namas certified professional medical auditor curriculum

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Presented by Regan Tyler, CPC, CPC-H, CPC-I, CPMA, CEMC

Senior Consultant & NAMAS Instructor

Primary Care

Agenda

• E/M components

• E/M case examples

• Nurse code 99211

• Incident to & Split/Shared

• Modifier 25 (and other E/M modifiers)

• New Chronic Care Management codes

What Defines The Level of

Evaluation and Management (E/M) Code?

History

Exam

Medical Decision Making

Nature of Presenting Problem

Counseling

Coordination of Care

Time

“KEY” Components

Contributory Factors

CPT clearly demonstrates number of “key components” required

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History

History- Subjective

• Chief complaint – clear, concise statement detailing the reason the patient is presenting today, usually in the patient’s own words

o According to CMS, the CC may be combined with the HPI

• HPI (history of present illness)

• ROS (review of system)

• PFSH (past family social history)

History of Present Illness - HPI

• Location – where is it. (pain in LLQ abdomen)

• Quality – how does is feel – (diffuse-achy, tingling, numb etc.)

• Severity – how bad is it (0 – 10 for pain-adults, 0-3 kids)

• Duration – how long (3 days)

• Timing – when does the symptom occur (worse after meals)

• Context - what happen to caused it (fell while playing basketball twisting his knee)

• Modifying factors - what did the patient do in an attempt to alleviate their symptoms, and the result. (took otc)

• Associated signs and symptoms – what else is bothering the patient. (diarrhea & vomiting)

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Brief HPI

Mr. Jones complains of a worsening sore throat for which he

has been taking Sudafed.

Mr. Jones complains of a worsening QUALITY sore throat

LOCATION for which he has been taking Sudafed MODIFYING

FACTORS

Brief HPI

Sally continues to show improvement over the past 2 months

with her cholesterol on the current regiment of Lipitor.

Sally continues to show improvement QUALITY over the past 2

months DURATION with her cholesterol on the current regiment

of Lipitor MODIFYING FACTORS

Extended HPI

Arnold returns today with worsening low back pain. He

has been taking Advil every 4 hours, and the pain is

rated a 7 out of 10.

Arnold returns today with worsening QUALITY low back

LOCATION pain. He has been taking Advil MODIFYING

FACTORS every 4 hours, and the pain is rated a 7 out

of 10 SEVERITY

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Extended HPI

Patient returns with stable diabetes that he has had for the

past 10 years for which he takes Glucophage. He finds that his

sugar is most unstable just before bedtime

Patient returns with stable QUALITY diabetes that he has had

for the past 10 years DURATION for which he takes Glucophage

MODIFYING FACTORS He finds that his sugar is most unstable

just before bedtime TIMING

Review of Systems-(ROS)

• An inventory of the body systems of the patient to determine if the

patient is experiencing additional signs and/or symptoms

• Expand on remarkable symptoms

• A complete ROS (10+ systems) – Positive or pertinent negative

responses must be individually documented with a statement that

captures the remainder of the required review (e.g., remainder of 10

systems ROS are reviewed and negative”). In the absence of such a

notation, at least ten systems must be individually documented.

Review of Systems

• Constitutional

• Eyes

• Ears, Nose, Mouth, Throat

• Cardiovascular

• Respiratory

• Gastrointestinal

• Genitourinary

• Musculoskeletal

• Integumentary

• Neurological

• Psychiatric

• Endocrine

• Hematologic/Lymphatic

• Allergic/Immunologic

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Review of Systems

• Complete – inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems.

DG: At least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented.

**For the remaining systems, a notation indicating all other systems are negative is permissible (or something to this effect suggesting 10+ total). In the absence of such a notation, at least ten systems must be individually documented

PFSH

• Past o Current medications

o Past surgeries

o Past illnesses/injuries

• Family o Review of medical events in the patient’s family, including diseases which may be

hereditary or place the patient at risk

• Social o Age appropriate review of past and current activities

Examination

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1995/1997 Guidelines

The documentation of each patient encounter should include:

• Reason for the encounter and relevant history, physical

examination findings and prior diagnostic test results;

• Assessment, clinical impression or diagnosis;

• Plan of care; and

• Date and legible identity of the observer.

Examinations- Objective

• 1995 guidelines o Count the number of systems/areas

o Single system exams are not well-defined…

• 1997 guidelines o Count the number of “elements” or “bullets” performed

o Single system exams are defined

o Harder to meet without templates/macros

Examination Documentation Reminders

• A notation of “abnormal” without elaboration is insufficient documentation.

• Unlike history, portions of examination can not be ‘deferred’

• A brief statement/notation indicating negative or normal findings is sufficient .

• Normal or negative findings must be listed by body area or organ system.

• Page 9 of 2015 CPT states the only difference between an Expanded Problem Focused examination and a Detailed examination is that one is “limited” and the other is “extended”

o You will need to determine which guidelines suit your providers best

and consider local carrier instruction

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Problem

Expanded

Detailed

Comprehensive

1995 - Body Areas 1997 -Elements

1 1 - 5

2 - 7

2– 7 * with 1 detailed

8 + organ systems

6 - 11

12 - 17

18 / 9

Multi - Sys Single - Sys

1 - 5

6 - 11

12 +

All Shaded +

1 Unshaded

Eye/Psych = 9

Body Areas / Organ Systems

Determine Level of Exam

Let’s Apply 1995 Concepts

PHYSICAL EXAMINATION: VITAL SIGNS: Stable, afebrile. GENERAL: Awake, alert and oriented x3. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: Clear to auscultation. ABDOMEN: Soft, minimal amount of tenderness right upper quadrant, no guarding, no rebound, no acute abdomen, stool in vault, no hepatosplenomegaly.

Bullet Page #1

• Bullet #1

• Bullet #2

• Bullet #3

• Bullet #4

• Bullet #5

• Bullet #6

PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 170/75, pulse 96, respirations 16, O2 saturation 97% on room air. Afebrile. GENERAL: Patient is alert and oriented to person, place and time. Is resting comfortably in bed in no acute distress. HEENT: Atraumatic, normocephalic. Pupils equal, round and reactive to light and accommodation. Extraocular movements are intact. Oropharynx is clear and moist. No exudate present. NECK: Supple. No lymphadenopathy. CARDIOVASCULAR: Regular rate and rhythm. Grade 2/6 systolic murmur. No rubs or gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, crackles or rhonchi. ABDOMEN: Positive bowel sounds. Appropriately tender to palpation in right upper quadrant. Nondistended. GENITOURINARY: External genitalia with normal appearance. Bimanual exam is within normal limits with no palpable masses. EXTREMITIES: No erythema, no edema. No calf tenderness.

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Bullet Page #1

• Bullet #1

• Bullet #2

• Bullet #3

• Bullet #4

• Bullet #5

• Bullet #6

PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure is 130/80, heart rate is 82, respiratory rate 16, temperature 98. Saturating 98% on two liter of oxygen. GENERAL: Patient is alert, oriented x3, in no acute distress. He appears somewhat drowsy. He is laying down in 30 degree head-up position in no respiratory distress. HEENT: Positive PERRLA. Sclerae nonicteric. Conjunctiva pink. Oral mucosa moist and I could not evaluate the JVD due to patient's thick neck and large body habitus. No carotid bruits could be appreciated. Thyroid within normal limits. NECK: Supple. CARDIOVASCULAR: Regular rate and rhythm, normal S1-S2. No murmur or gallops could be appreciated. LUNGS: Clear to auscultation bilaterally. No crackles, wheezings, rhonchi was appreciated. ABDOMEN: Normoactive bowel sounds, nondistended, nontender. No organomegaly. EXTREMITIES: Less than 1+ pitting edema in both lower extremities. No clubbing or cyanosis. Has good distal pulses in all four extremities. INTEGUMENTARY: Intact, no rash. NEUROLOGIC: Grossly intact with no focal, sensory, or motor deficits.


Components of MDM

• Medical Decision Making o Number of diagnosis or management

o Amount and/or complexity of data

o Risk of complication

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MEDICAL DECISION MAKING BOX A: Number Of Diagnosis or Management Options (N x P = R)

Problems Number Points Results

Self-limited or minor (stable, improved or worsening) Max = 2 1

Est. problem: stable or improved 1

Est problem: worsening, failing to change 2

New problem: no additional work-up planned Max = 1 3

New problem: additional work-up planned 4

Bring to line A in Final Result for MDM Total

Number of Diagnosis / Problems

Impression:

Shortness of breath

Hypertension

Patient is scheduled for pulmonary consult and started on fast

acting albuterol inhaler. F/U after consult.

Bullet Page #1

• Bullet #1

• Bullet #2

• Bullet #3

• Bullet #4

• Bullet #5

• Bullet #6

MEDICAL DECISION MAKING BOX B: Amount and/or Complexity of Data to be reviewed Points

Review and/or order of clinical lab test 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 obtaining history from

someone other than patient 1

Review and summarization of old records and/or obtaining

history from someone other than patient and/or discussion of

case with another health care provider 2

Independent visualization, tracing or specimen itself (not simply

review of report) 2

Bring to line B in Final Result for MDM Total

In order to get credit, the provider must document review & summary

You do not get 2 points if billing the professional component (-26)

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Amount of Data

Chest Pain

Diabetes

Chest X-Ray in the office today was normal. Patient scheduled

for 24-hour Holter monitor. Also ordered fasting A1C as patient

is overdue.

BOX C: Risk of Complication and/or Morbidity or Mortality

Presenting Problems Diagnostic Procedures ordered Management Options Selected

Min

imal

1 self-limited or minor problem

(eg. Cold, insect bite, tinea

corporis

Lab tests requiring venipuncture

EKG/EEG

Urinalysis

Ultrasound, X-RAYS

KOH prep

Rest

Gargles

Elastic bandages

Superficial dressings

Lo

w

2 or more self-limited or minor

problems

1 stable chronic illness

Acute uncomplicated illness or

injury

Physiologic test not under stress

Non-cardiovascular imaging

Superficial needle biopsies

Clinical lab test requiring arterial puncture

Skin biopsies

Over-the-counter drugs

Minor surgery w/ no identified risk

factors

Physical therapy

Occupational therapy

IV fluids without additives

Mo

der

ate

1 or more chronic illnesses w/mild

exacerbation, progression or side

effects of treatment

2 or more stable chronic illnesses

Undiagnosed new problem w/ uncertain prognosis

Acute illness with systemic

symptoms

Acute complicated injury

Physiologic test under stress

Diagnostic endoscopies w/no identified risk

factors

Deep needle or incisional biopsy

Cardiovascular imaging studies w/contrast, no identified risk factors

Obtain fluid from body cavity

Minor surgery with identified risk

factors

Elective major surgery w/o risk

(open, percutaneous, or endoscopic)

Prescription drug management

Therapeutic nuclear medicine

IV fluids with additives

Closed treatment of fracture or

dislocation w/o manipulation

Hig

h

1 or more chronic illnesses w/

severe exacerbation, progression,

side effects of treatment

Acute or chronic illnesses or

injuries that pose a threat to life or bodily function

Abrupt change in neurologic

status

Cardiovascular imaging studies w/contrast

w/ identified risk factors

Cardiac eletrophysiological tests

Diagnostic endoscopies w/indentified risk

factors

Discography

Elective major surgery (open,

percutaneous or endoscopic) w/risk

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

Risk

Patient presents today with hypertension, diabetes and

hyperthyroidism. Patient appears stable on current regimen

and no changes are required at this time.

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MEDICAL DECISION MAKING BOX D: Final Result for Complexity of Medical Decision Making: 2 of 3 required

A Number of diagnoses or

management options

≤ 1

Minimal

2

Limited

3

Multiple

≥ 4

Extensive

B Amount and 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 Straight

Forward

Low

Complexity

Moderate

Complexity

High

Complexity


Inguinal Hernia

New Problem, no work up

Diabetes

Not addressed

Hypertension

Not addressed

Robert presented today with acute abdominal pain. The ultrasound reveals a rather

large inguinal hernia that will need surgical intervention. We will schedule him with a

general surgeon first thing in the morning.

Review/order ultrasound

Major surgery without complications


Sore throat

Established Problem, worsening

Cough

New Problem, no work up planned

Patient returns with continued sore throat. Rapid Strep test done in the

office is negative. New productive cough complicating sore throat. Patient

given prescription for Tusslon pearls 250mg, every 4 hours for the next 24.

Will call if symptoms do not improve.

Order/review lab test

Prescription Drug Management

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New Versus Established Patients

A new patient is one who has not received any face to face professional service from the physician/qualified healthcare professional

or

another physician/qualified healthcare professional of the exact same specialty/subspecialty who belongs to the same group practice within the past three years (Check taxonomy codes if unsure)

Medicare regulation states: "Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician."

CPT Code 99211

Typical nurse visits include, patient education, injections, infusions, problem focused evaluations and specimen collection.

Per CPT, “Usually, the presenting problem(s) are minimal. Typically, five minutes

are spent performing or supervising these services.”

General Requirements ◦ Non – Physician must be: ◦ Employee or contractor for physician

Follow physician orders resulting from his/her evaluation of the patient

Be supervised by a physician

• “Because medical necessity is required, vital signs and blood pressure checks

may not be routinely performed at the time of another coded service in order to

bill for a 99211 visit” (e.g.., injections, INRs, etc.)

2013 CPT

Incident to

• Follow established patient’s on plan of care already

established by physician

• Cannot see new patients and bill incident to (report under

own ID)

• Cannot see established patients for a NEW problem (report

under own ID)

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Split / Shared Visits

• Patient is seen by both NPP and MD possibly at different

times

• Each provider documents their encounter

• Physician can use NPP’s documentation towards their total

encounter level

Split / Shared Visits

• EXAMPLES OF SHARED VISITS

• 1. If the NPP sees a hospital inpatient in the morning and the physician

follows with a later face-to-face visit with the patient on the same day,

the physician or the NPP may report the service.

• 2. In an office setting the NPP performs a portion of an E/M encounter

and the physician completes the E/M service. If the "incident to"

requirements are met, the physician reports the service. If the “incident

to” requirements are not met, the service must be reported using the

NPP’s UPIN/PIN.

Modifier 25

The following statements are false:

o I can always use this modifier for a new patient.

o I can always use this modifier when I did not plan the procedure.

o I can always use this modifier when the diagnoses are different.

o I can never use this modifier when the diagnoses are the same.

Appropriate Usage:

• “Modifier 25 indicates that on the day of a procedure, the patient's

condition required a significant, separately identifiable E/M service,

above and beyond the usual pre and post-operative care associated with

the procedure or service performed”

Source: WPS Medicare

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E/M Modifiers

Modifier 24: Unrelated E/M during global

Modifier 25: E/M with minor procedure

Modifier 32: Mandated Service

Modifier 57: E/M with major procedure

2015 CPT Changes

• 266 New Codes

• 147 Deleted Codes

• 129 Revised Codes

• Total of 9,951 CPT codes to master!

Evaluation & Management

Chronic Care Management

• 99490 – at least 20 minutes

Complex Chronic Care Management

• 99487 – 60 minutes

• +99489 – each additional 30 minutes

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• Chronic Care Management 99490

• “Patients who receive chronic care management series have

two or more chronic continuous or episodic health

conditions that are expected to last at least 12 months or

until the death of the patient, and that place the patient at

significant risk of death, acute exacerbation /

decompensation, or functional decline. Code 99490 is

reported when, during the calendar month, at least 20

minutes of clinical staff time is spent in care management

activities”


• Complex Chronic Care Management 99487

• The same criteria for CCM is required as well as establishment

or substantial revision of the a comprehensive care plan;

medical, functional and/or psychosocial problems requiring

medical decision making of moderate or high complexity; and

clinical staff care management series for at least 60 minutes,

under the direction of a physician or other qualified health care

professional

• Each add’t 30 minutes reported with add-on code 99489


• Recommend billing CCM and CCCM as soon as the time

threshold has been met.

• Will only be paid once per month to one provider – first one

with their claim in the door gets paid

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Advanced Care Planning

• 99497

• Advanced Care Planning – first 30 minutes

• +99498

• Each additional 30 minutes


• Advanced Care Planning 99497

• “…explanation and discussion of advanced directives such as

standard forms (with completion of forms, when performed) by

the physician; first 30 minutes face-to-face with the patient,

family member(s), and/or surrogate

• Each additional 30 minutes use add-on code 99498


• Advanced Care Planning can be billed on the same day as

other E/M services

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Application of Fluoride

● 99188 Application of topical fluoride varnish by a

or other qualified health care

professional

Cannot be reported if performed by ancillary staff

CMS will not cover

Regan Tyler, CPC, CPC-H, CPC-I, CPMA, CEMC [email protected]

CEU Index# 38868XYH

mailto:[email protected]

namas certified professional medical auditor curriculum

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