Evaluation & Management Place of Service

Full text

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Evaluation & Management

Place of Service

Hoda Henein, CHBME, CP

President & CEO, Active Management –

A Practice Management Consulting and Billing Company

• Fellow, Speaker, Billing & Coding Advisor – American Academy of

www.activemds.com activebilling@activemds.com

Telephone: 718-353-2702 Fax: 718-353-3014

• Fellow, Speaker, Billing & Coding Advisor – American Academy of

Podiatric Practice Management (AAPPM) & Langer Biomechanics

• Member of the Editorial Advisory Board for Podiatry Coding Alert

• Member of Healthcare Billing Management Association(HBMA)

• Member of American Academy of Professional Coders(AAPC)

• Member of American Medical Billing Association(AMBA)

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Active Management owns the copyright of the material here presented, including photographs and graphic designs,

unless otherwise specifically stated. In the case of some materials, Active Management has licensed rights to third parties.

This presentation is designed to be used to educate

attendees about medical billing and practice management. attendees about medical billing and practice management. The use of Active Management material for any purpose, including in hard copy or compilation for CD-ROM or any other electronic media, is prohibited unless prior written permission is obtained. In addition, the use of Active

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Evaluation & Management = Place of Service

How to determine the level to be How to determine the level to be

billed out? billed out?

E & M = CPT Code that refers

to a level of service in a

History Examination Time

to a level of service in a

particular setting.

These 7 components define the These 7 components define the

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Chief Complaint (CC)

History of Present Illness (HPI)

Review of Systems (ROS)

Past / family / social history (PFSH)

E&M

How to determine the level to be billed out?

Past / family / social history (PFSH)

Exam 97 - Elements

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(CC)

Chief Complaint

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(HPI)

history of present illness

- Eight possible elements

o

Location

o

Quality

o

Severity

o

Severity

o

Duration

o

Timing

o

Context

o

Modifying factors

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(ROS)

Review of Systems

A system is considered reviewed if the

patient’s positive responses and

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(ROS)

Review of Systems

14 possible systems that can be reviewed:

• Eyes • Skin

• Ears, Nose, Throat • Neurological

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(PFSH)

Past, Family and/or Social History

• Past History

– illnesses, operations, injuries and treatments

• Family History

– review of medical events in the patient’s direct

family members which may be relevant to the

– review of medical events in the patient’s direct

family members which may be relevant to the

patient’s CC

• Social History

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Determine the level of History

TYPE of History

HPI

ROS

PFSH

Problem Focused

Brief (1) N/A N/A

Expanded Problem

Focused

Brief (1)

Problem (1)

pertinent N/A

Detailed

Extended (4) Extended (2) Pertinent (1)

Detailed

Extended (4) Extended (2) Pertinent (1)

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Determine the level of Exam

Four possible types of Examinations

Problem Focused



(1 body area / organ system)

Expanded Problem Focused

Expanded Problem Focused



(2 to 7 body areas / organ systems; Limited)

Expanded Problem Detailed



(2 to 7 body areas / organ systems; Extended)

Comprehensive

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(MDM)

Medical Decision Making

Four levels of MDM based on



number of diagnoses or management

options



amount and/or complexity of data reviewed

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Putting It All Together

• Level of History

• Level of Exam

• Level of MDM

• Level of MDM

• Time face to face Physician and patient

– Only considered if >50% of face to face

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Learn 97 Guidelines

Document your bullets

Use a Template

E&M

How to determine the level to be billed out?

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Notes/Documentation

Suggestion: itemize each procedure separately

Reason: when the non-clinical adjudicator

reviews your procedure notes they can clearly see

all the procedures performed and the “Medical

Necessity” to justify them.

Necessity” to justify them.

If it is not written down…

It didn’t happen

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How to determine the level to be billed out?

How to determine the level to be billed out?

Why should you get EMR?

$$$

“It’s the economy

stupid……incentives!”

How can EMR make money?

$$$

It will document what you do…

E M R

$$$

It will document what you do…

…Fast, Complete, and Legible.

Are you prepared to change your work flow?

$$$

Trade off - More work upfront

… Less work at the back end.

Are you going to use it?

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Consultation Codes

NOT for Medicare Use

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Place of Services

POS is the location where the service was performed:

POS

Description

E&M Codes

11

11 Office / Adult Day Care 99201-5(New) / 99211-5(Est)

99241-5 (Consult New or Est)

12

12 Patient’s Home and DMERC products 99341-5(New) / 99347-50(Est)

20

20 Urgent Care Facility (New Code) 99201-5(New) / 99211-5(Est)

21

21 Inpatient Hospital 99221-3(New) / 99231-3(Est)

99251-5 (Consult New / Est) 99251-5 (Consult New / Est)

22

22 Outpatient Hospital 99201-5(New) / 99211-5(Est)

23

23 Emergency Room 99281-5

24

24 Surgical Center N/A

31

31 Skilled Nursing Facility (SNF) 99304-5(New) – Not used by

DPM 99307-10(Est) 32 32 Nursing Facility 33 33

Custodial Care Facility / Assisted

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Code

Place Of

Service

Description

Location, other than a hospital, skilled nursing facility (SNF), military

treatment facility, community health center, State or local public health

POS Description

11 11 12 12 20 20 21 21 22 22 23 23 24 24 31 31 11 11 12 12 20 20 21 21 22 22 23 23 24 24 31 31 32 32 11 11 Office

center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health

examinations, diagnosis, and

treatment of illness or injury on an ambulatory basis.

Patient’s Home Location, other than a hospital or other

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Code Place Of Service Description

20

20 Urgent Care Facility

Location distinct from a Hospital ER, an Office, or clinic, who’s purpose is to diagnose and treat illness or injury for unscheduled ambulatory patients

seeking immediately medical attention.

21

21 Inpatient Hospital

A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and non-surgical), and rehabilitation services by, or under, the supervision of physicians to patients

POS Description

under, the supervision of physicians to patients admitted for a variety of medical conditions.

22

22 Outpatient Hospital

A portion of a hospital which provides diagnostic, therapeutic (both surgical and non-surgical), and rehabilitation services to sick or injured persons who do not require hospitalization or

institutionalization.

23

23 Emergency Room A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided.

24

24 Surgical Center

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Code Place Of Service

Description

31

31 Skilled Nursing Facility

(SNF)

A facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital.

POS Description

hospital.

32

32 Nursing Facility

A facility which primarily provides to

residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than mentally retarded individuals.

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Podiatry Billing Modifiers

DME

Thank you!!!

Hoda Henein, CHBME, CP President & CEO, Active Management

Receivables Management

President & CEO, Active Management Management Consulting & Billing Company

All rights reserved. This material may not be reproduced, displayed, modified or distributed without the express prior written permission of the copyright holder.

www.activemds.com activebilling@activemds.com

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