Evaluation and Management (E/M) Training Module 9
AMA Disclaimer CPT copyright 2011 American Medical Association. All rights reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association. 2012 AAPC 2480 South 3850 West, Suite B, Salt Lake City, Utah 84120 800-626-CODE (2633), Fax 801-236-2258, www.aapc.com All rights reserved. CPC, CPC-H, CPC-P, CIRCC, CPMA, CPCO, and CPPM are trademarks of AAPC. CPT copyright 2011 AMA. All rights reserved. Page ii E/M Training
Module 1 M o d u l e 9 Specialty: Family Practice/Internal Medicine Family practice physicians focus on the overall health of the patient, including all diseases and related total health care of an individual and the family from adolescent to adult, often including some obstetrics. Internal medicine focuses on all diseases and related health care of an individual and the family with a focus on the adult population. Both specialties see a variety of diseases. Because of the focus on total health care for the patient, these specialties often see patients with multiple diagnoses making it imperative to understand application of ICD-9-CM codes. It is sometimes difficult to understand a chronic condition is only included in the E/M coding diagnoses if it is treated during that encounter, or becomes an active factor in the patient s care. As discussed in the ICD-9-CM chapter, the ICD-9-CM codes support medical necessity for the level of the visit. They also support the medical necessity for services performed during that visit. Many family practice offices perform minor procedures in the office at the time of an E/M visit. Medical Necessity CMS has developed policies regarding medical necessity based on regulations found in title XVIII, 1862(a)(1) of the Social Security Act. When a physician provides services to a Medicare beneficiary, he or she should bill only those services that meet the Medicare standard of reasonable and necessary for the diagnosis and treatment of a patient. National Coverage Determinations (NCD) explain when Medicare will pay for items or services. Each Medicare Administrative Contractor (MAC) is responsible for interpreting national policies into regional policies, called Local Coverage Determinations (LCD). LCDs explain when a given service is indicated or necessary, gives guidance on coverage limitations, describe the specific CPT codes to which the policy applies, and list ICD-9-CM codes that support medical necessity for the given service or procedure. LCDs have jurisdiction only within their regional area. If an NCD doesn t exist for a particular item, it s up to the MAC to determine coverage. If you are providing a service and the Medicare patient s diagnosis does not support the medical necessity requirements per the LCD, the service may not be covered. In such a case, the practice would be responsible for obtaining an Advance Beneficiary Notice of Noncoverage (Advance Beneficiary Notice, or ABN), as explained below. Commercial (non-medicare) payers may develop their own medical policies. These policies may not follow Medicare guidelines, and are specified in private contracts betweens the payer and the practice or provider. The Advance Beneficiary Notice (ABN) The ABN is a standardized form that explains to the patient why Medicare may deny the particular service or procedure. An ABN protects the provider s financial interest by creating a paper trail that CMS requires before a provider can bill the patient for payment if Medicare denies coverage for the stated service or procedure. The ABN form, entitled Revised ABN CMS-R-131, along with a full set of instructions, is available as a free download on the CMS Web site: www.cms. gov/bni/02_abn.asp. CMS will accept the ABN CMS-R-131 for either a potentially non-covered service or for a statutorily excluded service. CPT copyright 2011 AMA. All rights reserved. Page 1 E/M Training
Non-Medicare payers may not recognize an ABN. In some instances, health plan contracts may have a hold harmless clause found within the language that prohibits the billing to the patient for anything other than co-pays or deductibles. Preventive Services Family Practice/Internal Medicine offices commonly see patients for routine or preventive care. During the cold and flu seasons, they administer many pneumonia and influenza vaccinations. Pneumonia Under CMS guidelines, pneumonia vaccination is allowed once per lifetime for patients at risk. The guidelines further specify, however, that if the physician feels that the patient should have the shot more often, the service may be covered as long as diagnosis coding substantiates the need. Several codes may apply when reporting pneumonia vaccination: 90732 Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, for use in individuals 2 years or older, for subcutaneous or intramuscular use 90460-90472 Immunization administration for carriers who do not follow Medicare guidelines G0009 Administration of pneumococcal vaccine (Do not report this code with an E/M visit if the vaccination is the only reason for the visit) ICD-9-CM V03.82 Need for prophylactic vaccination against streptococcus pneumoniae (pneumococcus) Influenza The flu shot is covered every year, and Medicare will pay for a second vaccination if proven medically necessary. The flu vaccination does not require a physician to be present, according to CMS, nor does it require a physician order (which is why you can offer flu shots in a grocery store, for instance). Influenza virus vaccine codes are age-specific: 90654 Influenza virus vaccine, split virus, preservative-free, for intradermal use 90655 Influenza virus vaccine, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use 90656 Influenza virus vaccine, split virus, preservative free, when administered to 3 years and older, for intramuscular use 90657 Influenza virus vaccine, split virus, when administered to children 6-35 months of age, for intramuscular use 90658 Influenza virus vaccine, split virus, when administered to 3 years and older, for intramuscular use 90660 Influenza virus vaccine, live, for intranasal use 90662 Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use G0008 Administration of influenza virus vaccine (Do not report this code with an E/M visit if the vaccination is the only reason for the visit) 90460-90474 Immunization administration for carriers who do not follow Medicare guidelines When reporting the above codes, select a diagnosis of V04.81 Need for prophylactic vaccination and inoculation against other viral diseases. Medicare Initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV) Welcome to Medicare Physical An important Medicare benefit is the Welcome to Medicare Physical or IPPE (Initial Preventive CPT copyright 2011 AMA. All rights reserved. Page 2 E/M Training
Physical Exam). The IPPE is available to Medicare beneficiaries during the first 12 months of enrollment. The deductible requirement is waived. You can find the complete Medicare Preventive Services Guide on the CMS Web site: www. cms.hhs.gov/mlnproducts/downloads/mps_ QuickReferenceChart_1.pdf. The IPPE includes all of the following seven service elements: Review of beneficiary s medical and social history with attention to modifiable risk factors to disease detection Review of potential (risk factors) for depression (including past experiences with depression or other mood disorders) based on the use of an appropriate screening instrument [instrument may be defined through national coverage determination (NCD) process] Review of functional ability and level of safety; that is at a minimum a review of the following areas based on use of an appropriate screen instrument [instrument may be defined through NCD process]: hearing impairment activities of daily living falls risk home safety An exam to include measurement of height, weight, blood pressure, visual acuity screen and other factors deemed appropriate by the physician or qualified NPP based on the comprehensive medical and social history and current medical standards Performance and interpretation of an electrocardiogram (optional) Education, counseling, and referral, as deemed appropriate, based on the results of the review and evaluation services described in the previous five Education, counseling, and referral, including a written plan provided to the individual for obtaining the appropriate screening and other preventive services, which are separately covered under Medicare Part B benefits You should report an IPPE visit using G0402 Initial Preventive Physical Examination (IPPE). Annual Wellness Visit (AWV) Expanding on Medicare s preventive benefits, an Annual Wellness Visit (AWV) is allowed each year. The Annual Wellness Visits also includes Personal Prevention Plan Services (PPPS). The first AWV includes all of the following service elements: Establishing the beneficiary s past medical and family history An exam to include measurement of height, weight, body mass index, blood pressure, and other routine measurements deemed appropriate based on the medical and family history Establishing a list of care providers regularly involved in the care of the individual Detection of any cognitive impairment that the individual may have Review of risk factors for depression Review of functional ability and level of safety Create a written screening schedule Create a list of risk factors and conditions with recommendations for interventions Provision of personalized health advice During the subsequent AWV, the elements of the first AWV should be evaluated and updated. Specific requirements for both the first and subsequent AWVs can be found in the MCM, Chapter 12, 30.6.1.1. CPT copyright 2011 AMA. All rights reserved. Page 3 E/M Training
You should report the first AWV using G0438, allowed once per lifetime, and subsequent AWV visits with G0439, allowed once per year. Additional Preventive Services During preventive exams, the provider will often order lab tests such as general health panel. Sometimes, the venipuncture is performed in the office and the blood is sent out. Other times, the patient is sent to the lab for the venipuncture. Venipuncture is the collection of venous blood. The collection of the specimen by venipuncture is not considered an integral part of the laboratory procedure performed. Venipuncture frequently is bundled into any same-day E/M service, so check National Correct Coding Initiative (NCCI) edits before reporting. When the lab is performed by the physician s office, do not include the collection of the specimen via venipuncture or finger/heel/ear stick. When the specimen is obtained in the office and sent to a lab, handling and/or conveyance of specimen for transfer from the physician s office to a laboratory should be reported when the physician s office centrifuges the specimen, separates the serum and labels, or packages the specimens for transport to the laboratory. In this case, the venipuncture can also be reported. It is important when billing lab services you report the proper codes for panels. Some offices will send the specimens to labs, while other offices have lab services in the office. If performed in the office, select the appropriate code(s) to report the tests performed. To bill a panel all the tests in the panel must be performed. If one test is not performed on the list included in the panel, you would report each test separately. It is unbundling if you bill the tests separately when they are included in a panel. Urinalysis is commonly performed in the office. You must know if the test was automated or non-automated and whether microscopy was performed. One of the most common UAs performed in the office setting is 81002. Other common lab tests performed in the office include Rapid Strep Tests (87880) and Rapid Influenza Test (87804). The Clinical Laboratory Improvement Amendments (CLIA) (CLIA) regulations were passed in 1988 to establish quality standards for all laboratory testing, to ensure the accuracy, reliability, and timeliness of patient test results. Diagnostic test systems are placed into one of three CLIA regulatory categories: 1) waived tests; 2) tests of moderate complexity; 3) and tests of high complexity. Any lab or clinic performing any diagnostic test must have a CLIA number. All bills for tests must include the CLIA number of the testing location. Certificates for waived tests can be issued by application, without any inspection. Certificates for more complex testing require inspections, calibration of equipment, and other tests to assure the quality and accuracy of tests performed. Modifier QW is used when the service provided is a CLIA waived test. The modifier is required for Medicare claims. Third-party payers also may require QW; check with your individual payer. Common Procedures Performed in Family Practice/Internal Medicine As stated above, physicians in a Family Practice or Internal Medicine group will often perform minor in-office procedures. These procedures must be medically necessary to be covered by the carrier and documented in the medical record. Cosmetic procedures may be done in the office and not considered medically necessary, possibly resulting in the patient being responsible for the payment. Skin Tags Skin tags are defined as an outgrowth of both the epidermis and dermal fibrovascular tissue. The most common area for skin tags is the neck, back, and in the folds of skin (such as the underarm). Often the removal of skin tags is considered cosmetic. It is important to check the carrier CPT copyright 2011 AMA. All rights reserved. Page 4 E/M Training
guidelines for your patient as this is not a covered service for many carriers. CPT states that skin tag removal often is done by scissoring or any sharp method (using surgical scissors or a surgical blade to cut), ligature strangulation (tying suture material around the skin tag to stop the blood flow), electrosurgical destruction, or combination of treatment modalities, including chemical destruction or electrocauterization of wound, with or without local anesthesia. CPT code selection is determined based on how many skin tags are removed. Note that add-on code 11201 applies for each additional ten lesions or part thereof. If the provider removes 16 lesions, you would report 11200 and 11201. If the provider removed 25 lesions, however, you would still report 11200, 11201. Benign and Malignant Lesion Removal Lesion excision procedures 11400 11646 are grouped according to lesion pathology (benign or malignant), anatomic location and, finally, the excised diameter of the lesion. This last measurement is determined by adding together the lesion diameter and twice the narrowest necessary margin the physician removes. For example, if the lesion measures 2 cm in diameter, with margins on all sides of 0.5 cm, the excised diameter is 3.0 cm (2 cm + [0.5 cm x 2]). Be careful not to confuse the length of the incision with the width of the margins. Often, for instance, the physician will make an incision that is longer than the lesion to flatten the resulting scar, but this has no bearing on code selection for the excision. Example A patient has a 1 cm benign lesion on her cheek. The margin necessary for removal is.5 cm, but the physician takes an extra 1 cm margin to ensure good cosmetic outcome of the site since it is on the patient s face. The reportable size for coding would be 2 cm (1 cm lesion + 1 cm necessary margin). The extra 1 cm margin would not be reportable. Physicians should document the size of the lesion excision prior to removal. This is a matter of both clinical and coding accuracy. The lesion s size will decrease as soon as the first incision releases some of the tension on the skin, and the sample will likely shrink further when placed in formaldehyde. Do not base measurements according to the size of the surgical wound left behind. Because CPT classifies lesions as either benign or malignant, you should always wait for the pathology report before selecting CPT or ICD-9-CM codes to describe the excised lesion(s). There is a single exception to this rule: If the surgeon performs a re-excision to obtain clear margins at a subsequent operative session, you may report automatically the same malignant diagnosis you linked to the initial excision. This is true even if the pathology report on the second excision returns benign, because the original reason for the re-excision was malignancy. For example, the physician removes three lesions, all from the left arm, with excised diameters of 1 cm (benign), 1.5 cm (benign), and 2.5 cm (malignant). In this case, you should report: 11603 Excision, malignant lesion including margins, trunk, arms or legs; excised diameter 2.1 to 3.0 cm with diagnosis 11402 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 1.1 to 2.0 cm 11401 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.6 to 1.0 cm When reporting re-excisions of the same lesion (for instance, to remove a greater margin of tissue during the same session), report only a single code to describe the largest area excised. For re-excisions of the same lesion at a later session, report the appropriate excision code, based on size, with modifier 58 Staged procedural service appended. CPT copyright 2011 AMA. All rights reserved. Page 5 E/M Training
All excisions include simple closure, but intermediate or complex wound closures may be reported separately. Medical necessity must support separate billing for wound closure. Destruction of Lesion CPT codes 17000 17286 are used when reporting destruction of a lesion. According to AMA s CPT, Lesions include condylomata, papillomata, molluscum contagiosum, herpetic lesions, warts (eg, common, plantar, flat) milia or other benign, premalignant, or malignant lesions. Destruction means the ablation of benign, premalignant, or malignant tissues by any method, with or without curettage, including local anesthesia, and not usually requiring closure. There are several methods of destruction: electrosurgery, cryosurgery, laser, chemical treatment, and surgical curettage. Cerumen Removal Cerumen removal (69210 Removal impacted cerumen [Separate Procedure], one or both ears) is a designated separate procedure and is frequently bundled into other same-day procedures or services under NCCI edits. For example, if the provider performs cerumen removal on the same day as an E/M service, the removal is bundled to the E/M. Although, some payers may allow you to report both services. This code is inherently bilateral, and therefore modifier 50 or the billing of multiple units is not appropriate if the provider treats both ears. Additionally, cerumen must be impacted and requires the use of instrumentation for removal such as suction, curette, forceps or cerumen spoon to code 69210. Cerumen removal by ear lavage only does not qualify for the use of 69210. Documentation Dissection S: Established patient 1 is here with ear drainage from the left ear 2 over the last week. 3 He does notice that his hearing is not as good in this ear 4 and reports acute pain in this same ear. He really hasn t had much in the way of any cold symptoms. Right side, perhaps, feels slightly plugged but really not having other symptoms similar to this. 5 0: Examination of the right ear canal shows a complete occlusion with cerumen impaction. 6 After this is removed with ear irrigation, 7 the ear canal showed some erythema. The tympanic membrane, itself, is flat, normal markings and, otherwise, unremarkable. No evidence of fluid. Left side, however, shows a normal ear canal with some yellow fluid within the canal. The tympanic membrane, itself, is dull. There is a small posterior hole in the mid section revealing erythematous middle ear. 8 1 Established patient. 2 HPI: Location. 3 HPI: Duration. 4 HPI: Severity. 5 ROS: ENT. 6 Exam: OS ENT. 7 Removal of ear wax by irrigation is not reported separately. It is considered as part of the evaluation and management service. 8 Exam: OS ENT. CPT copyright 2011 AMA. All rights reserved. Page 6 E/M Training
A/P: (1) Acute otitis media, left ear 9 (2) Perforated left tympanic membrane 9 (3) Cerumen Impaction Right Ear 9 Plan: We cleared the ear of the cerumen impaction with ear irrigation. The patient to go on Ciloxan ophthalmic drops, 3 drops in the left ear q.3, 5 ml prescribed. Then he is also to use Amoxicillin 875 mg 1 p.o. b.i.d, # 20. 10 Will have him follow up in 2 weeks to reassess his ear. At this point, cautioned to keep things out of the ear. 9 New problem no further work-up planned. 10 Prescription drug management. CPT Code: 99213 ICD-9-CM code: 382.9, 380.4 Rationale: CPT code: Established patient office visits required 2 of 3 components. History HPI (brief), ROS (problem pertinent), PFSH (none) = expanded problem focused Exam Problem Focused Exam (1 Organ System) MDM New problem, prescription drug management = Moderate MDM During the evaluation and management service, the provider removed impacted cerumen with irrigation. Removal of impacted cerumen by irrigation only is considered inclusive to the evaluation and management code. In order for this to be reported separately, the physician would have had to utilize a suction cup, wax curettes, or other instrument to assist in the removal of the cerumen. ICD-9-CM code: The patient has acute otitis media. Look in the ICD-9-CM Alphabetic Index for Otitis/media/acute 382.9. The TM is also perforated. Look in the ICD-9-CM Alphabetic Index for Perforation/tympanum/with/ otitis media states to see otitis media, so this is not reported separately. For the cerumen impaction, look for Impaction/cerumen (ear) (external) 380.4. CPT copyright 2011 AMA. All rights reserved. Page 7 E/M Training