PAMELA PULLY CPC, CPMA BILLING/CLAIMS SUPERVISOR
GENESEE HEALTH SYSTEM
This information is accurate as of December 1, 2014 and is designed to offer basic information for coding
and billing. All information is based on experience, training and has been researched, interpreted and
carefully reviewed by this trainer. Medical
compliance/coding and billing information changes quickly. This can become outdated. This is intended
I use CPT, HCPCS and ICD-9 books for coding
Rules come from AMA, ICD-9, CMS and other
HIPAA and PPACA laws.
Any questions on information I am presenting please
ask. I will give you the source document used.
It is important to me to give the best and most up to
8 years at Genesee Health System
30+ years billing/coding/auditing most specialties.
Two national certifications from the American Academy
of Professional Coders (AAPC)
CPC - Certified Professional Coder
CPMA – Certified Professional Medical Auditor
Member of (AAPC), Past officer of local chapter.
Member of the National Alliance of Medical Auditing
Current officer of Michigan Association of
Goals for Training
Understand the over all risk of not coding
evaluation and management correctly.
Bell curves and the important role they play in
Have a better understanding of Evaluation and
Management (E/M) codes.
Understand the components and elements of an
Understand where to find rules and information
How to achieve the goals1. Risk--% of claims coded incorrectly.
2. Bell curves—How they help you find the outliers. 3. Evaluation and Management (E/M) codes.
4. The 7 Components of E/M.
5. Documentation requirements for each level of
6. 1995/1997 Exam Rules.
7. What makes someone a New patient vs Established
The perfect storm
Medical Economics April 09
-4 practices audited after
implementing EHR’s and using them as instructed and intended -Audit failures ranged from 20% to 95% of charts
-Fines ranged from $50,000 to $175,000+ per physician
-Non-compliant documentation also called a “canary in the coal mine” showed problems with usability, data integrity, and quality of care & liability
Interesting facts about recovery audits
How would you like an investment that returns
$7.20 for every dollar you invest? Our government has found just such an investment — healthcare
E&M coding, is a potential target; the 99213 and
99214 office codes were the top two CPT codes in terms of both charges and unit volume.
Recovery audits no longer if but when
Medicare Administrative Contractors (MAC)
Recovery Audit Contractors (RAC/RA)
Comprehensive Error Rate Testing (CERT)
Zone Program Integrity Contractor (ZPIC)
Health Care Fraud Prevention and Enforcement Action
Team (HEAT) .
Office of Inspector General (OIG)
Payment Error Rate Measurement (PERM)
3rd party payer audits
WPS Medicare e-News
Are You Billing these Evaluation and Management (E/M) Services
Review of recent Comprehensive Error Rate Testing (CERT) findings
for WPS Medicare providers in J8 reveals the three CPT codes used to report E/M services listed below were incorrectly coded at a rate of at least 44%.
99215 - Office or other outpatient visit for the evaluation and management of
an established patient
99223 - Initial hospital care, per day, for the evaluation and management of a
99222 - Initial hospital care, per day, for the evaluation and management of a
If you bill E/M services to Medicare, we highly recommend performing a
220.127.116.11 - Late Entries in Medical Documentation
(Rev. 377, Issued: 05-27-11, Effective: 06-28-11, Implementation:
The MACs, CERT, Recovery Auditors, and ZPICs shall give less weight when making review determinations to documentation, including a provider’s internal
query responses, created more than 30 calendar days following the date of service. If the MACs, CERT, or
Recovery Auditors identify providers with patterns of making late (more than 30 calendar days past the date of service) entries in the medical documentation,
What can we do to minimize risk?
Do not cross walk codes
Do not use time as the only factor for E/M
Do not treat all places or carriers the same
Do not use only one set of rules
Risk of doing things wrong
If you cross walk , the old medication review to one
E/M code you run the risk for not meeting the
documentation requirements. You will also be an outlier. (review on bell curve slide)
Using only time its wrong. You must have a time
statement to use time. You might not have
documented to that level. You may have “up coded”.
Using the same code for easy and difficult cases.
Doing this can lead to rejections and flags for audit.
Only following one carriers rules. They are different,
Risk of doing things wrong, continued
You can only use new patient codes when the client is new
to your group or has not been seen by a provider of that specialty for more than 3 years.
Every carrier has there own set of rules. Many are similar
however you need to review and stay familiar if you want to make the most or your coding and billing revenue.
Watch your codes and your documentation. Monthly peer
reviews with staff can prove to be enlightening for all. You can easily spot and outlier. Don’t give them an easy target.
Hire a certified coder.
90862 99213 Must include the
condition for which the medication is needed, type of medication, dosage, directions for use, any frequent side effects and the effect the medication is
having on the patients symptoms/condition
2 of 3 key elements for
Low Medical Decision
Evaluation and Management
There are 7 components to E/M 3 key elements and 3 contributory factors and time.
1. History 2. Exam
3. Medical Decision Making 4. Counseling
5. Coordination of care
Evaluation and Management
Chief Complaint (CC) sets the medical necessity. (CC) and Medical Decision Making (MDM) are the
most important part of an E/M code
Your E/M code can never be a higher level then
Time factor: You can only use time if more than
50% of the visit is spent counseling and it is documented.
You can have a higher level of E/M codes with less
The Chief Complaint also known as CC, is part of
the medical history taking, and is a concise statement describing the symptom, problem,
condition, diagnosis, physician recommended return, or other factors that are the reason for a medical encounter. (the medical necessity of this visit)
The patient's initial comments to a physician, nurse,
Understanding History Element of E/M
CMS required history elements
history CC HPI ROS Past, family, and/or social
focused Required Brief N/A N/A Expanded
focused Required Brief
Detailed Required Extended Extended Pertinent
Billing Provider Must Document the HPI
Per CMS rules: E/M services guide.
1. The Review of Systems and the Past, Family and/or
Social History may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, the physician must add a notation supplementing or confirming the
information recorded by others.
2. Only the physician or NPP that is conducting the E/M
service can perform the HPI. This is considered
Understanding the Exam element
1995 rules are simplistic. Usually not best rule to use for specialty physicians and NPP.
Limited to affected body or organ system (1 body area
or system related to problem) Problem Focused
Affective body area or organ system and other
symptomatic or related organ system (additional systems up to 7) Expanded Problem Focused
Extended exam of affected area (up to total of 7 or
more in depth then above) Detailed
General Multi-system exam (8 or more systems)
1995/1997 Exam rules
Best advise decide what works best for your
practiced and use it.
You can use 1995 for one claim and 1997 for
Eliminate the potential risk from an audit. Make
decision to use 1995 or 1997.
Write in policies and/or procedures. “We use 1997
Lets look at the 1997 exam for psych.
Understanding MDM Element of E/M
A-number of diagnosis or treatment
B-Risk of Complications and/or
Morbidity or Mortality
C-amount and/or complexity of data
A. number of diagnosis or treatment options
Number of Diagnoses or Treatment Options
A B x C = D Problem(s) Status Number Points Result
Self-limited or minor (stable, improved, or
worsening) Max = 2 1
Est. problem (to examiner); stable, improved 1
Est. problem (to examiner); worsening 2
New problem (to examiner); no additional Max = 1 3
New problem (to examiner); add. Workup planned 4
Risk of complications and/or morbidity or mortality
There is much information in this area. Let review CMS.gov site again.
Important factor in using the high level of toxic
medicine. You need to identify this either by
Amount and/or complexity data reviewed
Amount and/or Complexity of Data Reviewed
Reviewed Data Points
Review and/or order of clinical lab tests 1
Review and/or order of tests in the radiology section of CPT 1
Review and/or order of tests in the medicine section of CPT 1
Discussion of test results with performing physician 1
Decision to obtain old records and/or obtain history from someone other than patient 1 point Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider.
2 Independent visualization of image, tracing or specimen itself (not simply review of report) 2
AIMS test adds to E/M
Aims tests are not individually billable. Usually done
by non-physician provider.
If you review test positive or negative and document
you reviewed this is, an additional point is added to review of test data. The is in the MDM section of the E/M code.
This test falls under the Amount of data reviewed
and adds one point.
The only way to get points for reviewing old history
Time for counseling/coordination of care
You must spend more than 50% of the visit
on counseling or coordinating care.
It must be documented: Total time and the
amount of time spent on counseling or
You do not have to use start stop time of
Documentation of Time with Evaluation and
Time is built into the E/M codes. Providers are told to
base their E/M selection on the 3 key elements :
History, Exam and Medical Decision Making. Times are listed in the CPT manual with each level of service as a guideline only.
If a provider spends more than 50% of a face-to-face
Time must be documented as well as the detailed
description of the circumstance (counseling patient or coordinating care). For example: 55 minutes spent with patient, 30 minutes was spent in discussion
with patient and family regarding care.
Prolonged service codes can be reported in addition
to an E/M code when the length of time a provider spends with a patient in an outpatient setting
This code is for the office setting only.
If there is a nurse visit done in the home you have
to follow the rule: CPT code first HCPCS codes
There is no CPT code for nurse visit in the home so
you look to HCPCS.
The best HCPCS code for a nurse visit in the home
This is the most basic service done in the
Usually done by nurse when patients is not
being seen by doctor.
Can be billed same day as doctor visit when
it is a separately, identifiably different
Difference in New patient and Established patient
A new patient for a group practice is
one that has not been seen by anyone in
the group with the same discipline in
the last 3 years.
A new patient E/M code must meet 3 of
3 to be coded at that level.
An established patient only requires 2
E/M codes for different place of service
There are two groups of codes. New and
Residential home POS 12
a) They are in place and you need to familiarize
yourself with them.
b) Medical necessity is the most weighted elements in
c) There needs to be a reason for the visit the Chief
d) There are different guidelines for different carriers
Documentation rules for E/M
We now know the parts of E/M. We need to be
reminded that documentation must be complete in these areas.
You can lose or increase revenue with your
You must put down what you are doing and the
calculations in your head must be documented.
One doctor I worked with put it like this.
Fiscal Year 2015 HHS OIG Work Plan
Outpatient evaluation and management
services billed at the new-patient rate.
Questionable billing patterns for Part B
services during nursing home stays.
Physicians—Place-of-service coding errors
Physical therapists—High use of outpatient
Reduce risk, get it right
Understand there are areas of risk.
Identify by looking for your outliers. Create bell curves,
compare to national standards.
Learn rules and bill CPT (especially your E/M codes)
properly insuring Medicaid funds are used as payer of last resort.
Review your policies on coding and billing. Add
language to help reduce risk.
Have ongoing internal audits for proper documentation.
Have external audits and trainings. This is a moving
This is not rocket science---You can do it.
Many doctors have embraced the fact you have to
documents all you do.
You can start getting it right today.
Start a self audit plan. Review what you have done
right and fix what is wrong.
Keep up to date ALWAYS.