Evaluation and Management

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E/M codes
evaluation and management codes
used to report basic physician services
*taking of a history
*physical examination
*determining a diagnosis
*developing a treatment plan

the assignment of E/M codes vary by:
type of service
place of service
patients status

new patient
one who has not received services from a doctor or from a doctor of the same specialty or sub-specialty who belong to the same group practice within the past 3 years (doesnt have to b face to face it can b any professional service)

established patient
someone who has received services from a doctor or from a doctor of the same specialty who belongs to the same group practice within the past three years (doesnt have to b face to face it can b any professional service)

true or false when the patient is seen face to face the patient is considered an established patient?
true

counseling
a discussion with a patient or family concerning one or more of :
diagnostic results (impressions or recommended diagnostic studies)
risk and benefits of management (treatment) options
instructions for management (treatment) and or follow up
importance of compliance with chosen management (treatment options)
risk factor reduction or
patient and family education

E/M level
within each categor or subcategory of the E/M chapter there are 3 to 5 levels
level identify the varying intensities of :
H&P
conferences
effort
skill
time etc.

the determination of the E/M level is the responsibility of the
physician

___ components are used to determine the correct E/M level reported. the first ___ are considered key components
7
3

1 extent of patient history
problem focused
expanded problem focused
detailed
comprehensive

2 extent of physical examination
problem focused
expanded problem focused
detailed
comprehensive

3rd key component used to determine the correct E/M level reported
level of medical decision making

true or false another aspect of E/M selection involving the three key components is the specification in the CPT book of how many key components must be met in order to assign a particular level of E/M code
TRUE

time may be the controlling component in selecting an E/M code only when counseling takes up more than __% of the time the doctor spends face to face with the patient/family during a single visit

this includes time spent with parties who have assumed responsibility for the care of the patient or decision making whether or not they are family members (foster parents, persons acting in locum parentis, legal guardians)

must document time and discussion of activities

medicare patients must be present

50

true or false face to face means doctor/patient interaction not nurse/patient or other staff
TRUE

when counseling takes more than 50% of the face to face time the physician must document the counseling activities undertaken and the amount of time spent performing these activities in the ____
medical record

each E/M code has a ____ ___ attached to it. When a physician qualifies for the use of ___ the physician simply needs to look for the E/M code that most closely matches the ___ of the visit but does not go over
time frame

a physician who performs two or three key E/M components in addition to counseling may select an E/M code based on either the ___ ____ or the ___ ___
key components
time factor

when a physician provides more than one E/M service to a patient on the same day (date) for the same conditions report only __ E/M code because all E/M services provided on that date should be considered collectively to determine the appropriate level of E/M
1
the physician would report the code from the more intensive or expensive category. Want to select an E/M code from the inpatient hospital category. the code selected would be of a level that would cover all of the documentation and decision making activities performed on that day

if the physician must see the patient more than once in a day for unrelated conditions it is ____.

The visits must

the second visit should have modifier __

acceptable to report more than one EM code

take place at different times of the day. in this case each em code would be linked to different diagnosis codes on the insurance claim form

25 significant, separately identifiable EM service by the same physician on the same day of a procedure or other service appended. as such the reason for the multiple visits would be explained

on a ___ ___ each CPT code must have a related diagnosis code identified
CMS 1500 ( the claim form used by physician offices )

modifier ___ unrelated em service by the same physician during a postoperative period is ONLY appended to EM codes
24

modifier 24
permits a physician to report a visit (office, consultation, ER etc) during a previous surgerys postoperative period as long as the need for the visit is unrelated to the previous surgery.

to bill unrelated em services rendered by the surgeon during the postoperative period report the appropriate em code with modifier ___
24

only the ___ is to report EM codes with modifier 24. under normal circumstances a surgeon cannot bill for related EM visits during a postoperative period. Reimbursement for these routine postoperative visits has been included in the surgery payment. However if the need for an unrelated EM service arises during the postoperative period this EM visit can be bill for additional reimbursement
physician who performed the surgery

modifier 25
significant separately identifiable em service by the same physician on the same day of a procedure or other service
used to report an EM visit on the same day as a minor procedure or other CPT service
ordinarily Em services performed on the same day as a procedure is considered a routine component of the procedure/service and cannot be billed separately however if the patient condition requires a significant EM service above and beyond that normally provided for that procedure or service an EM service can be billed ass a separate item

modifier 27
multiple hospital em encounters on the same date
ONLY used by hospitals for reporting utilization of hospital resources related to separate and distinct EM encounters performed in multiple outpatient hospital settings on the same date
this modifier is appended to each appropriate outpatient and or emergency department EM code
provides a mechanism of reporting EM services provided by physicians in more than one outpatient setting (hospital emergency department, hospital based clinic)

modifier 32
mandated services
used to report an EM service mandated by medicare third party payer or other state/federal agency (psychiatric evaluation of a defendant)

modifier 27
if the hospital is responsible for billing both services both EM codes should be reported and appended with this modifier. it alerts the insurance company that the patient had two seperate encounters at the hosptial on the same date of service

this modifier is commonly used with confirmatory consultations (2nd opinion). Insurance companies normally require a second opinion prior to approving a high cost or high risk procedure
32

true or false when patients initiate 2nd opinions. The opinion is not mandated. Modifier 32 is not used when the patient or family requests the 2nd opinion?
true

modifier 57
decision for surgery
used to report an initial consultation or evaluation of the problem (reason for surgery) when it is rendered during the preoperative period of surgery

if the decision to perform major surgery is made more than one day prior to surgery report the appropriate em code with no modifier

true or false modifier 57 varies between CPT and meidcare
true

modifier 57 under CPT
CPT guidelines make no differentiation between major and minor procedures
this modifier is to be appended to an EM code whenever the decision to perform surgery occurs within the preoperative period
Modifier 25 is not used to represent the decision for surgery

modifier 57 under medicare
instruct coders that if the decision for surgery is made on the same day as minor surgery or a diagnostic procedure modifier 25 should be used instead of modifier 57
they consider modifier 57 to be reserved for major surgeries

true or false normal evaluation and management visits are not billed separately during a global surgical package. however CPT guidelines permit the reporting of an EM service during the preoperative period if the decision to perform surgery occurs during the evaluation process
true

true or false some insurance companies will not reimburse any normal em services during the global surgical package in these situations only the surgical procedure is reported
true

office or other outpatient services
the codes are sued to report em services provided in a physicians office or other ambulatory setting. Within this range of codes patients are classified as new or established.

hospital observation services
only the attending physician can report these. If another physician visits a patient while in observation status he or she should report one of the two categories as applicable
office or other outpatient services
consultation

admitted as an inpatient form observation
if a patient is admitted to the hospital as an inpatient on the same day (date) initial hospital observation services are rendered
report only the appropriate inpatient initial hospital care em code (refer to the previous discussion multiple em visits on the same date)

99217 observation care discharge services
reported if the discharge from the observation area is different from the date of admission to the observation area
extremely common when ppl are admitted during the evening hours. they frequently will cross over to the next day

subsequent observation days
while observation status should be less than 24 hours in length there are rare instances in which a patient may stay longer. If the stay should involve three dates of service a subsequent observation day EM code should be used for this between day in the observation area

observation services admitted and discharged on the same date
see observation of inpatient care services (admission and discharge services) under hospital inpatient services

office base codes new patient
201-205

office base codes established patient
211-215

211
if physician does not see patient. they only have a service. non doctor does engage in an EM service
can bill for service but not 211

observation codes
initial
subsequent
discharge
admission and discharge combo

hospital inpatient services – initial hospital care
day #1
restricted to attending
include all evaluation and management services provided on the same day by the admitting doctor ( whoever does the H P) hospiticists can b this.) unless another significant, separately identifiable service was provided. in this case the second em visit of the day should be reported with modifier 25

only an admitting ___ can use an initial hospital care code (99221-99223) as this code represents the initial visit it can only be reported once during a patients hospitalization
doctor

subsequent hospital care
not based on LOS
99231-99233
reported on a per day basis
if the physician visits the patient multiple times during the day for the same conditions only one em code should be reported.
most physician offices submit claims for inpatient hospital services after discharge this way only one claim must be submitted for the entire hospitalization. expected that different levels of subsequent care em codes be reported. a typical progression is to see em codes reflecting a higher intensity of services be used at the beginning of a hospital stay. as the patients condition improves lower level subsequent care em codes are more appropriate
used by the non attending if multiple physicians are involved on the care even if on day 1 or discharge
exception: qualify as consult

hospital discharge services
last day services restricted to attending
99238-99239
face to face evaluation and management service between the attending physician and the patient
only the attending physician on the service coordinating the patients care shall report the hospital discharge day management service
other physicians or qualified non physician providers who manage concurrent health care problems shall use the subsequent hospital care codes (99231-99233) to report a final visit
reported on the ate of the actual face to face visit even if the patient is discharged on a different calendar date
the em codes for hospital discharge services (99238-99239) may be used only once per hospitalization. there is a choice of <30 minutes or >30 minutes spent providing discharge management services. the services include the final examination of the patient, discussion of the hospital stay and discharge instructions, preparation of the medical record, writing of prescriptions, and completion of referral forms.
if a patient dies in the hospital the hospital discharge services code may be reported if the physician performs any of the criteria for hospital discharge services AND the physician had a face to face encounter with the patient that day.

hospital discharge services
may include pronouncing the death, completing death summary, talking with the deceased patients family
final physical exam
preparation of take home instructions
prep of discharge summary
closing out medical record
writing prescriptions
requesting referrals

death discharge services include
pronouncing death
if face to face services provided on date but not of the death services provided : code it as subsequent hospital care or critical care if applicable

surgical admission
since hospital visits are normally included in the global payment package for both minor or major surgery, a surgeon seldom uses hospital inpatient service em codes exceptions:

observation or inpatient care services (admission and discharge services)
99234-99236 used to report observations or inpatient encounters when the patient is admitted and discharged on the same date of service. the codes include all admission and discharge services
combination codes must exist as that basic em rule is one em code per patient per day for the same or related diagnosis
if the patient stay is less then 8 hours do not use these codes. report only an appropriate initial observation care or initial hospital care code (source: medicare claims processing manual)

24 unrelated em during a postoperative period
a condition arises during the postoperative period that is unrelated to the reason for surgery. in this case an appropriate level em code can be assigned with modifier

25 significant, separately identifiable em on the dame day as a procedure
a condition arises on the day of surgery that is unrelated to the reason for surgery. in this case an appropriate level em code can be assigned with modifier

57 decision for surgery
the decision to perform major surgery is made within 24 hours prior to surgery. In this case an appropriate em code can be assigned with modifier

consultation
high rvus
doctor A (attending physician) asks specialist doctor b to determine whats wrong
must be performed only after a request (verbal or written) has been made by a physician or other appropriate source. the request must be documented in the patients medical record. the need for the opinion or advice must be indicated. simply documenting refer to physician x for evaluation is inappropriate

the purpose of the consultation is to provide an ___ or ___
opinion or advice

the consulting physician can ___ diagnostic or therapeutic services
initiate

true or false documentation must be in the record reflecting the findings of the consultation. the documentation should reflect the consultations opinion as well as any services ordered or performed. The findings must also be communicated by written report to the requesting physician or source (CPT assistant august 2001)
true

true or false a consulting physician can initiate diagnostic services and therapy during the consultative encounter
true

during the initial visit it may come to pass taht the consultant assumes responsibility for managing all or a portion of the patients condition. in these cases the consultant may report an initial consultation code for the first visit but future visits should ___ be billed as a consultation
not

when it comes to consultations if the patient is seen again in the office the patient is considered an ___ patient. if the initial consultation takes place in the hospital additional visits during the hospitalization should be reported with subsequent hospital care codes
established

can an established physician serve as a consultant on his own patient?
depends its all about the intent of the request
3 things present
written request by requesting doctor
intent is to provide advice/expertise
consultant must send written report back to the referring doctor

transfer of care (or referral)
considered to be a direct transfer of the management of the patient ( to treat a specific problem). a referral of a patient by a physician without a written or verbal request being documented in the medical record should be coded with “office or other outpatient setting” or “subsequent hospital care” em codes

office or other outpatient consultations
unlike office visits consultation codes make no distinction between new and established patients. if at a consultation visit the consultant initiates a follow up visit the next visit should be reported by using an “office or other outpatient services established patient” code.
consultation codes cannot be used since a consultation must be initiated by another referring physician
if an additional request for an opinion regarding the same or different problem is received from the original or referring physician the office consultation code may be used again

hospital inpatient consultations
code is to assigned when the consulting physician meets the consultation criteria. normally a written request will be made by the attending physician. If after the initial consultation the consulting physician participates in the management of the patient future visits should be reported with subsequent hospital care codes not another consultation code. its a mechanism of providing an opinion and guidance to the attending physician. Once the consultant becomes an active member of the patients healthcare team he she is no longer simply providing an opinion but is actively engaged in rendering care

medicare consultation rule
no longer covers consultation CPT codes
if performed in office use office or other op services (new or established)
if performed on a hospital inpatient use initial hospital care
attending physician uses initial hospital care AL (principal physician of care)
if performed in ED use ED em codes (pay very little because practice expense has been zeroed out )

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