evaluation and management codes justine strand, mph, pa-c patricia castillo, ms, pa-c victoria...
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Evaluation and Management Codes
Justine Strand, MPH, PA-C
Patricia Castillo, MS, PA-C
Victoria Kaprielian, MD
Basics of E&M coding
• history
• physical examination
• medical decision making
• time
Categories of E&M codes
• Outpatient
• Inpatient
• Consultation
• Emergency department
Categories of E&M codes, cont’d
• Nursing home
• Rest home
• Home visits
• Other
Levels of codes
• Problem focused
• Expanded problem focused
• Detailed
• Comprehensive
History levels
• Problem focused (PF)– chief complaint– brief HPI
• Expanded problem focused (EPF)– CC, HPI– problem-pertinent ROS
History, continued
• Detailed (D)– CC, HPI– extended ROS– pertinent PMH, FH, or SH
• Comprehensive (C)– CC, HPI– complete ROS, PMH, FH, SH
History examples: asthma
• PF: Breathing fine, no complaints
• EPF: include medication use, recent URI sx
• D: add assessment of exposure to allergens, family hx asthma, some ROS
• C: lifelong history of asthma; full PMH, FH, SH, ROS
Exam levels
• Problem focused (PF)– affected body area or organ system
• asthma example: lungs
Exam levels, continued
• expanded problem focused (EPF)– above plus– other symptomatic or related organ systems
• example: lung exam plus ENT or heart
Exam, continued
• Detailed (D)– extended exam of affected body area and
related organ systems
• exam of lungs, ENT, cardiovascular, and extremities
Exam, continued
• Comprehensive (C)– complete multi-system exam
• complete exam
Basics of E&M coding
• history
• physical examination
• medical decision making
• time
Elements of medical decision-making
• number of diagnoses and management options to be considered
• amount and complexity of data reviewed– labs– prior records– consultant reports
• risk level: complications, morbidity, mortality
Diagnoses and decision-making
• Beware of “coding by diagnosis”
Medical decision-making
Level complexity Dx/tx options Data reviewed
Risk
Straight-forward Minimal Minimal Minimal
Low Limited Limited Low
Moderate Multiple Moderate Moderate
High Extensive Extensive High
Decision-making examples
1. doing fine, no change
2. check peak flow, adjust medications
3. nebulizer treatment with peak flows before and after, review past levels, add steroid, discuss criteria for urgent care
4. start home nebs, oral steroids; review hospital chart; discuss medication side effects and risks; consider hospitalization, discuss criteria for ER
Other factors
• New vs. established patient– new = not seen within 3 years– documentation requirements stricter (3/3)
Other factors
• time– lesser element– use if counseling > 50% of encounter– document face-to-face time
Putting it together: established pts
• Requires 2 of 3 elements
History Exam MDMFace-to-
face
99211supervision
onlysupervision
onlyStfrwd 5 min.
99212 PF PF Stfrwd 10 min.
99213 EPF EPF Low 15 min.
99214 D D Moderate 25 min.
99215 C C High 40 min.
Putting it together: new pts
• Requires 3 of 3 elements
History Exam MDMFace-to-
face
99201 PF PF Stfrwd 10 min.
99202 EPF EPF Stfrwd 20 min.
99203 D D Low 30 min.
99204 C C Moderate 45 min.
99205 C C High 60 min.
Common errors
• Undercoding
• Overcoding
Other settings
• Same system
• Different specifics
Health Maintenance
Age New pt Established pt
Less than 1 year 99381 99391
1-4 years 99382 99392
5-11 years 99383 99393
12-17 years 99384 99394
18-39 years 99385 99395
40-64 years 99386 99396
65 and over 99387 99397
Procedures
• Procedure only visits
• Combined procedure and E&M visits
• Modifier -25
Modifier 25
• Health maintenance visits
• Reimbursement issues
Prolonged services
• Face-to-face
• Other
Prolonged services
• Examples
How it works in practice
• Each practice develops their own system
• Encounter forms--provider marks with:– charge code(s)– diagnoses– procedures/tests/therapies performed
What if you get it wrong?
• undercoding
• overcoding
Summary
• Code for what you do
• Document in sufficient detail to justify level
• Be as specific as possible
• Include diagnoses appropriate for every service delivered
• Remember modifiers when needed
• Keep learning!