (established patient, level IV), because two of the three key components for this are present. It cannot be overemphasized that documentation in the medical record is necessary to justify the level of service. Arbitrarily choosing a level of service will no longer be possible. It is obvious, for example, that you cannot perform five level III new patient encounters (99203) in one hour. Your medical records may be audited, and documentation must be found to justify the level of service described and billed. The four contributory components that aid in confirming the level of service, but are not necessary for all patient encounters are: counseling coordination of care nature of the presenting problem, and time Contributory factors such as "nature of the presenting problem" and amount of time spent nearly always match the level of service determined by the three key components. After you work through a few examples from your own practice, you will see how nicely this system works. The nature of the presenting problem can be classified as minimal, self-limiting or minor, low severity, moderate severity or high severity (see Table IV for specific definitions of these terms). Time is defined as the time it usually takes a physician to perform the service. For new and established patient encounters ( and ), it is the total face-to-face

3 physician-patient time. (Time is defined differently for other evaluation-and-management codes.) It should not be regarded as a hard-and-fast amount, and should not be used as the sole determination of level of service. It should merely be used as a guide (just like nature of the presenting problem) once the level of service has been determined. Therefore, after determining the level of service using history, examination and medical decision making, verify your choice by examining the "nature of the presenting problem" and "time," as indicated in Table V. These components should nearly always correspond to the level of service that you have chosen based on the three key components. One significant exception in the above rule exists. If counseling or coordination of care dominates an en-counter--that is, if either component comprises more than 50 percent of the face-to-face physician/patient contact--then time is considered the key or controlling factor. Consider the vignette for a level III new patient (99203): a detailed history is taken that includes the chief complaint, the history of present illness, a past medical history with system review, and a pertinent family and social history (occupation, specific work duties, etc.). A detailed or even a comprehensive physical exam is performed, since a complete forearm and hand examination is required. The medical decision making is of low complexity, since the number of diagnosis and management options is "limited, " the amount and complexity of data to be reviewed is "limited," and the risk of morbidity/mortality is "moderate" (see Table IV). Remember that two out of the three criteria must be met or exceeded to determine the type of medical decision making. Table V indicates that this "translates" to a Level III new patient(99203). This is further confirmed by the contributing components: The nature of the presenting problem is of "moderate severity," since the risk of morbidity without treatment is moderate and there is an increased probability of prolonged functional impairment. Moreover, the time of this encounter averages 30 minutes face to face. Initially, this may seem to be a very involved, cumbersome process, but as you practice with a few of your own clinical examples and go through it step by step, you will see that the categories do indeed describe quite accurately your patient encounters. The vignettes listed are provided to help you determine levels of service for new and established plastic surgery patients. The AMA has not, unfortunately, provided us with specialty-specific examples for each level of service, so we have designed our own. The accompanying tables have been constructed to summarize the information needed in easily usable form. Use the tables and this CPT Corner as a reference when coding new and established patient encounters. Since this is an entirely new system and we are all just beginning to use it, I encourage your comments and suggestions. Table 1 History Problem Focused (PF)

4 Chief complaint Brief HPI Expanded Problem Focused (EPF) Chief complaint Brief HPI Problem pertinent system review Detailed (DET) Chief complaint Extended HPI Extended System Review Pertinent PMH, PH, and/or SH Comprehensive (COMPR) Chief complaint Extended HPI Complete System Review Complete PMH, FH, and/or SH Table II Examination Problem Focused (PF) Limited to the affected body area or organ system Expanded Problem Focused (EPF) Affected body area or organ system and other symptomatic or related organ systems Detailed (DET) Extended examination of the affected body area and other symptomatic or related organ systems Comprehensive (COMPR) Complete single-system specialty examination or a complete multisystem examination TYPE OF DECISION MAKING STRAIGHT- FORWARD Table III Medical Decision Making NUMBER OF DIAGNOSIS OR MANAGEMENT OPTIONS AMOUNT AND/OR COMPLEXITY OF DATA TO BE REVIEWED minimal minimal or none minimal LOW limited limited low RISK OF COMPLICATIONS AND/OR MORBIDITY/MORTALITY

5 COMPLEXITY MODERATE COMPLEXITY HIGH COMPLEXITY multiple moderate moderate extensive extensive high Table IV Nature of the Presenting Problem Minimal (MIN) May not require presence of the physician. Service provided under the physician's supervision. Self-limited or minor (SL/MIN) Runs a definite and prescribed course; Transient in nature; Not likely to permanently alter health status OR Has good prognosis with management and compliance Low Severity (LOWSEV) Risk of morbidity without treatment is low Little to no risk of mortality without treatment Full recovery without functional impairment is expected. Moderate severity (MODSEV) Risk of morbidity without treatment is moderate; Moderate risk of mortality without treatment; Uncertain prognosis OR Increased probability of prolonged functional impairment High severity (HISEV) Risk of morbidity without treatment is high to extreme: Moderate to high risk of mortality without treatment; OR High probability of severe, prolonged functional impairment Table V New and Established Patient Evaluation-and-Management codes 3/3 New 2/3 Established

6 CODE HISTORY PHYSICAL* MDM* NATURE TIME NEW-I PF PF SF SL/MIN 10 NEW-II EPF EPF SF LOWSEV 20 NEW-III DET DET LOWCOM MODSEV 30 NEW-IV COMPR COMPR MODCOM MODSEV/HISEV 45 NEW-V COMPR COMPR HICOM MODSEV/HISEV 60 EST-I MAY NOT REQUIRE MD MIN 5 EST-II PF PF SF SL/MIN 10 EST-III EPF EPF LOWCOM LOWSEV/MODSEV 15 EST-IV DET DET MODCOM MODSEV/HISEV 25 EST-V COMPR COMPR HICOM MODSEV/HISEV 40 *Key components Vignettes New Patient, Level 1: year-old man seen for reassurance about an isolated seborrheic keratosis on his upper back. 5-year-old girl seen for suture removal from a simple laceration, placed by another physician. New Patient, Level II: year-old woman with post-traumatic PIP arthritis. Exam of hand, review of X-rays. Prescribe anti-inflammatories. (Note: The history and examination are expanded and problem focused, and the medical decision making is straightforward. Use Table V to determine that this is a Level II new patient encounter.) New Patient, Level III: year-old construction worker with a three-day-old laceration on his forearm with numbness in his index finger and inability to flex IP of thumb. Complete forearm/hand exam. Surgery options discussed, with explanation of potential morbidity/disability of median-nerve paralysis. New Patient, Level IV: year-old female, post modified-radical mastectomy for infiltrating ductal carcinoma, seen for breast reconstruction. Strong family history of breast cancer. Bilateral breast and axillary exam. Contralateral breast ptosis. Pathology slides reviewed. Breast reconstruction options detailed, including options for surgery on opposite breast. (Note: Although this patient encounter probably requires a comprehensive history and a comprehensive examination, the medical decision making is of moderate complexity. See Table III.) New Patient, Level V: 99205

7 60-year-old smoker, heavy drinker, diabetic with weight loss, bleeding, ulcerated lesion on the floor of the mouth and an ipsilateral neck mass. Complete head/neck and intraoral exam. CT scan reviewed. Discuss workup, including endoscopy; prognosis; and radiation and surgery as manage-ment options (anticipating composite resection with pectoralis flap). (Note: Medical decision making is of high complexity, so choose Level V.) Established Patient, Level I: Ten-year-old child seen in office to remove sutures from a 2 cm intermediate repair (12051) on the forehead, performed four days ago in the E.R. Established Patient, Level II: year-old athlete seen for removal of splint applied for an ulnar collateral ligament sprain of the thumb. Thumb exam and initiation of therapy. Established Patient, Level III: year-old female, one year post excision of a nasal basal cell with a nasolabial flap. New, suspicious recurrent lesion on the nose and a suspicious lesion on the back. Exam of both areas, with plan to excise. (Note: An expanded, problem-focused history and examination are performed. Medical decision making is of low complexity.) Established Patient, Level IV: year-old man, two years post wide excision of melanoma on the thigh with STSG and groin dissection. Now presenting with a groin mass and a suspicious, pigmented lesion adjacent to STSG. Established Patient, Level V: year-old established patient two years post burn with bilateral ectropion, hypertrophic facial burn scars, near absence of the left breast and burn syndactyly of both hands. Examination, explanation of options and discussion of multi-stage reconstruction of the face, breast and hands. 45-year-old female, two years post breast reconstruction with polyurethane implant. No specific problems, but seeks consultation due to fear created by the implant controversy in the media. Forty-five minute discussion of capsular contracture, cancer risk from implant, adjuvant disease, recent FDA rulings and current status of implants. (Note: Counseling dominates this encounter, so time is the key factor.) Dr. Janevicius is chairman of the Society's CPT Committee.