Physician Coding DIAGNOSIS AND EVALUATION AND MANAGEMENT 2 - - PowerPoint PPT Presentation
1 Physician Coding DIAGNOSIS AND EVALUATION AND MANAGEMENT 2 Objectives Define Diagnosis and Procedures Define Evaluation and Management Separate component Understand the requirements for different levels of service Learn how
DIAGNOSIS AND EVALUATION AND MANAGEMENT
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Define Diagnosis and Procedures Define Evaluation and Management
Separate component
Understand the requirements for different levels of service Learn how to properly select the correct level for an E/M
service
Coding Based on Time Understand Medical Necessity
How it differs from Medical Decision Making
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Definition
Primary diagnosis – reason for the visit Signs and Symptoms Code only if no definitive diagnosis is stated
Importance (WHY) Multiple Diagnoses
Why was the patient there? What are the signs and symptoms? Decipher the signs and symptoms Was a diagnosis made? Are the signs and symptoms related to or due to the diagnosis? Are there more than one diagnosis?
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Identify the main term Locate the main term in the alphabetic index Review the subterms Follow cross reference instructions like “see” or “see also” Verify the code in the Tabular list Refer to instructional notations in the Tabular Assign codes to the highest level of specificity Code the diagnosis until all elements are completely
identified
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Definition Importance Manuals Level I: The AMA CPT codes and modifiers (national codes)
Physician or provider service = CPT code
Level II: HCPCS they are CMS-designated codes and alpha modifiers (national
codes)
Supplies or durable medical equipment = HCPCS national code
Level III: Codes specific to regional fiscal intermediary or individual insurance
carrier (local codes) and not found in either levels I or II
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Category I Codes Evaluation and Management (Codes 99201-99499) Anesthesia (Codes 00100-01999, 99100-99140) Surgery (Codes 10021-69990) Radiology (Codes 70010-79999) Pathology and Laboratory (Codes 80047-89398) Medicine (Codes 90281-99607) Category II Codes Category III Codes Appendices A-M Index
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HCPCS was developed by CMS in 1983
Five-character alphanumeric system for coding services. Starting with a letter followed with numbers.
A Codes – Transport Services , Medical & Surgical Supplies, Miscellaneous & Experimental (A0021 – A9999)
B Codes – Enteral and Parenteral Therapy (B4034 – B9999)
C Codes – CMS Hospital Outpatient Payment System (C1300 – C9999)
D Codes – Dental Procedures (Moved to the CDT (Current Dental Terminology Manual))
E Codes – Durable Medical Equipment (E0100-E9999)
G Codes – Temporary Procedures/Professional Services (G0000-G9999)
H Codes – Behavioral Health and/or Substance Abuse Treatment Services (H0001 – H9999)
J Codes – Drugs Other than Chemotherapy (J0100 – J9999)
K Codes – Temporary Codes Assigned to DME Regional Carriers (K0000 – K9999)
L Codes – Orthotics/Prosthetic Procedures (L0100 – L4999)
M Codes – Other Medical Services (M0000 – M0301)
P Codes – Laboratory Services (P0000 – P9999)
Q Codes – Temporary Codes Assigned by CMS (Q0000 – Q9999)
R Codes – Diagnostic Radiology Services (R0000 – R9999)
S Codes – Temporary National Codes Established By Private Payers (S0000 – S9999)
T Codes – Temporary National Codes Established by Medicaid (T1000 – T9999)
V Codes – Vision Services (V0000 – V2999)
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The E/M section is the most frequently reported section in the CPT Include services provided in the physician’s office, to patients in a
nursing home or extended care facility, to inpatients and outpatients, etc
Code assignment in the E/M section varies according to three factors: Place of service
Office, Hospital, Emergency Department, Nursing Home, etc
Type of service
Office Visit, Consultation, Admission, etc
Patient status
New, Established, Outpatient, Inpatient
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99381 & 99391 – Age younger than one 99382 & 99392 – Age 1 – 4 99383 & 99393 – Age 5 – 11 99384 & 99394 – Age 12 – 17 99385 & 99395 – Age 18 – 39 99386 & 99396 – Age 40 – 64 99387 & 99397 – 65 years and older
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Office Visit New Patient 99201 – Level I 99202 – Level 2 99203 – Level 3 99204 – Level 4 99205 – Level 5 Established Patient 99211 – Level 1 99212 – Level 2 99213 – Level 3 99214 – Level 4 99215 – Level 5
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Select the category or subcategory of service and review the guidelines;
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Review the level of E/M service descriptors and examples;
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Determine the level of history;
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Determine the level of exam;
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Determine the level of medical decision making; and
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Select the appropriate level of E/M service.
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1995 vs. 1997 Guidelines Exam is the Main difference Seven components
History Exam Medical Decision Making Counseling Coordination of Care Nature of Presenting Problem Time
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Key Components
History Exam Medical Decision Making
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History of Present Illness (HPI) Chronological description of the patient’s illness Location Duration Quality Severity Timing Context Modifying factors Associated sign and symptoms
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Constitutional Eyes Ears, nose, mouth, throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary Neurological Psychiatric Endocrine Hematologic/lymphatic Allergic/Immunologic
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Past, Family and/or Social History (PFSH)
Past History Family History Social History
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History of Present Illness (HPI) Review of Systems (ROS) Past, Family, and/or Social History (PFSH) Level of History Brief (1-3 elements) No ROS No PFSH Problem Focused Brief (1-3 elements) Problem Pertinent (1 system) No PFSH Expanded Problem Focused Extended (4 or more) Extended (2-9 systems) Pertinent (1 history) Detailed Extended (4 or more) Complete (10 or more) Complete (2-3 history areas) Comprehensive
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Examination – may be
body areas or organ systems
Body Areas
Head, including face Neck Chest, including breasts Abdomen Genitalia, groin, buttocks Back, including spine Each extremity Examination
Organ Systems
Constitutional Eyes Ears, nose,
mouth and throat
Cardiovascular Respiratory Gastrointestinal Genitourinary
Examination
Organ Systems
Musculoskeletal Skin Neurologic Psychiatric Hematologic/
lymphatic/ immunologic
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Problem Focused – a limited examination of the affected body area or organ system. 1 body area or organ system Expanded Problem Focused – a limited examination of the affected body area or organ system and other symptomatic or related organ system(s). 2 – 7 body areas or organ systems – limited exam Detailed – an extended examination of the affected body area(s) and other symptomatic or related organ system(s) 2 – 7 body areas or organ systems – extended exam Comprehensive – a general multi-system examination or complete examination of a single organ system 8 or more organ systems OR complete single organ system
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Problem Focused – a limited examination of the affected body area or organ system. 1 body area or organ system Expanded Problem Focused – a limited examination of the affected body area or organ system and other symptomatic or related organ system(s). 2 – 7 body areas or organ systems – limited exam Detailed – an extended examination of the affected body area(s) and other symptomatic or related organ system(s) 2 – 7 body areas or organ systems – extended exam Comprehensive – a general multi-system examination or complete examination of a single organ system 8 or more organ systems OR complete single organ system
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Elements – Number of management
Minimal, limited,
multiple, extensive
– Amount and/or complexity
Minimal or none, limited,
moderate, extensive
– Risk of complications,
morbidity, and/or mortality
Minimal, low, moderate,
high
# of dx or mgmt
Amt and/or complexity
Risk of Complications Type of Decision Making
Minimal Minimal or none Minimal Straightforward Limited Limited Low Low complexity Multiple Moderate Moderate Moderate complexity Extensive Extensive High High complexity
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Contributing Components
Counseling Coordination of Care Nature of Presenting Problem Time
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New Patient
HISTORY
Problem focused Expanded problem focused Detailed Comprehensive Comprehensive
EXAM
Problem focused Expanded problem focused Detailed Comprehensive Comprehensive
MDM
Straightforward Straightforward Low Moderate High
LEVEL OF VISIT
99201 99202 99203 99204 99205
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Established Patient
HISTORY
Problem focused Expanded problem focused Detailed Comprehensive
EXAM
Problem focused Expanded problem focused Detailed Comprehensive
MDM
Straightforward Low Moderate High
LEVEL OF VISIT
99212 99213 99214 99215
According the Centers for Medicare & Medicaid Services (CMS), “In the case where
counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter (face-to-face time in the office or other
considered the key or controlling factor to qualify for a particular level of E/M services.
“If the physician elects to report the level of service based on counseling and/or
coordination of care, the total length of time of the encounter (face-to-face or floor time, as appropriate) and time counseling and/or coordinating care should be documented. Also, the record should describe the counseling and/or activities to coordinate care.”
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Medical Decision Making or MDM involves choosing a level of service
(based on the documentation) that reflects the provider’s effort when establishing a diagnosis and/or selecting the course of treatment or management option.
Medical necessity involves substantiating that the patient’s condition
required the treatment.
MDM requires practitioners to choose a level of service that best reflects
the amount of effort the practitioners will put into deciding a course of treatment.
Medical necessity, however, requires substantiating that the diagnosis
and suggested actions were medically required for proper treatment.
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Marlegny.Mourino@OrlandoHealth.com