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 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
3 ICD-10-CM Coding Definition Primary diagnosis – reason for the visit Signs and Symptoms Code only if no definitive diagnosis is stated Importance (WHY) Multiple Diagnoses
4 Questions To Ask Yourself 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?
5 Steps To Coding 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
6 Procedural Coding 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
7 CPT Format 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
8 HCPCS Format 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)
Evaluation and Management 9 (E/M) 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
PREVENTIVE MEDICINE SERVICES 10 (99381-99429) 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
Office Visit 11 11 Established New Patient Patient 99201 – 99211 – Level I Level 1 Categories and 99202 – 99212 – Subcategories Level 2 Level 2 99203 – 99213 – Level 3 Level 3 99204 – 99214 – Level 4 Level 4 99205 – 99215 – Level 5 Level 5
Evaluation and Management 12 Coding Leveling Select the category or subcategory of service and 1. review the guidelines; Review the level of E/M service descriptors and 2. examples; Determine the level of history; 3. Determine the level of exam; 4. Determine the level of medical decision making; and 5. Select the appropriate level of E/M service. 6.
13 E/M Leveling 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
14 E/M Leveling Key Components History Exam Medical Decision Making
15 History History of Present Illness (HPI) Chronological description of the patient’s illness Location Duration Quality Severity Timing Context Modifying factors Associated sign and symptoms
16 History - Review of Systems (ROS) Musculoskeletal • Inventory of body systems Integumentary Constitutional Neurological Eyes Psychiatric Ears, nose, mouth, throat Endocrine Cardiovascular Respiratory Hematologic/lymphatic Gastrointestinal Allergic/Immunologic Genitourinary
17 History Past, Family and/or Social History (PFSH) Past History Family History Social History
History 18 Past, Family, and/or Social History of Present Illness (HPI) Review of Systems (ROS) Level of History History (PFSH) Brief No ROS No PFSH Problem Focused (1-3 elements) Brief Problem Pertinent Expanded Problem No PFSH (1-3 elements) (1 system) Focused Extended Extended Pertinent Detailed (4 or more) (2-9 systems) (1 history) Extended Complete Complete Comprehensive (4 or more) (10 or more) (2-3 history areas)
Exam 19 Examination – may be Examination Examination body areas or organ Organ Systems systems Organ Systems Constitutional Musculoskeletal Eyes Body Areas Skin Ears, nose, mouth and Head, including face Neurologic throat Neck Psychiatric Cardiovascular Chest, including breasts Respiratory Hematologic/ Abdomen lymphatic/ Genitalia, groin, buttocks Gastrointestinal immunologic Back, including spine Genitourinary Each extremity
Exam 20 Problem Focused – a limited examination of the affected 1 body area or organ system body area or organ system. Expanded Problem Focused – a limited examination of the 2 – 7 body areas or organ systems – affected body area or organ system and other limited exam symptomatic or related organ system(s). Detailed – an extended examination of the affected body 2 – 7 body areas or organ systems – area(s) and other symptomatic or related organ system(s) extended exam Comprehensive – a general multi-system examination or 8 or more organ systems OR complete complete examination of a single organ system single organ system
Exam 21 Problem Focused – a limited examination of the affected 1 body area or organ system body area or organ system. Expanded Problem Focused – a limited examination of the 2 – 7 body areas or organ systems – affected body area or organ system and other limited exam symptomatic or related organ system(s). Detailed – an extended examination of the affected body 2 – 7 body areas or organ systems – area(s) and other symptomatic or related organ system(s) extended exam Comprehensive – a general multi-system examination or 8 or more organ systems OR complete complete examination of a single organ system single organ system
Medical Decision Making 22 Elements – Number of management options # of dx or Amt and/or Risk of Type of Minimal, limited, mgmt complexity Complications Decision multiple, extensive options of data Making – Amount and/or complexity Minimal or of data to be reviewed Minimal Minimal Straightforward none Minimal or none, limited, Limited Limited Low Low complexity moderate, extensive Moderate – Risk of complications, Multiple Moderate Moderate complexity morbidity, and/or mortality High Minimal, low, moderate, Extensive Extensive High complexity high
Evaluation and Management 23 Leveling Contributing Components Counseling Coordination of Care Nature of Presenting Problem Time
24 Determine the Level of E/M New Patient Expanded Problem HISTORY problem Detailed Comprehensive Comprehensive focused focused Expanded Problem EXAM problem Detailed Comprehensive Comprehensive focused focused MDM Straightforward Straightforward Low Moderate High LEVEL 99201 99202 99203 99204 99205 OF VISIT
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