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Document Sample
Coding for Occupational Health
Encounters
How to Get the Workload Credit You
Deserve
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.
Contents:
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
selection
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?
REIMBURSEMENT
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
codes.
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
appropriate
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
years).
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
complaint.
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
Code
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-
morbidities.
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
problem.
The four types of History include: Problem focused,
Expanded Problem focused, Detailed and
Comprehensive.
Determine your Documented Level of
History
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
history.
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
Musculoskeletal
Skin
Neurologic
Psychiatric
Hematologic/lymphatic/immunologic
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
Not
PF EPF D C C Require PF EPF D C
Exam MD
Presence
SF SF L M H SF L M H
MDM
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
Code
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
99381-99397
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-
99350.
99401-99412
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-
99215).
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
PROCEDURAL RVU’S
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
Summary
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
―reimbursement‖.
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.
Questions?
Contact Information:
Angela N. Andersen, CPC
Office 757.953.1241
Cell 757.333.2066
Angela.Andersen@med.navy.mil
