Evaluation and Management Coding

Vol. 12 •Issue 25 • Page 8
Evaluation and Management Coding

This is the last column for 2002 and I wish to announce to readers that this is my last column as author of CCS Prep! I truly have enjoyed providing study assistance to all of you since 1998. Alas, I have decided to pursue other endeavors in the field and truly want to thank each and every one of you for reading the column. I look forward to reading the column by the new author next year! It has truly been a wonderful experience for me.

In this last column, we will discuss some of the issues in assigning evaluation and management (E&M) codes. As you know, at the current time, the Centers for Medicare and Medicaid Services (CMS) has instructed hospitals to use their own (E&M) guidelines for now for the FACILITY (hospital) side of coding/billing for clinic and emergency services. These will vary by facility, as some are using various point systems or time to assign codes. CMS is looking to streamline this into one acceptable standard system to be used by all facilities for billing. The American College of Emergency Physicians (ACEP) model is being considered. Poten-tially, 10 new “G” codes may be developed for facility E&M coding.

There are CMS guidelines for the PHYSICIAN coding/billing side, frequently called “professional fee coding,” which we will discuss in this column. The Department of Health and Human Services (HHS) Advi-sory Committee has recently recommended that the E&M documentation guidelines be abolished and another yet undetermined system be used. We are not sure how this will affect the exams next year so be sure to follow up on this issue. We will discuss here some of the more common and more general issues. Due to limits on space, only the codes are presented. Please refer to your CPT code book for descriptions.

Documentation Guidelines For E&M Services
Although the exam will not require you to use the Documentation Guidelines for E&M Services to assign each component for the E&M code, there may be multiple-choice questions about the guidelines. The exams usually give you the level of history, physical exam and medical decision-making and then have you assign the code from there. Be sure to check the 2003 exam book when it is published. There are currently two sets of documentation guidelines for E&M services, the 1995 and the 1997 guidelines. CMS has stated that physicians can use either the 1995 or 1997 guidelines, whichever is more beneficial to them. However, the physician cannot mix the two sets together on one case. You must choose one only per case, 1995 OR 1997.

The main differences between them are as follows:

a) In the 1997 HPI of the history component, the status of at least three chronic or inactive conditions is one element. This is not present in the 1995 guidelines.

b) The physical exam is completely different in the 1997 guidelines. There is a general multi-system exam and single organ system exams. All of these have specific bullets that must be documented to get to the four levels of physical exam.

Many offices prefer the 1995 guidelines, as they are less cumbersome in the physical exam area.

CPT Definitions
I encourage everyone to review the guidelines at the beginning of the E&M section and then all notations after each subsection. There is valuable information for coding in all of these areas. Many of the multiple choice exam questions may be taken right from these areas. Read them now and highlight the areas you deem important for studying.

Critical Care
Critical Care is a very in-depth area of the E&M section of CPT. In the professional edition CPT book, it begins on page 19 with more than a page of instructions. Review these in depth. The time chart is helpful in determining the correct codes. The Medicare Carriers Manual, section 15506 F states: “Cri-tical Care Service and other E&M Services Provided on Same Day–If critical care is required upon the patient’s presentation to the emergency department, only critical care codes 99291-99292 may be reported. Emergency department codes will not be paid for the same day. If there is a hospital or of-fice/outpatient evaluation and management service furnished early in the day and at that time the patient does not require critical care, but the patient requires critical care later in the day, both critical care and the evaluation and management service may be paid.”

Beware of coding consultations. Many physicians “refer” their patients to other physicians. It is inappropriate for the physician “referred to” to bill for a consultation. This physician is actually taking over the care of the patient and should have an E&M code reflective of that, depending on the area of service (office visit, hospital visit, etc). Many coding professionals discourage the use of the word “referral” when an actual consult is being pursued to eliminate confusion. See the revised Section 15506 of the Medicare Carriers Manual, which can be found at CMS’s Web site at: http://cms.hhs.gov/manuals/14_car/3b15052.asp#_15506_0 for more information.

Non-Physician Practitioners
There are rules to be followed for Medicare patients and many other payers for physicians who employ auxiliary personnel (i.e., physician assistants, nurse practitioners, etc.) to assist in rendering services to their patients and include the charges for their services on their own physician bill. These are considered “incident to” services. Incident to only applies to physician “extenders” or “NPPs” as they are called that do NOT bill under their own provider number. The MD has to be billing for them. The incident to service must be an “integral” part of a doctor’s diagnosis or treatment, provided under the direct supervision of a physician, performed by an employee of that doctor, and something ordinarily done in a doctor’s office or clinic. See MCM 2050, 2050.1. A recent Medicare Program Transmittal has been issued by CMS that discusses shared services performed on a patient by both the physician and non-physician practitioner, each with a billing UPIN/PIN number. Please see http://cms .hhs.gov/manuals/pm_trans/R1776B3.pdf for this memo and review the entire content. Transmittal 1780 gives example documentation requirements and was recently issued Nov. 22, 2002. See http://cms.hhs.gov/manuals/pm_trans/R1780B3.pdf.

Modifiers are tested in part I (multiple choices) of the CCS-P examination. This could change for 2003 exams so be sure to check the exam guides when they come out. For study purposes, be sure to review Appendix A of your CPT book on modifiers.

A fantastic reference for physician professional fee billing and coding is the Part B Answer Book, 2002 Edition published by PART B NEWS. You can reach them at (877) 397-1496 to subscribe. They also offer a great bulletin board you can subscribe to. It has hundreds of members and you can receive e-mails on differing issues presented by members. Go to www.partbnews.com and click on the box on the lower left corner.

E & M coding and billing rules are very involved and intricate. It is not possible to cover everything in this brief article. Be sure to keep up to date as rules change quickly as evident by the two transmittals included above. Be sure to review AHIMA’s Communities of Practice, Evaluation and Management Coding area for more information.

Now answer the following questions. Research the CPT Assistant, Documentation Guidelines for E&M Services and AHA Coding Clinic for HCPCS if applicable, after answering from memory. Due to limits on space, only the codes are presented. Please refer to your CPT code book for descriptions. Assign CPT codes for the professional fee (physician billing rules).

A) There are seven components of E&M code assignment. What are the “key” components?

1. All are “key” components and must be used in code in assignment.

2. History, physical exam and medical decision-making

3. Time, history and medical decision-making

4. History, physical exam, medical decision-making and time

B) What is a chronological review or description of the patient’s symptom(s) defined by location, quality, severity, duration, timing, context, modifying factors and associated signs and symptoms?

1. History of present illness

2. Physical exam

3. Review of Systems

C) When the physician spends more face to face/floor time (50 percent or greater) counseling the patient and/or family and coordinating care with other health care providers, than is spent on the three key components, and this is documented, what becomes the controlling factor in determining the Evaluation and Management level?

1. Medical Decision Making

2. Time

3. Use the three key components if documented

D) What modifier was revised for 2002 that describes two surgeons working on distinct parts of a surgery?

1. -60

2. -66

3. -62

E) If a fracture reduction is performed on a patient in a MVA, and the physician also conducts a separately identifiable E&M service for a head injury that is properly documented, then:

1. Code the fracture reduction and the E&M level code with modifier -25.

2. Code only the fracture reduction as the E&M is included in the procedure.

3. Code the fracture reduction and the E&M code with modifier -51.

F) An “Observation or Inpatient Care Services” (Including Admission and Discharge Services) requires how many key components to be documented?

1. Two of three key components

2. Three of three key components

3. Two of three key components plus either code 99238 or 99239

G) A physician has a patient as an inpatient and reviews the patient’s record on the floor. A physician assistant from the same group practice who is billing under his own UPIN/PIN number sees the same patient the same day and performs evaluation and management services. The case is billed:

1. Under the physician assistant’s UPIN/PIN only

2. Under both the MD and the physician assistant’s UPIN/PIN number

3. Under the MD’s UPIN/PIN number as “incident to”

Good luck to all of you taking the future exams!

It has been great assisting you in your preparations!

Patricia Maccariella-Hafey is director of education for Health Information Associates Inc., a company specializing in providing coding compliance review services, education and contract coding for hospitals. The corporate office is headquartered in Pawley’s Island, SC.

Coding Clinic is published quarterly by the American Hospital Association

“CPT only ” 2001 American Medical Association. All Rights Reserved.

A) 2. History, physical exam and medical decision-making. (See p. 9 of CPT Professional Edition, notes under each E&M code)

B) 1. History of present illness.

C) 2. Time. See the E&M documentation guidelines.

D) 3. Ð62. See the Appendix A of your CPT book.

E) 1. Code the fracture reduction and the E&M level code with modifier Ð25 (see modifier Ð25 in CPT Appendix A).

F) 2. Three of three key components. See this section in CPT book, 99234-99236. (A note under 99239 tells you to not code both the codes).

G) 1. Under the physician assistant’s UPIN/PIN only. See transmittal 1776 issued Oct. 25, 2002 by CMS. The doctor did not see the patient face to face so only the NPP can bill.