Full text






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 This can become outdated.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


Disclaimer cont.

 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



 Pamela Pully

 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

Specialist (NAMAS)

 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

assessing risk.

 Have a better understanding of Evaluation and

Management (E/M) codes.

 Understand the components and elements of an

E/M code.

 Understand where to find rules and information


How to achieve the goals

1. 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


Timeliness requirement - 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

established patient

Expanded problem

focus history

Expanded problem

focus exam

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

your MDM.

 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


Chief Complaint

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

Type of

history CC HPI ROS Past, family, and/or social


focused Required Brief N/A N/A Expanded


focused Required Brief


pertinent N/A

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

workup planned

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

coordinating care.

You do not have to use start stop time of


N.A.M.A.S. 5/9/2014

Documentation of Time with Evaluation and

Management Services:

 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


N.A.M.A.S. 5/9/2014

 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

is T1002.



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

AFC/Group home.

There are two groups of codes. New and


New 99324-99328

Established 99334-99337

Residential home POS 12

New 99341-99345



Documentation Guidelines

a) They are in place and you need to familiarize

yourself with them.

b) Medical necessity is the most weighted elements in

a E/M.

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


Good News

 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.


Thank you



Related subjects :