Evaluation & Management Coding Category Selection Individual Exercises

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Evaluation & Management Coding Category Selection Individual Exercises

Note: Unless otherwise stated, each problem is intended to be independent of the preceding problems. Do not assume that any facts from any preceding problem carry forward unless the problem states otherwise.

1. Mr. Lee became ill on Saturday morning. He presents to the Emergency Department where Dr. Fuller, a PCP, was providing coverage in the ED at the time because an ED physician was not available. Dr. Fuller took Mr. Lee’s history, performed an examination and wrote him a prescription. Mr. Lee did not see any of the ED physicians. Should Dr. Fuller’s services be reported as outpatient visit (99201-99215) or an ED visit (99281-99285)?

ED visit (99281-99285) Although not stated in the CPT manual, per CPT Assistant, July 2002, the use of the ED visit codes is not limited to ED physicians.

2. Dr. Russell saw Mr. James in the office. Dr. Russell took Mr. James history, performed an examination and admitted him as an inpatient that same day. Should the services provided by Dr. Russell in her office be coded as an outpatient visit (99201-99215) or as initial hospital care (99221-99223)?

Initial Hospital Care (99221-99223) As discussed in the “initial hospital care” guidelines, when a patient is admitted to the hospital in the course of an outpatient encounter in a physician’s office, the outpatient encounter is not separately

reported. Rather, the services provided in the outpatient setting are considered part of the admission and should be considered when selecting the level for the “initial hospital care” code.

3. In June 2003, Dr. Smith saw Mrs. Washington in the office. Although Mrs. Washington had been a patient of Dr. Smith for 25 years, Dr. Smith had not provided any services for Mrs. Washington since January 1998. Dr. Smith took Mrs. Washington’s history,

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a new patient office visit (99201-99205) or an established patient office visit (99211-99215)?

New Patient Office Visit (99201-99205). It has been more than three years since the last encounter. The fact that this patient was a long-standing patient of the physician’s does not affect the application of the three-year rule.

4. Mrs. Honeycut saw Dr. Mayo in his office in January 1996. In March 2001, Mrs. Honeycut called Dr. Mayo’s office with a minor problem. Mrs. Honeycut discussed the problem with Dr. Mayo’s nurse who, in turn, discussed the problem with Dr. Mayo. Dr. Mayo called in a prescription for Mrs. Honeycut. In August 2001, Dr. Mayo saw Mrs. Honeycut in the office. Dr. Mayo took Mrs. Honeycut’s history, performed an examination and wrote a new prescription. Should this encounter be coded as a new patient office visit (99201-99205) or an established patient office visit (99211-99215)?

New Patient Office Visit (99201-99205) As discussed in the E&M section

guidelines, only face-to-face encounters are considered for purposes of the three-year rule. While writing the March prescription involved “professional services,” the services were not face-to-face.

5. Dr. Russell admitted Mr. Jones to the hospital. Due to a sudden change in Mr. Jones health status, Dr. Russell discharged him that same day. Should this encounter be coded as initial inpatient hospital care (99221-99223), observation or inpatient care services (99234-99236) or hospital discharge services (99238-99239)?

Observation or Inpatient Care Services (99234-99236) The category “observation or inpatient care services” is used whenever a patient is admitted (to either

observation or as an inpatient) and discharged on the same date.

6. Dr. Davis (an internist) “admitted” Mrs. Partridge to observation and asked Dr. George (a neurologist) to consult on the case (the request was documented in Mrs. Partridge’s medical record by Dr. George). That same day Dr. George took Mrs. Partridge’s history, performed an examination and ordered medications for her from the hospital pharmacy. Dr. George dictated a consultant’s report which was immediately placed in the patients chart. Should Dr. George’s encounter be coded as initial observation care (99218-99220), an outpatient consultation (99241-99245), or an inpatient consultation (99251-99255)?

Outpatient Consultation (99241-99245) As discussed in the “office or other

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7. Dr. Edwards saw Mrs. Moore, who has no current medical problems, for an annual physical. Dr. Edwards took Mrs. Moore’s history and performed an examination. No problems were discovered. Should Dr. Edwards’ services in the office be coded as an office visit (99201-99215) or a preventive medicine service (99381-99397)?

Preventive Medicine Service (99381-99397) CPT provides specific codes for reporting “preventative medicine” services.

8. Same as above except during the course of the examination Dr. Edwards discovered a significant problem that required additional history, a more extensive examination and a prescription. Should the entire encounter be coded as an office visit (99201-99215), a preventive medicine service (99381-99397) or both?

Both. As discussed in the “preventive medicine services” guidelines both codes would be reported with the -25 modifier appended to the office visit code.

9. Dr. Warren saw Ms. Terry for treatment of a sexually transmitted disease. Dr. Warren took Ms. Terry’s history, performed an examination, wrote a prescription and spent 15 minutes counseling Ms. Terry on techniques for reducing her risk of STD in the future. The entire encounter lasted 20 minutes. Should Dr. Warren’s services be coded as an office visit (99201-99215) or individual preventive medicine counseling (99401-99404)?

Office Visit (99201-99215) As discussed in the “counseling and/or risk factor reduction intervention” guidelines, the counseling codes should not be used for patients with symptoms or established illness.

10. Ms. Jensen saw Dr. Fret (an internist) for a gynecological problem. Dr. Fret recommended that Ms. Jensen’s problem be treated medically although they discussed surgical options. Four days later, Ms. Jensen decided to consult with Dr. Thomas (an OB/GYN) for a second opinion. Dr. Thomas saw Mrs. Jensen in the office. Dr. Thomas took her history,

performed an examination and informed her that he concurred with the treatment plan recommended by Dr. Fret. Dr. Thomas then sent Dr. Fret a letter providing him with her opinion on Ms. Jensen’s condition and treatment. Should Dr. Thomas’s services in the office be coded as an office visit (99201-99215), an office consultation (99241-99245) or subsequent hospital care (99231-99233)?

Office Visit (99201-99215) As discussed in the “consultation” guidelines, a “consultation” initiated by a patient and/or family and not requested by a

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11. Dr. Goodwin (an internist) saw Ms. Purdue. Dr. Goodwin suspected a gynecological problem. Dr. Goodwin called Dr. Thomas (an OB/GYN) and asked her to evaluate Ms. Purdue. Dr. Thomas saw Ms. Purdue in the office. She took Ms. Purdue’s history and performed an examination. She then called Dr. Goodwin and provided him with her

opinion regarding Ms. Purdue, recommended a course of treatment and thanked him for the referral. There was no written communication back to Dr. Goodwin from Dr. Thomas. Should Dr. Thomas’s services in the office be coded as an office visit (99201-99215) or an office consultation (99241-99245)?

Office Visit (99201-99215) As discussed in the “consultation” guidelines, a consult requested by a physician requires a written report back to the requesting

physician.

12. Dr. Johnson (an internist) saw Ms. Bane. Dr. Johnson suspected a gynecological problem. Dr. Johnson called Dr. Thomas (an OB/GYN) and asked her to evaluate Ms. Bane. There was no written request sent to Dr. Thomas by Dr. Johnson. However, based on Dr.

Johnson’s verbal request (which was documented by Dr. Thomas and Dr. Johnson in each of their medical records), Dr. Thomas saw Ms. Bane in the office. She took Ms. Bane’s history and performed an examination. She then wrote Dr. Johnson and provided him with her opinion regarding Ms. Bane, recommended a course of treatment (which was filed in Ms. Bane’s medical record) and thanked him for the referral. Should Dr. Thomas’s services in the office be coded as an office visit (99201-99215) or an office consultation (99241-99245)?

Office Consultation (99241-99245) All of the criteria for a consult have been met in this case. The request for a consult may be made orally (but must be

documented).

13. Dr. Thomas also wrote a prescription for Ms. Bane during the previous question and made a follow-up appointment for Ms. Bane to see her again in three days. Should Dr. Thomas’s initial services (not the follow-up visit) be coded as an office visit (99201-99215) or an office consultation (99241-99245)?

Office Consultation (99241-99245) The fact that a consultant initiated care during the course of an initial consult does not preclude coding the encounter as a consult.

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with an update on Katherine’s status. Should Dr. Jackson’s encounter be coded as a new patient office visit (99201-99205) or an office consultation (99241-99245)?

New Patient Office Visit (99201-99205) Although there was a request made, an opinion rendered and a report was written, this encounter is considered a transfer of care. Per the E/M Services guidelines, if a portion of a patient’s care is

relinquished to another physician and they explicitly agree to accept responsibility the consultation codes should not be reported.

15. Janie is a newborn (born today) who is initially evaluated in the NICU as an inpatient by Dr. Collins, a neonatologist for transient tachypnea. Her condition is not classified as a constant threat to life but necessitates intensive respiratory monitoring, frequent vital signs and constant observation. Should Dr. Collins’ services be coded as an initial inpatient neonatal critical care (99468) or initial hospital care, for evaluation and management of a normal newborn (99460) or initial hospital intensive care services (99477)?

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Evaluation &

Management

Management

Evaluation & Management (E/M)

Professional services are those face-to-face services rendered by a physician.

–E/M services can also be reported by p y other qualified healthcare

professionals as long as it is within their scope of practice.

Evaluation & Management (E/M)

Evaluation and management codes can be assigned based on:

– Key Components (History, Exam and Medical Decision Making)

• Example: 99201-99215 (Office visits)

– Time

• Example: 99291-99292 (Critical Care)

– Per Day

• Example: 99460- 99463 (Newborn Services)

– Age

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New vs. Established Patients

• New

Has not received services from that physician or

another physician of the same specialty/same group within past 3 years

• Established

–Has received services from that physician or

another physician of same specialty/same group within past 3 years

•See Decision Tree diagram in E & M guidelines

New vs. Established Patients

• On-call/covering physicians

–Per CPT, a physician who renders a service should report the patient’s

t it ld b t d b

encounter as it would be reported by the physician who is not available • Example: Dr. Smith is on call for Dr.

Jones and sees an established patient of Dr. Jones. Dr. Smith reports an established patient visit (99211-99215)

E & M Services- History

• History

–Chief complaint

–History of present illness (HPI) –Review of systems (ROS) –Past, Family and Social History

E & M Services – History

• Chief

Complaint-–A concise statement generally in the patient’s own words that describe patient s own words that describe the reason for the encounter (i.e. signs & symptoms)

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E & M Services – History

• History of Present Illness

–A chronological description of the development of the patient’s present illness. Including descriptors like: • Location – e.g., pain in the left lower quadrantg , p q

Quality – e.g., cramp-like pain in the abdomen

Severity – e.g., moderate pain in the abdomen

Timing – e.g., periodic abdominal pain but more consistent lately

Context – e.g., abdominal pain worse after eating

Modifying Factors – e.g., gets less intense after taking 2 Tums.

• Associated Signs and Symptoms – e.g., abdominal pain is usually accompanied by a nauseous feeling

E & M Services – History

• Review of Systems

–An inventory of body systems obtained through a

series of questions asked by the provider seeking to identify signs and/or symptoms

•Helps define problem, clarify differential diagnosis, identify appropriate exam/diagnostic studies

E & M Services – History

• Past, Family and/or Social History (PFSH) –Review of patient’s past experiences with

illnesses, injuries, and treatments

( j ill ti di ti ll i )

•(e.g., major illnesses, operations, medications, allergies)

–Review of family members’ medical history

•(e.g. cause of death, hereditary diseases)

–Age appropriate review of past/current activities

•(e.g. marital status, use of drugs, alcohol, or tobacco)

History Definitions

• Problem Focused- Chief complaint; brief history of present illness or problem

–Example: leg pain; patient reports hitting

l b d f hil lki d

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History Definitions

• Expanded Problem Focused- Chief complaint; brief history of present illness; problem pertinent system review

problem pertinent system review –Example: leg pain; patient reports

hitting leg on bed frame while walking around bed. The pain has lasted approximately three months. The The physician asked if pain radiates or gets physician asked if pain radiates or gets worse with increased movement. worse with increased movement.

History Definitions

• Detailed- Chief complaint; extendedextended history of present illness; problem pertinent system review extendedextended to include a limited number to include a limited number of additional systems; pertinent past, family, of additional systems; pertinent past, family, yy ; p; p pp ,, y,y, and or social history directly related to the and or social history directly related to the patient’s problem(s)

patient’s problem(s)

–Example: Patient has leg and arm swelling, provider reviews heart, lungs, skin, vitals. Patient’s mother and grandmother have CHF.

History Definitions

• Comprehensive- Chief complaint; extended history of present illness; review of systems directly related to the problem(s) identified in the history of present illness plus a review of plus a review of all additional body systems; complete all additional body systems; complete past all additional body systems; complete all additional body systems; complete past, family, and social history

–Example: Patient has shortness of breath with mild chest pain. Vitals, HEENT, heart, lungs, GI, GU, neuro, lymphatic,

musculoskeletal are reviewed. NKDA, family history negative for heart disease, does not smoke.

E&M Services -- Examinations

• The extent of the examination performed is dependent on the clinical judgment and on the clinical nature of the presenting problem. There are four types:

–Problem focused

–Expanded problem focused

–Detailed

–Comprehensive

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Examination Definitions

• Problem focused

–A limited limited exam of the affected body area or organ system

Examination Definitions

• Expanded Problem focused

–A limited limited exam of the affected body area or organ system and other symptomatic and other symptomatic or related organ system(s)

or related organ system(s) or related organ system(s). or related organ system(s).

Examination Definitions

• Detailed

–A extended extended exam of the affected body area or organ system and other and other symptomatic or related organ system(s) symptomatic or related organ system(s) symptomatic or related organ system(s). symptomatic or related organ system(s).

Examination Definitions

• Comprehensive

–A comprehensive exam can be met in one of TWO ways:

•A general multimulti--systemsystem exam

•A general multimulti--systemsystem exam

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Medical Decision Making – Definition

• Refers to the complexity of establishing a diagnosis and/or selecting a management option. The three elements include:

Number of possible diagnoses/number of

–Number of possible diagnoses/number of management options considered

–Amount/complexity of data to be obtained, reviewed, and analyzed

–Risk of complications, morbidity and/or mortality as well as comorbidities

Determining level of Medical Decision Making

• Types of Medical Decision Making –Straightforward

–Low Complexity –Moderate Complexity –High Complexity

Medical Decision Making --Definition

• 2 out of 3 elements must be met or exceeded for a given type of

decision making

–See Table 2 in E & M Services guidelines

Complexity of Medical Decision Making: Example #1 Number of Diagnoses or Management Options Amount and/or Complexity of Data to be Reviewed Risk of Complications and/or Morbidity or Mortality Type of Decision Making

minimal minimal or none minimal Straightforward

Low Low

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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Complexity of Medical Decision Making: Example #1- Answer

Number of Diagnoses or Management Options Amount and/or Complexity of Data to be Reviewed Risk of Complications and/or Morbidity or Mortality Type of Decision Making

minimal minimal or none minimal Straightforward

Low Low

minimal minimal or none minimal Straightforward

limited limited low Low complexity

multiple moderate moderate Moderate Complexity

extensive extensive high High Complexity

High High

Complexity of Medical Decision Making: Example #2 Number of Diagnoses or Management Options Amount and/or Complexity of Data to be Reviewed Risk of Complications and/or Morbidity or Mortality Type of Decision Making

minimal minimal or none Minimal Straightforward

Low Low

minimal minimal or none Minimal Straightforward

limited limited Low Low complexity

multiple moderate Moderate Moderate Complexity

extensive extensive high High Complexity

High High

Complexity of Medical Decision Making: Example #2 - Answer

Number of Diagnoses or Management Options Amount and/or Complexity of Data to be Reviewed Risk of Complications and/or Morbidity or Mortality Type of Decision Making

minimal minimal or none minimal Straightforward

Low Low

minimal minimal or none minimal Straightforward

limited limited low Low complexity

multiple moderate moderate Moderate Complexity

extensive extensive high High Complexity

High High

Complexity of Medical Decision Making: Example #3 Number of Diagnoses or Management Options Amount and/or Complexity of Data to be Reviewed Risk of Complications and/or Morbidity or Mortality Type of Decision Making

minimal minimal or none minimal Straightforward

Low Low

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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Complexity of Medical Decision Making: Example #3 - Answer

Number of Diagnoses or Management Options Amount and/or Complexity of Data to be Reviewed Risk of Complications and/or Morbidity or Mortality Type of Decision Making

minimal minimal or none minimal Straightforward

Low Low

minimal minimal or none minimal Straightforward

limited limited low Low complexity

multiple moderate moderate Moderate Complexity

extensive extensive high High Complexity

High High

Complexity of Medical Decision Making: Example #4 Number of Diagnoses or Management Options Amount and/or Complexity of Data to be Reviewed Risk of Complications and/or Morbidity or Mortality Type of Decision Making

minimal minimal or none minimal Straightforward

Low Low

minimal minimal or none minimal Straightforward

limited limited low Low complexity

multiple moderate moderate Moderate Complexity

extensive extensive high High Complexity

High High

Complexity of Medical Decision Making: Example #4- Answer

Number of Diagnoses or Management Options Amount and/or Complexity of Data to be Reviewed Risk of Complications and/or Morbidity or Mortality Type of Decision Making

minimal minimal or none minimal Straightforward

Low Low

minimal minimal or none minimal Straightforward

limited limited low Low complexity

multiple moderate moderate Moderate Complexity

extensive extensive high High Complexity

High High

Complexity of Medical Decision Making: Example #5 Number of Diagnoses or Management Options Amount and/or Complexity of Data to be Reviewed Risk of Complications and/or Morbidity or Mortality Type of Decision Making

minimal minimal or none minimal Straightforward

Low Low

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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Complexity of Medical Decision Making: Example #5- Answer

Number of Diagnoses or Management Options Amount and/or Complexity of Data to be Reviewed Risk of Complications and/or Morbidity or Mortality Type of Decision Making

minimal minimal or none minimal Straightforward

Low Low

minimal minimal or none minimal Straightforward

limited limited low Low complexity

multiple moderate moderate Moderate Complexity

extensive extensive high High Complexity

High High

Time

• Counseling and/or coordination of care

– When more than half of the face-to-face (office or other outpatient) or floor/unit time (hospital or nursing facility) is spent with the patient and/or family providing counseling and/or coordination of care, the CPT code may be y selected based on the total time of the face-to-face or floor/unit time of the encounter.

Documentation

•Total length of time of the encounter

•How much time spent in coordination of care and/or counseling

•Issues discussed (brief notation)

–(Relevant history, exam and medical decision making, if performed, should also be noted on the patient’s record.)

Counseling

• Discussion with a patient/family regarding concerns of one or more of the following:

–Diagnostic results, impressions, and/or recommended diagnostic studies

–Prognosis

–Risks and benefits or management (treatment) options

–Instructions of compliance with chosen management (treatment) options

–Risk factor reduction

–Patient and family education

Time

• Today’s office visit for an established patient was 15 minutes in length. 10 minutes was spent discussing

management of patient’s diabetes with detailed pros an cons of each treatment method.

–>50% time spent counseling •Report 99213 (typical time spent is 15

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Coding Traps

• If time is documented don’t assume that the time

documented is for counseling and/or coordination of care

Audit Sheet Example #1

New Office/Consults Established Office

If a column has 3 circles, draw a line down the column and circle the code OR find the column with the circle farthest to the left, draw a line down the column and circle the code.

If a column has 2 or 3 circles, draw a line down the column and circle the code OR draw a line down the column with the center circle and circle the code.

History PF EPF D C C Minimal problem that may not require presence of physician PF EPF D C Examination PF EPF D C C PF EPF D C Complexity of MDM SF SF L M H SF L M H

New Office Visit

99201 9920299203 99204 99205

Inpatient Consultation 99251 9925299253 99254 9925599211 99212 99213 9921499215 Office or Outpt.

Consultation 99241 9924299243 99244 99245

Audit Sheet Example #2

New Office/Consults Established Office

If a column has 3 circles, draw a line down the column and circle the code OR find the column with the circle farthest to the left, draw a line down the column and circle the code.

If a column has 2 or 3 circles, draw a line down the column and circle the code OR draw a line down the column with the center circle and circle the code.

History PF EPF D C C Minimal problem that may not require presence of physician PF EPF D C Examination PF EPF D C C PF EPF D C Complexity of MDM SF SF L M H SF L M H

New Office Visit

99201 9920299203 99204 99205

Inpatient Consultation 99251 9925299253 99254 9925599211 99212 99213 9921499215 Office or Outpt.

Consultation 99241 9924299243 99244 99245

Audit Sheet Example #3

New Office/Consults Established Office

If a column has 3 circles, draw a line down the column and circle the code OR find the column with the circle farthest to the left, draw a line down the column and circle the code.

If a column has 2 or 3 circles, draw a line down the column and circle the code OR draw a line down the column with the center circle and circle the code.

History PF EPF D C C Minimal problem that may not require presence of physician PF EPF D C Examination PF EPF D C C PF EPF D C Complexity of MDM SF SF L M H SF L M H

New Office Visit

99201 9920299203 99204 99205

Inpatient Consultation 99251 9925299253 99254 9925599211 99212 99213 9921499215 Office or Outpt.

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Audit Sheet Example #4

Emergency Dept New/Established

If a column has 3 circles, draw a line down the column and circle the code OR find the column with the circle farthest to the left, draw a line down the column and circle the code.

History PF EPF EPF D C

Examination PF EPF EPF D C

Complexity of MDM SF L M M H

99281 99282 99283 99284 99285

Audit Sheet Example #5

Emergency Dept New/Established

If a column has 3 circles, draw a line down the column and circle the code OR find the column with the circle farthest to the left, draw a line down the column and circle the code.

History PF EPF EPF D C

Examination PF EPF EPF D C

Complexity of MDM SF L M M H

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Evaluation and Management Group Exercises

1. Sally is seen by Dr. Able on 10/1/08 for ear pain. Her last encounter prior to this visit with Dr. Able was on 8/20/2005. Dr. Able performs an expanded problem focused history, an expanded problem focused exam and medical decision making was moderate. Sally was instructed to return if symptoms persist. The total visit was 45 minutes of which 25 minutes were dedicated to the exam. How should these services be reported? 99202 Rationale: Sally has not seen her family physician for over 3 years making her a new patient again. For a new patient you must meet or exceed all 3 key components

2. Sally returns on 11/12/2010 and sees Dr. Boyd, another family physician within the practice. He performs a problem focused history, an expanded problem focused exam and medical decision making was of moderate complexity. The total visit was 20 minutes of which 15 minutes were dedicated to the exam. How would these services be reported? 99213 Rationale: Sally has received services from someone in the practice, same specialty within the past 3 years on 8/20/05. Since Sally is an established patient, only 2 out of 3 key components must meet or exceed.

3. Ken, a new patient, presents to Dr. Geoffrey with a chief complaint of abdominal pain. History consists of extended history of present illness, problem pertinent system review to include an additional number of body systems; pertinent past, family and social history related to chief complaint. (Detailed) The exam consisted of an extended exam of the affected body areas and other symptomatic/related organ systems. (Detailed) Medical decision making consisted of multiple diagnoses/management options, limited amount of data reviewed, and risk of complication(s), morbidity/mortality was moderate.

(Moderate) The total visit was 30 minutes of which 20 minutes were dedicated to the exam. How should these services be reported?

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4. Jodi, an established patient, presents to Dr. Fitch with a chief complaint of chest pain. History consists of extended history of present illness; problem pertinent systems review to included a limited number of additional systems; pertinent past, family and social history. (Detailed) The exam consists of a complete examination of the cardiovascular system. (Comprehensive) The medical decision making consists of multiple

management options, moderate amount of data to be reviewed, and high risk of

complications, morbidity/mortality. (Moderate) The total visit was 25 minutes of which 15 minutes were dedicated to the exam. How should these services be reported? 99214 Rationale: As an established patient only 2 out of the 3 key components must be met or exceeded. Key components are based on definitions.

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Evaluation & Management Coding Level Selection Individual Exercises

What is the correct E&M CPT code(s), including modifiers, for each of the following scenarios?

1. A patient was seen in the Emergency Department by a primary care physician for severe right lower quadrant pain. No ED physician is involved in the case. The PCP performed a comprehensive history and a comprehensive exam. The medical decision making was of moderate complexity.

99284 The PCP reports this encounter using an ED E&M code because there was no ED physician involved. For ED services, all 3 of the 3 key components are required, regardless of whether the patient was new or established.

2. Ms. Smith returned to Dr. Jones after three years have elapsed. She referred herself for peripheral vascular disease that has progressed. Dr. Jones performed a comprehensive history and a comprehensive exam. The documentation for the encounter indicated

multiple management options, a moderate amount of data to be reviewed and a high risk of complications.

99204 Based on the information provided, medical decision making was of

moderate complexity. Because this was a new patient encounter, all 3 of the 3 key components are required.

3. Ms. Jacobs was placed in observation care by Dr. Anderson on Friday for evaluation of chest pain. She remained in observation on Saturday and was discharged from observation care on Sunday. On Saturday, Dr. Anderson documented an expanded problem focused history, detailed exam and medical decision making of moderate complexity. Code for Dr. Anderson’s visit on Saturday.

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4. Greg went to the office of Surgeon A for a left groin mass that he noticed after lifting heavy objects at work. Surgeon A determined that Greg has an inguinal hernia that should be repaired. The worker’s compensation claim office required Greg to obtain a second opinion before they will cover the surgery. They sent Greg to Surgeon B. Surgeon B saw Greg in the office and performed an expanded problem focused history and an expanded problem focused exam. Medical decision making was straightforward. Surgeon B sent a written report back to worker’s compensation concluding that Greg must have the hernia repaired. Code Surgeon B’s service.

99242-32. At first blush, one might conclude that this encounter should not be reported as a consultation because the services were not requested by another physician. However, the CPT consultation guidelines state that a consultation may be requested by a physician or “other appropriate source” which includes an insurance company. The -32 modifier is necessary because the consultation was mandated by a third-party (i.e., the worker’s compensation claim office).

5. Shirley, a 28 year old established patient, presented to her gynecologist for her routine annual physical. Shirley had no problems to report. The physician performed a gender and age appropriate evaluation including a comprehensive review of systems a comprehensive past, family, and social history as well as a comprehensive assessment of pertinent risk factors.

99395 Preventive medicine visits are coded by age, not by key component.

6. Shirley, the same patient as in the above question, presented again one year later for her routine annual checkup. The physician performed a complete preventive medicine check-up. The physician found a breast lump during the exam. In order to further diagnose the breast lump, the physician performed a problem-focused exam (above and beyond the preventive medicine exam). Low complexity medical decision making was also required in connection with the breast lump, however, no additional history was required in connection with the breast lump.

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7. Milton, a 14 year old boy, presented to his cardiologist’s office for an evaluation relating to a fairly serious heart defect. Milton was an established patient and was accompanied by his parents. The cardiologist performed a comprehensive history and a comprehensive exam. Medical decision making was of high complexity. The total time spent on the history, exam and decision making was 40 minutes. The cardiologist then continued to discuss Milton’s case with Milton and his parents for an additional 80 minutes.

99215, 99354, 99355 The cardiologist may report the 80 minutes of additional time as prolonged services. Note that the prolonged service codes are add-on codes.

8. Dr. Bob saw Jeremy, 40 year old male, in the office. He took a detailed history and performed a detailed exam for Jeremy, a new patient. Jeremy has end stage renal disease and diabetes. The diagnoses and risks of mortality were extensive and high respectively. There was an extensive amount of data for Dr. Bob to review. Dr. Bob’s documentation shows that 25 minutes out of the total 45 minutes of encounter time were spent counseling Jeremy on his diseases. Dr. Bob documented the various options discussed with Jeremy and the coordination of care with the other participating physicians.

99204 Based on key components, this encounter would be coded as a 99203. However, as discussed in the E&M section guidelines, because counseling

dominated (i.e., took up more than 50% of the total encounter time), Dr. Bob may code this encounter based on time. The typical time for a 99204 is 45 minutes, consequently, Dr. Bob may code this encounter as a 99204 even though the encounter does not meet the 99204 requirements for coding based on key component.

9. Same as above except a month later, Dr. Bob is called to the hospital. When he reports to the Intensive Care Unit, he finds that Jeremy is critically ill. He has suffered cardiac arrest and kidney failure and has gangrene covering his feet. Dr. Bob spends one hour and forty-five minutes of uninterrupted time providing critical care services for Jeremy. During this time, Dr. Bob performs a comprehensive exam, interprets a single view chest x-ray and performs ventilation management. Medical decision making was of high complexity. How should these services be reported?

99291, 99292x2 These were critical care services and are therefore coded based strictly on time. It would not be appropriate to assign additional codes for the chest x-ray CPT code (71010-26) or the ventilation management (94002) because these services are included in the critical care code per the guidelines.

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candidate for the surgery due to her other medical problems. Jane decided to confirm that she was not a good candidate by consulting with another bariatric surgeon, Dr. Hayes. Dr. Hayes evaluated Jane in his office by performing a detailed history and a detailed exam. Dr Hayes also reviewed a moderate amount of data, had a limited number of management options and risk of complications was high. Jane had never seen Dr. Hayes or any other physician in his practice before. Dr. Hayes also concluded that Jane was not a good candidate for gastric bypass surgery. How should Dr. Hayes’ E &M services be reported?

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