coding for established rational physician office patients ...emuniversity.com/redax/est.pdf · for...

Rational Physician Coding for Established

Office Patients

Peter R. Jensen, MD, CPC www.EMuniversity.com

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Peter R. Jensen, MD, CPC

For clinically driven E/M coding education, go to www.EMuniversity.com

Rational Physician Coding for Established Office

Patients

Goals

Learn the documentation requirements for established office patientsIdentify the “correct” level of careAvoid undercodingEnsure E/M complianceLearn to use the approved E/M “shortcuts”Keep the focus on patient care

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$19.28$35.74$58.06$88.12$119.54

Established Office Patients

Most commonly billed CPT codes on the planet99211992992992992

5.2%

56%

49,912,657 Encounters

#2 ranked CPT code

108,985,507 Encounters

#1 ranked CPT code

CompComp99215

ng and/or

co ation of ca

W ing ba ime, no specific documentation requirements for History, Physical and MDM

the otted t AND an haltime ust have be evoted cou ling and co nation o

Coding Based on Time

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Rational Physician Coding

RiskDataProblems

Primacy of Medical Decision-Making

MDM =

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Determining the MDM

High Complexity

HighExtensiveExtensive

Moderate Complexity

ModerateModerateMultiple

Low Complexity

LowLimitedLimited

Straight-Forward

MinimalMinimalMinimal

Level of MDM

RiskData Reviewed

Number of Diagnoses

Need 2 out of 3 to qualify for given level of MDM

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1.

2.

3.

His

Documentation Requirements

40HighCompComp9921525ModDetailedDetailed9921415LowEPFEPF9921310SFPFPF992125NoneNoneNone99211

TimeMDMExamHistoryE/M Code

2 out of 3 key components must qualify

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99211

Outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem(s) are minimal.

CPT Manual

5RequiredMDNo99211TimeMDMExamHistoryE/M Code

Secofrequcode encouReimabout


Ti

99211

5RequiredMDNo99211


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99211

Face-to-face interaction

have to be in the office suite (“incident to”)

99211 Documentation

No specific docu

on patient care

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99211 Examples

BP

What Does a 99211 Look Like?

After adjusting blood pressure

current medications

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No specific documentation requirements

NANANA99211MDMExamHistoryTarget Code

99211 Documentation

99211HistoryPhysical ExamMedical Decision-Making

No specific documentation requirements

NANANA99211MDMExamHistoryTarget Code

99211

CC: BP check

Interval History: The patient is

BP were also discussed

“E/M”Substance

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99212

10SFPFPF99212


6 – 11 from any systemsEPF

12 from any systemsDet

1 – 5 from any systemsPF

2 from EACH of NINE systemsComp

BulletsExam

None1BriefEPF

1/32 – 9ExtDet

NoneNoneBriefPF

3/310ExtComp

PFSHROSHPIHx

OR

Requires documentation of qualifying MDM plus either a problem focused history OR a problem

focused exam

Third mfrequecode fencouReimbabout


Time required would be 10 minutes

99212

10SFPFPF99212


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You see an otherwise completely healthy 44 YOM with OA controlled with THgrYfo

Self limited

New problework-up pla

New problework-up pla

Establishedworsening

Established

Prob

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High44High


d

ing for

gs no

•Rest•Gargles•Superficial dressings

•Laboratory tests •Chest X-rays•EKG/EEG, Echocardiogram

•One self-limited or minor problem, e.g., cold, insect bite, tinea corporis.

Minimal

Management Options

Diagnostic ProceduresPresenting ProblemsRisk

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Target Code: 99212




SFPFPF99212

99212

Planning out the Documentation

Are

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1. What level of care is

documentation

asks?

Rational Physician Coding

SFPFPF99212MDMExamHistoryTarget Code

Ethical Documentation

OR2 out of 3 key components must qualify

A problem focused history requires a brief HPI and no elements of ROS or PFSH

Problem Focused History

Problem Focused Exam

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MDM

99212 Documentation

99212Problem

MDM

CC: F/U complaints.


NoneNoneBriefPFPFSHROSHPIHistory


level of history

History

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CC: F/U OAIE

Physical ExamConstitutional Eyes ENMT Neck

Chest/Breasts

CV GI GULungs

Ta

Tw

•Inspect•Assess

(DOES

Exam

CC: F/U OAInterval History: No new complaints.Ex

Im1.Pl1.2.

Medical Decision-Making

9Targ

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CC: F/U OAInterval History:

MDMExamHistoryTarget Code

Two out of Three is all you Need For established office patients, only two out of three

ending” might look.

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CC: F/U OAInterval

2. RTC in six months



NoneNoneBriefPFPFSHROSHPIHistory

One HPI ElementLocation

Zero Exam Bullets

Alternative Ending: 99212

Any Two will Do The example above qualifies as a 99212 based

change so this still counts as one of our quali-fying key components.

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Third frequecode fencouReimbabout


Tim

99213

15LowEPFEPF99213



99213

15LowEPFEPF99213






BulletsExam

None1BriefEPF

1/32 – 9ExtDet

NoneNoneBriefPF

3/310ExtComp

PFSHROSHPIHx

OR

Requires documentation of qualifying MDM plus either an expanded problem focused history OR an

expanded problem focused exam

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The same patient returns in six months.He stcontrgolf gYou rTID, pthree

Self limited or mi

New problem, adwork-up planned

New problem, nowork-up planned

Established probworsening

Established prob

Problems

To

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•Over the counter drugs•Minor surgery, with no risk factors•PT/OT

•Physiologic tests not under stress, e.g., PFTs•Non-cardiovascular imaging studies with contrast

•Two or more self-limited or minor problems•One stable chronic illness•Acute uncomplicated injury or

Low




Minimal

Management Options


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Target Code: 99213




OR

LowEPFEPF99213MDMExamHistoryTarget Code

99213

Planning out the DocumentationTwo out of

any organ systems

Let’s go for the History First

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CC: Knee Pain

Interval History: Bilater

for polyarticular joint pain

or myalgias

Two HPI ElementsLocation, Context

One ROSMusculoskeletal



None1BriefEPFPFSHROSHPIHistory

CC: Knee PainInterval

bilateral knee effusionsImpression1. Worsening OA

Plan1. Start Motrin 800 mg TID, prn2. RTC in four months with renal profile and CBC

An EPF Exam requires AT LEAST 6 bullets from ANY organ systems


Constitutional Eyes ENMT Neck

Chest/Breasts

CV

Skin

Musculoskeletal

Neurologic

Psychiatric

GI GULungs

1

2


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CC: Knee PainInterval History: Bilateral knee pain is no longer controlled with Tylenol. His knees hurt playing golf.

ROS:

Exam:

Impressio1. Wors

Plan1. Start2. RTC


9921Target

CC: Knee Pain

Interval History: Bilateral knee pain is no longer controlled with Tylenol. His knees hurt playing golf.

R

Ex

Im1.

Pl1.2.

Alternative Ending

T

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Alternative Ending: 99213CC: Knee PainInterval History:

His knees hurt playing golf.

ee stiffness and decreased n

nee effusions

Impression1. Worsening

Interval History:

MDMExamHistoryTarget Code

Alternative Ending: 99213 The example above qualifies as a 99213 based o

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Second mfrequentlcode for tencounteReimburabout $8



99214

15LowEPFEPF99213



99214

25ModDetDet99214






BulletsExam

None1BriefEPF

1/32 – 9ExtDet

NoneNoneBriefPF

3/310ExtComp

PFSHROSHPIHx

OR

Requires documentation of qualifying MDM plus either a detailed history OR a detailed exam

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rns for follow-up.otrin, but he has BP of 155/80.rvasc 5 mg QD

-up visit in three

MDM Points

Self limited or minor (

New problem, additiowork-up planned

New problem, no addiwork-up planned

Established problem, worsening

Established problem,

PtsProblems/DDx PtsData Reviewed

Total

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•Over the counter drugs•Minor surgery, with no risk factors•PT/OT•IV fluids, without

•Physiologic tests not under stress, e.g., PFTs•Non-cardiovascular imaging studies with contrast•ABG

•Two or more self-limited or minor problems•One stable chronic illness•Acute uncomplicated injury or illness, e.g., cystitis, allergic

Low




Minimal

Management Options



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Target Code: 99214




OR


99214

Planning out the DocumentationTwo out of three key co

any

organ systems

In this case, it would be impossible to obtain a detailed

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9214Detailed HistoryDetailed ExamModerate MDM

CC: Follow-up OAInterval

MDM

Contains no elements of HPI, ROS or PFSH and therefore does not qualify for ANY level of history.

CC: Follow-up OAInterval History: No new complaints.


Physical ExamConstitutional Eyes ENMT Neck

Chest/Breasts

CV

Skin

Musculoskeletal

Neurologic

Psychiatric

GI GULungs

Detailed Physical Exam requires at least 12 bulletsfrom ANY organ systems

Gen: NAD, conversantVitals: 155/80, 65,

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99215

40HighCompComp*99215


CC: Follow-up OAInterval History: No new complaints.



Gen: NAD, conversantVitals: 155/80, 65, 98.6Neck: No JVD or carotid

renal profile

Hi

M

Lo

S

RiskData PtsProb PtsMDM

ModDetDet99214MDMExamHistoryTarget Code

*In this case, clude an exte

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99215

40HighCompComp*99215






BulletsExam

None1BriefEPF

1/32 – 9ExtDet

NoneNoneBriefPF

3/310ExtComp

PFSHROSHPIHx

OR

Requires documentation of qualifying MDM plus either a comprehensive history OR a

comprehensive exam

99215: What it Takes

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MDM Points

Self limited

New problwork-up pl

New problwork-up pl

Establisheworsening

Establishe

Pro

•Drug therapy requiring intensive monitoring for toxicity•Obtain DNR or de-escalate care

factors•Cardiac EP studies•Diagnostic endoscopies, with identified risk factors

•Onwith•Acute or chronic illness or injury, which poses a threat to life or bodily function•An abrupt change in neurological status

High

•Onexac•Tw•Ununce

Moderate

•Twmin•On•Acillnerhini

Low

•Onprobtinea

Minimal

Risk

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Calculating the Overall MDM

Min0 - 11SF

RiskData Problems MDM Complexity

Nee

Target Code: 99215




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OR

HighCompComp*99215MDMExamHistoryTarget Code

99215Planning out the DocumentationTwo out of three key components requiredWe know

99215 Example


99215Comprehensive HistoryComprehensive ExamHigh Complexity MDM

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CC: Chest Pain

HPI: Patient complains of intermittent chest pain, which began about three weeks ago and


2/310ExtendedComp*PFSHROSHPIHistory

HighCompComp*99215MDMExamHistoryTarget Code

For established office patients, only a modified co

shorthand, “All other sys-

tems reviewed and are negative.”

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2 out of 3

• Assessment of extremity edema

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Assessment: 1. Atypical chest pain 2. Etiology may be GI but need to rule out CAD3. Stable HTN4. Stable OA

Plan: 1. Start trial of Protonix 40 mg PO QD2. Nuclear stress test in am. 3. Continue PRN Motrin for

dimensions are needed to qualify for any given level of complexity.

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99215

Target Code History Exam MDM 99215 Comp* Comp High

Requires two out of three qualifying key components

CC: Chest Pain

Interval History: The patient’ complains of intermittent chest pain which began about three

weeks ago and is described as burning

have moderate risk.

0.7

137 98

14

24

12 36

101 4.1

MDM Prob Pts Data Pts Risk

SF ≤ 1 ≤ 1 Min

Low 2 2 Low

Mod 3 3 Mod

High ≥ 4 ≥ 4 High

EKG shows NSR with normal axis and no diagnostic ST changes.

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CC: Chest PainHPI: Patient complains of intermittent chest pain, which began about three weeks ago and is desPMH: Positive for OA SH: Remarkable for o

Alternative Ending

ROS: Complete ROS

Complexity MDM

HighMDM

High≥4≥4

Mod33

Low22

O ify for any given le ample qualified w O am instead of th T for this alterna-ti

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Alternative Ending: 99215

Target Code History Exam MDM 99215 Comp* Comp High

Requires two out of three qualifying key components

CC: Chest Pain

Interval History: The patient’

only

have moderate risk.

0.7

137 98

14

24

12 36

101 4.1

MDM Prob Pts Data Pts Risk

SF ≤ 1 ≤ 1 Min

Low 2 2 Low

Mod 3 3 Mod

High ≥ 4 ≥ 4 High

EKG shows NSR with nor-mal axis and no diagnostic ST changes.

Bullets Used Constitutional • Three vital signs • General appearance Eyes • Exam of sclerae/lids • Exam of pupils/irises Musculoskeletal • Exam of spine/ribs • Exam of digits Neck • Exam of neck • Exam of thyroid Lungs • Auscultation of lungs • Assess respiratory effort CV • Auscultation of heart • Palpation of heart Abdomen • Abdominal Exam • Exam of liver/spleen Skin • Inspection of skin • Palpation of skin Psyche • Assessment of affect • Assessment of orientation (Qualifies as a comprehensive exam)

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Is it Okay to Use Templates?

Templates are acceptable The examiner

(See the next page for our E/M University template for established office patients)

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E/M University: For practical E/M coding education, visit us at www.EMuniversity.com

PF: 1 - 5 bullets (99212) EPF: 6 - 11 bullets (99213) Det: 12 bullets (99214) Comp: 2 bullets from EACH of NINE systems (99215)

See also dictated note from today

Comp: ≥ 4 HPI elements or status of 3 problems, plus 10 ROS plus 2 out of 3 components of PFSH—Okay to review prior PFSH to qualify (99215)

Minimal Risk Low Risk Moderate Risk High Risk

•One self limited problem (e.g., cold, insect bite)

• Two self-limited problems • One stable chronic illness • Acute uncomplicated illness

(e.g., cystitis/rhinitis) • OTC drugs

• Mild exacerbation of one chronic illness • Two stable chronic illnesses • Undiagnosed new problem • Acute illness with systemic symptoms

(e.g., pyelonephritis, colitis) • Prescription drug management

• Severe exacerbation of chronic illness • Illness with threat to life or bodily function • Abrupt change in neurological status (e.g., TIA/weakness) • Parenteral controlled substances • Decision for DNR or to de-escalate care • Drugs requiring intensive monitoring for toxicity

Constitutional: NAD, conversant, pleasant (appearance) BP HR RR T

Exam Findings & Data Reviewed

Eyes: Anicteric sclerae, moist conjunctiva, no lid-lag PERRLA fundi clear, disc margins sharp

ENMT: NC/AT oropharynx clear; no erythema/exudate normal hearing normal auditory canals/TM’s intact

Neck: Supple, FROM no thryomegaly or carotid bruits

Lungs: CTA and percussion normal respiratory effort

CV: RRR, no MRGs normal PMI No LE edema ABD: Soft, NABS, no masses no HSM no hernias

Skin: Normal temperature, tone, texture and turgor; no induration or subcutaneous nodules no rash, lesions or ulcers Psych: A & O X 3 appropriate affect intact judgment

Neuro: CNs II - XII intact no focal sensory deficits

2 out of 3 Key Components Required E/M Hx Exam MDM Time

99212 PF PF SF 10 99213 EPF EPF Low 15 99214 Det Det Mod 25 99215 Comp Comp High 40

______________________________________ Signature

Data Reviewed Pts Review and/or order clinical lab tests 1

Review and/or order radiology tests 1

Review and/or order medical test (PFTs, EKG, echo, cath)

1

Discuss test with performing MD 1

Review of image, tracing, specimen 2

Decision to obtain old records 1

Review and summa-rize old records 2

4 3 1 2 1 Problem Points

Esta

blis

hed,

stab

le

Patient: Date:

CC: Interval History:

Medications: reviewed; see today’s medication list for details (counts as ONE element of PMH). Pertinent PFSH:

Comprehensive PFSH taken during a previous encounter was re-examined and reviewed with the patient. For details, refer to the note in this chart dated:

PF: 1 -3 HPI elements or the status of 1 - 3 problems (No ROS required)(99212)

EPF: 1 - 3 HPI elements or the status of 1 - 3 problems plus at least 1 ROS (99213)

Det: ≥ 4 HPI elements or the status of 3 problems, 2 - 9 ROS plus at least 1 element of PFSH (99214)

ROS (-) Positive Findings Constitutional

Eyes

ENT

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Skin

Musculoskeletal

Psychiatric

Endocrine

Neurological

Hem/Lymphatic

Allergic/Immun

H

is

to

ry

E s t a b l i s h e d O f f i c e V i s i t

P

hy

si

ca

l

MD

M

(three vital signs)

1. 2. 3. 4. 5.

Assessment & Plan

New

, fur

ther

w/u

is p

lann

ed

New

, no

furth

er w

/u p

lann

ed

Esta

blis

hed,

not

con

trolle

d

99212

99213

99214

99215

Self-

limite

d or

min

or (m

ax 2

)

MDM Prob Pts Data Pts Risk E/M SF ≤ 1 1 Min 99212 Low 2 2 Low Mod 3 3 Mod 99214 High ≥ 4 4 High 99215

Only 2 out of 3 components required

99213



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A “Routine Office Patient”

YoanAftprone

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A Detailed History requires 4 HPI elements (or the status of 3 chronic problems), 2 – 9 ROS and 1 PFSH

A Detailed Exam requires a total of 12 bullets from ANY organ systemsOR


99214


How would it look using a template?

ModDetDet99214MDMExamHistoryTarget Code

History

John Doe

The patient’s HTN and

1/3PFSHROSHPIHistory

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Physical Exam

X

130/80X

X X

NAD; conversant130/80

MDMExam


s with BMP, nd CBC

rent Rx

84

7

Moderate MDM

ModDetDet99214MDMTarget C

2 st qualify

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History Physical MDM

Select the “correct” level of carePerform the documentation in a purpose-driven manner“Less is More”It’s okay to use templatesRelax and let the patient dictate the level of care

Peter R. Jensen, MD, CPC

Online and On-site Physician-to-Physician E/MCoding Education

1-888-U-EM-CODE

[email protected]

Practical E/M Coding Education

www.EMuniversity.com

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coding for established rational physician office patients ...emuniversity.com/redax/est.pdf · for...

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