Compliant EM Coding and Documentation Outpatient Coding

Compliant EM Coding and Documentation Outpatient Coding Steve Adams, MCS, COC, CPC, CPMA, CPC-I, PCS, FCS, COA Steve.adams@ingaugehsi.com 770-709-3598

www.thecodingeducator.com

Incident To & Shared Visits E and M Coding for: - New Office Visits - Established Office Visits - Consultation Visits Preventive Services - Tobacco - Home Health - AWV Discussion Points

Incident To & Shared Visit

Incident To Billing (office) Four standard criteria: 1.Physician must be in office 2.Must be an established patient 3.Must not change anything from previous plan of care 4.Doctor should see patient every 3 rd or 4 th visit (shows active participation)

Shared Visits (hospital) Two standard criteria: 1.NPP sees patient and documents note 2.MD sees patient and documents mini hx, exam and MDM on same date

E&M Coding

Code Selection Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.

Office Outpatient Services

Outpatient Visit New 99201-99205 Requires All Three Key Elements

Q1. Which of the following statements is most compliant with CMS documentation? 1. 14 point system review normal 2. See HPI for ROS 3. ROS positive for SOB, all other systems reviewed were negative 4. All of the above 0% 0% 0% 0% 1. 2. 3. 4. 10

New Patients Think: 99202 No treatment 99203 Short term meds, OTC, minor surgery 99204 Long term meds, major surgery 99205 Sick enough to admit / major surgery with risks / extensive data Also check grid to make sure you document correct history and examination!!

Initial Visits New Outpatient Peer Data Dr. Gotcha 45% 54% 27% 31% 22% 1% 4% 5% 6% 6% 99201 99202 99203 99204 99205

New/Consultation Patient Visits (3 out of 3) Code Minutes History Examination Decision-Making 99201 10 99241 15 99251 20 CC 1HPI Problem Focused Problem Focused 1995 (1) 1997 (1 check) Straightforward Diagnosis Minimal Data Minimal or None Risk Minimal 99202 20 99242 30 99252 40 CC 1 HPI 1 ROS Exp. Problem Focused Exp. Problem Focused 1995 (2 7) 1997 (6 checks) Straightforward Diagnosis Minimal Data Minimal or None Risk Minimal 99203 30 99243 40 99253 55 Detailed CC 4 HPI or status of 3 chronic conditions 2 ROS Medical or Family or Social History Detailed 1995 (4-7 need 4x4) 1997 (12 checks) Low Diagnosis Limited Data Limited Risk Low OTC, Short-term Meds, Minor Surgery 99204 45 99244 60 99254 80 Comprehensive CC 4 HPI or status of 3 chronic conditions 10 ROS Medical, Family, Social History Comprehensive 1995 (8) 1997 (2 checks from 9 areas); or 1997(all checks in border & 1 check in others) Moderate Diagnosis Multiple Data Moderate Risk Moderate Long term Rx or Major Surgery 99205 60 99245 80 99255 110 Comprehensive CC 4 HPI or status of 3 chronic conditions 10 ROS Medical, Family, Social History Comprehensive 1995 (8) 1997 (2 checks from 9 areas); or 1997(all checks in border & 1 check in others) High Diagnosis Extensive Data Extensive Risk High

1995 Comprehensive (8) 1. Const: Vital signs listed above. Well developed, well nourished and in no acute distress. Alert and oriented X s 3. No mood disorders noted, calm affect. 2. Eyes: Sclera white, conjunctiva clear, lids are without lag. PERRLA. Pupils and irises are equal and round without defect. 3. ENT: TMs intact and clear, normal canals, grossly normal hearing. Oropharanx clear and moist without erythema. Gums pink, good dentition. 4. Lymph/Neck: No masses, thyromegaly, or abnormal cervical notes. No bruit. Tracheal midline. 5. Cardio: RRR, Normal S1, S2 w/o murmurs, rubs or gallops. Skin warm and dry. No peripheral edema. 6. Respiratory: Chest symmetrical, respirations non-labored. No dullness or flatness. Clear bilaterally to auscultation, non-tender to palpitation. 7. Musculo: No deformity or scoliosis noted. No frank gait disturbance noted. No cyanosis or edema. Pulses normal in all 4 extremities. No atrophy or abnormal movements. Appropriate muscle strength bilaterally. 8. Neurologic: No focal deficits, cranial nerves II-XII grossly intact with normal sensation, reflexes, coordination, muscle strength and tone. 9. GI/Abdomen: Soft, non tender, non distended, no hepatosplemomegaly, normal bowel sounds, no masses noted.

What Doesn t Count (8) - 1995 Head Neck Thyroid Abdomen Extremities Back Under the 1995 Guidelines CMS and the AMA want you to examine ORGAN SYSTEMS and not body areas with regard to any code with the number (8) in the exam criteria

Expanded vs. Extended The difference is not the number of systems examined. Two to seven systems are required for both examinations. The difference is the detail in which the examined systems are described.

1995 Detailed 4-7 (4x4) 1. Const: Vital signs listed above. Well developed, well nourished and in no acute distress. Alert and oriented X s 3. No mood disorders noted, calm affect. 2. Eyes: Sclera white, conjunctiva clear, lids are without lag. PERRLA. Pupils and irises are equal and round without defect. 3. ENT: TMs intact and clear, normal canals, grossly normal hearing. Oropharanx clear and moist without erythema. Gums pink, good dentition. 4. Lymph/Neck: No masses, thyromegaly, or abnormal cervical notes. No bruit. Tracheal midline. 5. Cardio: RRR, Normal S1, S2 w/o murmurs, rubs or gallops. Skin warm and dry. No peripheral edema. 6. Respiratory: Chest symmetrical, respirations non-labored. No dullness or flatness. Clear bilaterally to auscultation, non-tender to palpitation. 7. Musculo: No deformity or scoliosis noted. No frank gait disturbance noted. No cyanosis or edema. Pulses normal in all 4 extremities. No atrophy or abnormal movements. Appropriate muscle strength bilaterally. 8. Neurologic: No focal deficits, cranial nerves II-XII grossly intact with normal sensation, reflexes, coordination, muscle strength and tone. 9. GI/Abdomen: Soft, non tender, non distended, no hepatosplemomegaly, normal bowel sounds, no masses noted.

1997 Bullet Guidelines Allow you to document systems and areas, however you have to be very specific about what you document about those systems and areas. Most EMRs are based on the 1997 guidelines but are not compliant

Multi-System

Single System

What To Do I ll have a copy of those guidelines posted on my web site and I ll give you a link on medicalofficeblog.com Make sure that you are only getting credit for what the government says you get credit for documenting. THIS IS A CRITICAL COMPONENT OF YOUR EMR COMPLIANCE

Q2. A new patient is someone not seen by you or a member of the same group, same specialty, within the last? 0% A. New problem new patient 0% 0% 0% B. Two years C. New practice new patient D. Three years 10

Outpatient Visit Established Patient 99211-99215 Requires Two of Three Key Elements

Q3. When billing for a 99214 based on a counseling driven encounter, what is the minimum amount of time you are required to spend face-to-face with the patient? A. 17 minutes B. 25 minutes C. 45 minutes D. 40 minutes 0% 0% 0% 0% A. B. C. D. 10

Established Patients Think: 99212 One stable condition 99213 Two stable or one unstable problem 99214: - 3 chronic stable on meds - 2 unstable on meds - 1 stable and one unstable on meds 99215 Sick enough to admit/extensive dx with risk or data Also check grid to make sure you document correct history and examination or counseling time!!

Established Visits Established Outpatient Peer Data Dr. Gotcha 45% 43% 41% 36% 18% 5% 1% 4% 5% 1% 99211 99212 99213 99214 99215

Established Patient Visits (2 out of 3) 99211 N/A N/A N/A N/A 99212 10 CC 1HPI Problem Focused Problem Focused 1995 (1) 1997 (1 check) Straightforward Diagnosis Minimal 1 Data Minimal or None 1 Risk Minimal 1 1 stable problem 99213 15 CC 1 HPI 1 ROS Exp. Problem Focused Exp. Problem Focused 1995 (2 7) 1997 (6 checks) Low Diagnosis Limited 2 Data Limited 2 Risk Low 2 2 stable problems 1 unstable problem 99214 25 Detailed CC 4 HPI or status of 3 chronic conditions 2 ROS Medical or Family or Social History Detailed 1995 (4-7 need 4x4) 1997 (12 checks) Moderate Diagnosis Multiple 3 Data Moderate 3 Risk Moderate 3 3 stable problems on meds 1 stable and 1 unstable on meds 2 unstable problems on meds New problem requiring major surg 99215 40 Comprehensive CC 4 HPI or status of 3 chronic conditions 10 ROS Medical, Family, Social History Comprehensive 1995 (8) 1997 (2 checks from 9 areas); or 1997(all checks in border & 1 check in others) High Diagnosis Extensive 4 Data Extensive 4 Risk High 4 Very sick patient with extensive data review and high risk

Counseling Dominated 3 standard criteria for time: 1. Total Face-to-Face time of provider 2. That more than 50% was counseling 3. Topics you discussed If the level of care is being based on time spent with the patient for counseling/coordination of care documentation should support the time for the visit and the documentation must support in sufficient detail the nature of the counseling

Signature Requirements Make sure you properly SIGN all your notes, orders, test results; all documentation that supports a claim in the patient chart should have the provider s signature. If the provider is initialing this documentation he/she must also print their name by the initials or circle the typed name on an office form. This lets the reviewer clearly see that who documented the medical record.

Consultation Visits

Q4. Which of the following codes should be used when seeing a new Medicare patient in your office for the first time moderate complexity consultation? 0% A. 99254 0% 0% 0% B. 99214 C. 99204 D. 99244 10

Outpatient Visit Consults 99241-99255 Requires All Three Key Elements

Preventive Medicine Services

Q5. G0436 (Tobacco cessation counseling) is billable in what place of service (8 times per year, per patient)? A. Office B. Hospital C. Nursing Home D. All above 0% 0% 0% 0% A. B. C. D. 10

Tobacco Cessation Codes The CPT Codes: 99406: Smoking and tobacco cessation counseling; intermediate, greater than 3 minutes, up to 10 minutes, 99407: Smoking and tobacco cessation counseling; intensive, greater than 10 minutes, The Diagnosis Codes Medical dx of the patient at the time of the visit the tobacco is affecting If used with E/M, don t forget modifier 25

New Tobacco Cessation Codes The HCPCS Codes: G0436: Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes, G0437: Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, greater than 10 minutes, The Diagnosis Codes ICD-9 code 305.1 (non-dependent tobacco use disorder), or ICD-9 code V15.82 (history of tobacco use).

Home Health Certification The HCPCs Codes: G0179 Re-certification for Medicare-covered home health under a plan of care, including contacts with home health agency and review of reports of patient status required by physician to affirm plan of care G0180 - Certification for Medicare-covered home health under a plan of care, including contacts with home health agency and review of reports of patient status required by physician to affirm plan of care

New AWV Codes G0438 (Annual wellness visit; includes a personalized prevention plan of service (PPPS), first visit); and G0439 (Annual wellness visit; includes a personalized prevention plan of service (PPPS),subsequent visit). We note that practitioners furnishing a preventive medicine E/M service that does not meet the requirements for the IPPE or the AWV would continue to report one of the preventive medicine E/M services CPT codes in the range of 99381 through 99397 as appropriate to the patient's circumstances, and these codes continue to be noncovered by Medicare."

1. Health Risk Assessment AWV - Initial 2. Establishment of an individual's medical and family history. 3. Establishment of a list of current providers and suppliers that are regularly involved in providing medical care to the individual. 4. Measurement of an individual's height, weight, body mass index (or waist circumference, if appropriate), blood pressure, and other routine measurements as deemed appropriate, based on the individual's medical and family history. 5. Detection of any cognitive impairment that the individual may have. 6. Review of the individual's potential (risk factors) for depression, Review of the individual's functional ability and level of safety, based on direct observation. 7. Review of the individual's functional ability and level of safety, based on direct observation 8. Establishment of the following: ++ A written screening schedule, such as a checklist, for the next 5 to 10 years ++ A list of risk factors and conditions for which primary, secondary or tertiary interventions are recommended. 9. Furnishing of personalized health advice to the individual and a referral, as appropriate. 10.. Any other element determined appropriate through the National Coverage Determination process.

1. Health Risk Assessment AWV - Subsequent 2. An update of the individual's medical and family history. 3. An update of the list of current providers and suppliers that are regularly involved in providing medical care to the individual, as that list was developed for the first AWV providing personalized prevention plan services. 4. Measurement of an individual's weight (or waist circumference), blood pressure, and other routine measurements as deemed appropriate, based on the individual's medical and family history. 5. Detection of any cognitive impairment, as that term is defined in this section, that the individual may have. 6. An update to both of the following: ++ The written screening schedule for the individual as that schedule was developed at the first AWV providing personalized prevention plan services. CMS-1503-FC 761 ++ The list of risk factors and conditions for which primary, secondary or tertiary interventions are recommended or are underway for the individual as that list was developed at the first AWV providing personalized prevention plan services. 7. Furnishing of personalized health advice to the individual and a referral, as appropriate, to health education or preventive counseling services or programs as that advice and related services are defined in paragraph (a) of this section. 8. Any other element determined through the NCD process.

Breast / Pelvic Exam The HCPCS Code: G0101 Pelvic and Breast Exam The Diagnosis Codes V72.31 Routine gynecological exam V76.47 Screening for neoplasm of the vagina V76.49 Screening of woman without a cervix V76.2 Screening for neoplasm of cervix V15.89* - Every Year Presenting health hazards

Obtain Pap Smear The HCPCS Code: Q0091 - Obtaining screen pap smear The Diagnosis Codes V72.31 Routine gynecological exam V76.47 Screening for neoplasm of the vagina V76.49 Screening of woman without a cervix V76.2 Screening for neoplasm of cervix V15.89* - Every Year Presenting health hazards

Incident To & Shared Visits E and M Coding for: - New Office Visits - Established Office Visits - Consultation Visits Preventive Services - Tobacco - Home Health - AWV Discussion Points

Evaluation Please take < 90 seconds to evaluate this session. Time permitting, speaker will take questions following evaluation. Responses are not displayed and are important in maintaining high quality education.

The overall performance of the speaker: 1. Poor 2. Fair 3. Average 4. Good 5. Excellent 0% 0% 0% 0% 0% 1. 2. 3. 4. 5. 10

How well were the learning objectives met? 1. Poor 2. Fair 3. Average 4. Good 5. Excellent 0% 0% 0% 0% 0% Poor Fair Average Good Excellent 10

Did speaker present a balanced view of therapeutic options? 1. Yes 2. No 3. N/A 0% 0% 0% Yes No N/A 10

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As a result of this program, do you intend to change your patient care? 1. Yes 2. No 0% 0% Yes No 10

Thank you!

Questions?

Any Questions Direct: 706-483-4728 E-Fax: 770-709-3698 E-mail: Web: steve.adams@ingaugehsi.com www.thecodingeducator.com Facebook: facebook.com/kingofcoders