Coding for Occupational Health Encounters

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					Coding for Occupational Health

How to Get the Workload Credit You

        Angela N. Andersen, CPC
               Lead Coder
     Naval Medical Center Portsmouth
               March 2008
              E&M Coding
Upon completion of this presentation, the
   participant should be able to:
1. Identify the three key components of
   E&M coding
2. Recognize the difference between new
   and established patients as it relates to
   documentation and coding.
3. More accurately document and select
   the appropriate E&M code for the
   services rendered.

   What are E&M Codes?
   Why Code?
   How do Codes equate to Workload Credit?
   Why is Documentation important?
   What documentation should be included on
    every encounter?
   Determining the correct E&M code
   Time as the determining factor for E&M code
   Preventive Medicine E&M code requirements
    What are E&M Codes?

   The Evaluation & Management (E&M) codes
    are a sub-set of the CPT codes.
   Can be used by all privileged providers
   Describes:
       Complexity of care provided to a patient for non-
        procedural visits.
       The place of service (inpatient or outpatient)
       The type of service (new vs. est., consult,
        preventive, ER, critical care, etc)
                    Why Code?

Why is it important to code in the military?
    1.   Third Party Payers/Inter-agencies
    2.   Prospective Payment System (PPS)
    3.   FITREP input
    Over coding = Fraud
    Under coding = Lost RVUs/Revenue
Coding & Workload Credit
   A Relative Value Unit (RVU) is assigned to
    most of the CPT codes, including the E&M
   The more complex the service, the higher
    the RVU value assigned
       New Patient RVUs > Established Patient RVUs
       Consult RVUs > New patient RVUs
       Prev Med RVUs > Established patient RVUs
   Under the PPS, RVU average = $72.00
          What do Coders look for?
Every patient encounter should be legible and include:
 Date of Encounter*
 Reason for the visit (chief complaint)
 Appropriate history of present illness
 An exam when necessary or appropriate; i.e. a new
  patient (consistency and problem pertinent)
 Review of lab, xray, other ancillary services when
 Assessment*
 Plan of care/Treatment options*
 Provider signature*
                     *Taken Care of or required fields in AHLTA (CHCSII)

Remember: It is the Content, not the volume, of
  documentation that determines your E&M code!
   Determining the Correct E&M Code
There are three key components to consider when selecting
   the appropriate E&M:
         History
         Exam
         Medical Decision Making (MDM)
All three components must be documented for a new
   patient (new to clinic or not seen within the past three
   years). Indicate in CC if patient is new.
Only two of the three components must be documented for
   established patients (seen within the past three

E&M selection should never be based on the
  allotted time on the appointment schedule!
Why is Documentation Important?

The documentation must support the E&M code you select.

Your documentation must support the medical necessity of
  the services provided. The first step is to clearly
  document the reason for every visit – the chief
The use of ―Follow-up‖ is insufficient documentation as it
  does not indicate medical necessity. It is acceptable to
  document ―Follow-up for _____‖.
Remember: The coding rule of thumb is “If it isn’t
  documented, it wasn’t done!”
        Determining the Correct E&M

To determine the correct level E&M code,
  consider the complexity of your patient’s
  condition and your medical decision making,
  then support that level of complexity with your
  documentation of history and/or exam.

Remember: For a new clinic patient, initial
  consult, initial inpatient visit or ED encounter,
  you must document all three key
  components—history, exam and your medical
  decision making.
                 MDM Component

Medical Decision Making (MDM) refers to the complexity of
  determining a diagnosis and/or the selection of a treatment
  option. It is measured by documentation of the following:
 Number of diagnoses and/or management options that must
  be considered.
 Amount and/or complexity of data to be reviewed.
 Risk of complications, morbidity and/or mortality, and co-

The four types of MDM include: Straightforward, Low
  Complexity, Moderate Complexity, and High Complexity.

To assist in determining your level of MDM see Attachment A
           History Component

Documentation of History includes:
 Chief Complaint
 History of Present Illness (HPI)
 Review of Systems (ROS)
 Past, Family and or/Social History (PFSH)

The extent of history is dependent on clinical
  judgment and the nature of the presenting
The four types of History include: Problem focused,
  Expanded Problem focused, Detailed and
                     Determine your Documented Level of
                     Mark the entry in the farthest right column to describe your HPI,
                       ROS and PFSH. If one column contains 3 marks, the type of
                       history is indicated at the bottom. If no column has 3 marks,
                       the column marked farthest to the left identifies the type of

HPI (history of present illness) elements:                                    •           •             •             •
 • Location • Severity        • Timing • Modifying Factors                  Brief       Brief       Extended      Extended
 • Quality      • Duration • Context • Associated Signs                     (1-3)       (1-3)      (4 or more)   (4 or more)
                                           or Symptoms

ROS (review of symptoms):                                                    •           •              •            •
 • Constitutional • Ears,nose      •   GI        • Skin,breast   • Endo     None          1          At least    10 or more
   (wt loss, etc)   mouth,throat   •   GU        • Neuro                               System            2        Systems*
 • Eyes           • Card/vasc      •   Musculo • Psych           • Resp                              Systems
 • Hem/lymph      • Immuno         •   All others Neg

PFSH (past medical, family, social history) areas:                           •           •              •             •
  • Past Medical History                                                    None        None            1         Complete
  • Family History                                                                                   History     (3 for New,
  • Social History                                                                                    Area        2 for Est)

                                                                          PROBLEM    EXPANDED       DETAILED     COMPRE-
*ROS: 10 or more systems, or some systems plus statement ―all others      FOCUSED     PROBLEM      99203, 214,   HENSIVE
negative‖                                                                  99201,     FOCUSED         243         99204,
                                                                          212, 241   99202, 213,                 205, 215,
                                                                                        242                      244, 245
                              Exam Component
The following Body Areas and Organ Systems are recognized in
  E&M documentation:
Body Areas                            Organ Systems
   Head/Face                            Constitutional (vitals,etc)
   Neck                                 Eyes
   Chest/breasts/axillae                Ears/nose/mouth/throat
   Abdomen                              Cardiovascular
   Genitalia/groin/buttocks             Respiratory
   Back, including spine                Gastrointestinal
   Each extremity                       Genitourinary

The four types of Exam include: Problem focused, Expanded
  Problem focused, Detailed and Comprehensive.

To assist in determining your level of PE see Attachment B
                                      Final E&M Selection
          Determining your Level of Service:
                   PF = Problem Focused                            SF = Straightforward
                   EPF = Expanded Prob Focused                     L = Low Complexity
                   D = Detailed                                    M = Moderate Complexity
                   C = Comprehensive                               H = High Complexity

                              New Office/Consults                                             Established Office
          Requires all 3 components w/in a column (or choose lowest         Requires at least 2 components within a column (or
                                   column)                                                choose lowest column)

              PF            EPF         D           C          C          Minimal       PF         EPF          D           C
History                                                                  Problem
                                                                         That may
              PF            EPF         D           C          C          Require       PF         EPF          D           C
Exam                                                                        MD

             SF             SF          L           M          H                       SF           L           M           H

Level      99201 or      99202 or   99203 or     99204 or   99205 or      99211       99212       99213       99214       99215
            99241         99242      99243        99244      99245
                 Determining the Correct E&M

Consider the patient who has multiple chronic problems requiring
  prescription drug management. This patient would be
  considered a moderately complex patient and with the proper
  documentation of the other two components (Hx and Exam)
  this can be coded as a level four E&M visit.
   For a new patient/consult level IV visit (99204, 99244): Need to document a
    comprehensive history and comprehensive exam.

   For an established patient level IV (99214): Need to document a detailed
    history and/or detailed exam.
           Time as a Key Component
If more than 50% of your time with a patient is spent
   counseling or coordinating care, time can be used in
   selecting the E&M level.
 Document counseling topics/coordination of care.
       Prognosis, differential diagnoses, risks/benefits of
        treatment, compliance, discussion with another
        healthcare provider
   Document provider’s total face-to-face time plus time
    spent counseling or coordinating care for patient.
       Example: 45 min visit/30min counseling
**Do not include resident/support staff time with patient.
    Preventive Medicine

   New Patient
       99381-99387
   Established Patient
       99391-99397
   Counseling
       99401-99404 Individual
       99411-99412 Group

99381-99397 are based on the age of the patient
99401-99412 are based on time spent counseling.
   Preventive Medicine
  This code series includes counseling / anticipatory
  guidance / risk factor reduction interventions which are
  provided at the time of the initial or periodic
  comprehensive preventive medicine examination.
  Comprehensive in this code series is NOT synonymous
  with the comprehensive examination required in 99201-
  This code series cannot be coded on the same day as a
  preventive medicine examination visit. To code for
  these services the patient cannot have any symptoms
  or an established illness.
                   Capture More Workload
           Smoking Cessation Counseling
               G0375 3-10 minutes
               G0376 10+ minutes
           Digital Rectal Exam for Prostate Cancer Screening
               G0102
           Visual Acuity Exam (Snellen Chart)
               99173
           Needle Sticks!!
               96150 – when the OH nurse see’s a patient due to a
                needle stick he/she can code this encounter as 99499 E/M
                and 96150 CPT with the applicable ICD-9 primary for the
                wound and a secondary ICD-9 code of the External cause.

NEW 2008 E/M Codes for Smoking Cessation 99406 and
99407 to replace the procedural codes G0375 and G0376.
        Common Coding Errors in OH
   V68.0x Issuance of Certificate
       This is a PRIMARY only ICD-9 code and should not be used
        in the secondary diagnosis slot.
   V70.x General Medical Exam
       This is a PRIMARY only ICD-9 code and should not be used
        in the secondary diagnosis slot.
   Routine visits that turn into an Acute visit for a finding
    upon exam.
       Providers must document all applicable information
        required for the preventive service.
       If an acute finding is discovered and managed during the
        same encounter – the provider should ―Expand‖ his/her
        documentation pertinent to this finding and code an
        ADDITIONAL separate E/M code for the acute finding.
        Common Coding Errors in OH
   Coding in AHLTA –
       You MUST verify the E/M code chosen by AHLTA in the
        Disposition screen.
            It has been a common place error that providers are being
             given non-count E/M code 99429 for preventive visits OR
             Preventive E/M 99381-99397 for acute care visits.
       New patient vs. Established patient
          While the front desk books these appointments – providers
             should always double check the patients ―status‖ in AHLTA.
                 New patients are worth higher RVU’s and you will lose out if you
                  let the system default to an established patient E/M.
       Preventive Medicine and Acute Care – Same Day
            AHLTA will not automatically code your encounter with a
             Preventive E/M (99381-99397) and an Acute E/M (99201-
                 The provider must manually code the additional E/M code in the
                  disposition screen based on his/her documentation. *Be sure to
                  add a 25 modifier to your Acute E/M.
                   E/M RVU’S
   99201   0.45          99387   2.06
   99202   0.88          99394   1.36
   99203   1.34          99395   1.36
   99204   2.30          99396   1.53
   99205   3.00          99397   1.71
   99211   0.17          99358   2.10
   99212   0.45          99359   1.00
   99213   0.92          99401   0.48
   99214   1.42          99402   0.98
   99215   2.00          99403   1.46
   99384   1.53          99404   1.95
   99385   1.53          99411   0.15
   99386   1.88          99412   0.25
   94010   0.17      93000   0.17
   99000   0.05      93010   0.17
   36415   0.06      G0375   0.24
   99173   0.00      G0376   0.48
   96150   0.50      G0102   0.17
   96151   0.48

   Are you going to let RVU’s slip away?
   By incorporating some of the information
    discussed today into your notes, you can
    honestly increase your RVU’s and
   Keep in mind that AHLTA does not code for
    you completely – you must always check your
    codes before finalizing your note.
   Templates are your best tool to maximize your
    coding in AHLTA.

Contact Information:

Angela N. Andersen, CPC
Office 757.953.1241
Cell 757.333.2066

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