HCA Encounter Form Education May 2006 - PowerPoint

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                               Encounter Form Education
                                              May 2006

Office / Outpatient Visits
Documentation Requirements
Billable Time
99211 Services
Preventative Medicine Visits
 Office Visits

New vs. Established

A “new” patient (99201-99205) is someone who has not seen a provider (MD, PA, NP) within same
  group; same specialty; same group payor ID number within the last 3 years.

   An “established (99211-99215) patient is someone that has seen a provider (MD, PA, NP) within
   group; same specialty; shared group payor ID # within the last 3 years.

New/Established designation is regardless of location of initial service. If a patient is seen in the
  hospital by Dr. A and later continues care with Dr. A in his/her office, they are established.

   If you are a new physician who has taken over patients from a retiring physician and the patient
   seen either that provider or another provider in the same group; same specialty; same payor ID
   number within the last 3 years, they will be established to you.
   The medical record is a “legal” document.

   The medical record should be complete and legible

   The reason for the visit should be clear

   The date and legible identify of the observer clearly noted

   The rationale for ordering diagnostic and other ancillary services
    should be easily inferred.

   The patient’s progress, response to and changes/revisions in
    Treatment/diagnosis or need for continued treatment should be well
One of 2 things will happen when you provide an E&M office, outpatient
consultation or inpatient service to a patient.


1)    You will spend 50% or more of the visit in a discussion; counseling; discussing
      mgmt options, coordinating care whereby then you need to document “time
      spent in these activities” or
2)    You will spend 50% or more of the visit securing an HPI, Exam and determining
      the assessment and plan (eg. workup, treatment). If this occurs, a notation of
      time spent performing this review is NOT required. Instead elements of HPI,
      Exam and medical decision making will support your code selection.
Billable Time                (>50% of the total visit time)

When the patient is present, counseling includes discussions on:

       Diagnostic results, impressions, and/or recommended studies; prognosis; risks and benefits
    of management (treatment) options;

      Instructions for management (treatment) and/or follow-up;

      Importance of compliance with chosen management (treatment) options;
      Risk factor reduction; and patient and family education.

    Coordination of Care w/other health care professionals

   *Remember to “document time” spent in discussion.
The Documentation Process
E&M Coding – when HPI, Exam and MDM predominant (>50% of total visit time)

A provider note is broken up into 3 key sections

   History
   Exam
   Medical Decision Making
The Documentation Process
E&M Coding
The HPI and Examination are described as:

   Problem Focused
   Expanded Problem Focused
   Detailed
   Comprehensive

The MDM (Medical Decision Making) is described as:

   Straightforward/Minimal
   Low
   Moderate
   High Complexity Mgmt
The Documentation Process
E&M Coding - HPI

The HPI requires:

   Reason for the Visit
   Present Factors
    (timing, location, modifying factors, signs/symptoms, duration, quality, context, and/or severity)

   Review of Systems
   Past, Family, Social History
The Documentation Process
E&M Coding - Exam

The Exam requires:

   1995 or
   1997 guidelines
1995 Exam Guidelines

Body Areas (ea. are a count of 1)

   Head/Face
   Neck
   Abdomen
   Chest, including breast & Axillae
   Genitalia, groin, buttocks
   Back, including spine
   “Each” extremity
1995 Exam Guidelines
Systems (ea. are a count of 1)

   Constitutional
   Eyes
   Ears, Nose, Mouth, Throat
   Cardiovascular
   Respiratory
   GI
   GU
   Musculoskeletal
   Skin
   Neuro
   Psych
   Hematologic
   Lymphatic
   Immunologic
    1997 Exam Guidelines
In 1997 the AMA and CMS proposed a different set of guidelines for documentation of
the provider exam. 9 specialties participated and developed individual specialty
templates to represent what they believed incorporated elements of their exam.

Single System (S)                  Multi-Specialty (M)

    Cardiovascular                    Anyone
    ENT
    GI
    GU
    Skin
    Neuro
    Muscloskeletal
    Psych
    Skin
Difference between 1995 & 1997 Exam

You could and still say: HEENT: Normal

You would have to state the elements reviewed within a
system/body area – eg. Oropharnyx is clear, TM’s are normal
Medical Decision Making
1 of 3 Key Categories

Category 1:

Self-limiting/minor problem (stable, improved)          1 pt
Established problem (stable, improved)                           1   pt
Established problem (worsening, not optimally responding)        2   pts
New Problem w/o workup                                           3   pts
New problem with workup                                          4   pts

1pt=minimal; 2pt=low risk; 3pt=moderate risk; 4+pts= high risk

Note: Please list all problems affecting your decision making on that visit.
         Please indicate if problem is new; worsened; stable, mild/serious
         exacerbation and/or life-threatening.
Medical Decision Making
2 of 3 Key Categories

Category 2:

Review/order labs                 (regardless of # ordered/reviewed)   1   pt
Review/order radiology tests      (regardless of # ordered/reviewed)   1   pt
Review.order EEGs, EKGS           (regardless of # ordered/reviewed)   1   pts
Discuss results w/interpreting provider                                1   pt
Obtain old records other then from pt                                  1   pt
Review/Summarize old records and or obtain history from someone
Other then patient and/or discussion of case w/another healthcare
Provider                                                               2 pts
Independent Review of image/specimen/tracing                           2 pts

2=low risk
3=moderate risk
4+= high risk
Medical Decision Making
3 of 3 Key Categories

Category 3:

Minimal (reassurance, no OTC, no medication mgmt)
  Colds
  URI w/o Fever
  Bug bite

Low risk (1 stable Chronic problem, acute uncomplicated illness)

   Sinusitis
   Vaginitis
   URI w/Fever
   Bronchitis (not serious/pneumo)
   Headache w/o nausea vomiting
   Low back pain
Medical Decision Making
3 of 3 key areas continued

Moderate risk (2+ stable CI, 1 CI w/mild exacerbation; undiagnosed new problem)

   Hard node in breast w/workup
   Headache/migraine w/nausea/vomiting
   Blood in stools
   3+ stable chronic problems
   Mild exacerbation of 1 chronic illness

High risk    (significant exacerbation of a CI, threat to life/self)

   Chest pain
   Significant Shortness of Breath; COPD pt.
   Multiple Chronics evaluated (HTN, Diabetes, Renal Failure, COPD, Hyperlipidemia)
   Significant exacerbation of 1 chronic illness
  New Patient Visit (99201-05)
  Consultations (99241-45)
HPI                Exam                       MDM        Code

1PF,0ROS,OPFS      1 body area/system (95)    Straight          99201 (10 min)
Update 1 CI (97)   1 element           (97)                     99241 (15 min)

1PF;1ROS;OPFS      2-7 Ltd sys/areas   (95)   Straight          99202 (20 min)
Update 1 CI (97)   6-11 elements       (97)                     99242 (30 min)

4PF;2-9ROS;1PFS    2-7 Ext sys/areas   (95)   Low               99203 (30 min)
Update 3 CI (97)   12 elements         (97)                     99243 (40 min)

4PF;10ROS;2PFS     8 sys/areas         (95)   Moderate          99204 (45 min)
Update 3 CI (97)   All Boxed Areas     (97)                     99244 (60 min)

4PF;10ROS;2PFS     8 sys/areas         (95)   High              99205 (60 min)
                   All Boxed Areas     (97)                     99245 (80 min)
   Established Office Visit (99211-99215)

HPI                  Exam                                MDM            Code

               Does not require the presence of a physician         99211 (5 min)

1PF,0ROS,OPFS        1 body area/system (95)             Straight   99212 (10 min)
Update 1 CI (97)     1 element           (97)

1PF;1ROS;OPFS        2-7 Ltd sys/areas   (95)            Low        99213 (15 min)
Update 1 CI (97)     6-11 elements       (97)

4PF;2-9ROS;1PFS      2-7 Ext sys/areas   (95)            Moderate   99214 (25 min)
Update 3 CI (97)     12 elements         (97)

4PF;10ROS;2PFS       8 sys/areas          (95)           High       99215 (40 min)
Update 3 CI (97)     All Boxed Areas      (97)
99211 Billable Services
Examples of office/clinic visits generally billable using 99211:

   A blood pressure eval for an est pt whose physician requested a f/u visit to ck blood pressure

   Refilling medication for a patient whose prescription has run out to hold him over until her can
    get an appointment (pt must be present in office suite)

   Discussion with patient in person following laboratory tests that indicate the need to adjust
    medications or repeat order of tests

   Suture removal following placement by a different physician/physician group

   Visit for instructions/patient education on how to use a peak flow meter

   Diabetic counseling

   Dressing change for an abrasion/injury
99211 Non Billable Services

Examples of services generally not billable using 99211:

   Blood draw - should be billed using CPT 36415

   Laboratory tests - the lab performing the test should bill the appropriate codes

   Monitoring of cardiology tests, such as thallium stress tests, where such monitoring
    is inherent in the performance of the test

   Injection of medication - use CPT drug administration code and drug code

   Influenza vaccination - use vaccination code and administration code only
Consultations (99241-45)
Place of Service: office/outpt/ER

Documentation Criteria:

   Document name of referring physician name

   Indicate in HPI that the visit is a result of a “request for consultation”

   Provide a written report to the requesting provider unless there is a shared record
    situation (aka inpatient; or same specialty consult)
CPT Codes 99241-99245

If a provider requests (verbal or written) a consultation.

If you are a specialist and you hold a particular expertise a member of your group can refer a
patient for consultation to you.

   If you see a patient in the “outpatient” setting of a hospital per the request of a provider of
   another specialty or same specialty and your expertise is required.

   Code for a consultation in the ER, if the ER physician calls you in to evaluate whether or not a
   patient should be admitted. If they are not admitted by the provider or a member of his/her
   specialty group then submit code 99241-99245. If they are admitted and you are the admitting
   provider then you can only code for the admission (99221-99223).
Preventative Medicine Visits
CPT Code 99381-87 (new) 99291-97 (est)

 Preventative Medicine Visit Codes include payment for:

    The review of “stable” chronic problems
    Routine Screenings (eg. Pap smear, breast & pelvic, manual rectal exam)
    Risk Factor Counseling

 Billable Separately When Billed on Same Day as Physical are:

    99211-99215 E&M Office Visit codes (for re-management of existing problems or new
     problems (need mod 25)
    Do not bill 2 new E&M’s in same day
    Injections, Immunizations
    Procedures Performed (exception Medicaid – they will only pay for procedure)
    Some Screenings
    Labs (Indicate signs/symptoms or diagnosis to support testing)
    Physicals - Medicare

   MC does not pay for physicals (99381-87; 99391-97) other then new mc beneficiaries
    (next slide)

   They will pay for 99211-99215 services (eg. medically necessary follow-up or new
    problems addressed during a physical.

   They will pay for problems addressed during a physical when a modifier 25 is affixed.

   MC will pay for screenings performed during a physical if the service is performed
    during a covered period. (eg. paps covered every 2 yrs).
Medicare “New MC Beneficiary”

   G0344: Effective 1/1/05 MC will pay physical / new MC enrollee / within 6 mths

   G0366: EKG (global)
   G0367 (EKG tracking only)
   G0368 (EKG Inter & Rep Only)

   Medicare does not pay for routine annual physicals (99381-87; 99391-97)

   Medicare will pay for 99211-99215 services (eg. medically necessary follow- up or
    new problems) billed w/physicals. Mod 25 needs to be affixed to 99211-15 codes.
Medicare – “New MC Beneficiary”
Required Documentation
Initial Exam includes review of:

  Attention to risk factors for disease detection
  Past medical, Social & Surgical history
  Experiences w/illnesses
  Hospital stays
  Operations
  Allergies
  Injuries & treatments
  Current medication & supplements
  FH (hereditary or place the individual at risk) History of alcohol, tobacco,
    illicit drug use
  Diet
  Physical activities

Psych Eval - Depression
  Individual’s potential (risk factors) for depression including current or past
   experiences w/depression or other mood disorders.
  Refer to appropriate screening instrument for persons without a current diagnosis of
   depression recognized by a National Professional Medical Organizations.
Medicare – “New MC Beneficiary”
Required Documentation

  Performance and interpretation of an EKG.

Functional Abilities / Level of Safety
   Mininum review must include assessment of:
   Hearing impairment
   Activities of daily living
   Falls risk
   Home safety

  Measurement of individual’s height, weight, blood pressure
  Visual acuity screen
 Other age-appropriate factors as deemed appropriate by the provider based on the
   individual’s med/social history and current clinical standards.
Medicare – “New MC Beneficiary”
Required Documentation
Risk Factor Counseling
   Education, counseling and referral as deemed appropriate by the provider based on results of
    the review

Provide Brief Written Plan
  A checklist or alternative provided to the individual for obtaining the appropriate screening and
   other preventive services which are covered separately under Medicare Part B.

11 points checklist:
   Immunizations (pneumococcal, Influenza, Hep B and their administration.
   Mammography screening
   Pap smear & pelvic examination screening
   Prostate cancer screening tests
   Colorectal cancer screening tests
   Diabetes outpatient self-mgmt training services
   Bone mass measurements
   Glaucoma screening
   Medical nutrition therapy for individuals with diabetes or renal disease
   Cardiovascular screening blood tests
   Diabetes screening tests
Physicals - Medicaid

   Will pay for physicals if pt ONLY has Medicaid

   Will not pay for physical if billed AFTER Medicare denial.

   Will not pay for physicals billed with screenings on same day.

   They do not recognize modifier 25 at all.
Physicals – HMO’s “Managed Care Plans”

   Will pay for physicals

   Will also pay for problems addressed during a physical (eg. UTI dx 599.0 billed with

   They will not pay for screenings if billed in conjunction with an annual physical
    unless high risk or abnormal dx submitted.

   They will however pay for screenings if billed with an E&M office visit code (99201-
    05 or 99211-15) vs. a physical cpt code.
Screenings – Pap Smear

   Code a Q0091 for the collection of the pap smear.

   Code diagnosis code V76.2 (low risk of malignant neoplasm) or V15.89 (high risk)

   Coverage every 2 yrs.
Screenings – Breast & Pelvic

   Code G0101 if “both” the breast & pelvic exam are performed.

   Code Dx. code V76.10

   If G0101 is billed with a Physical it will reject as a “bundled” service for Tufts, HPHC
    (blues pays)

   It is reimburseable when it is billed by itself as the “sole” service or with an E&M
    office visit code.

   Coverage every 2 years.

   G0101 requires the review and documentation of 7 out of 11 areas in GU system.
Screening – Breast & Pelvic
Documentation Requirements
G0101 requires documentation of 7/11 elements:

   Inspection and palpation of breasts for masses or lumps, tenderness, symmetry or
    nipple discharge.

   Digital rectal examination including sphincter tone, presence of hemorrhoids, and
    rectal masses.

   Pelvic examination (w/or w/out specimen collection for smears and cultures)

    · External genitalia (general appearance, hair distribution, or lesions)
    · Urethral meatus (size, location, lesions, or prolapse)
    · Urethra (masses, tenderness, or scarring).
    · Bladder (fullness, masses, or tenderness).
    · Vagina (general appearance, estrogen effect, discharge, lesions, pelvic support,
     cystocele, or rectocele)
    · Cervix (general appearance, lesions, or discharge).
    · Uterus (size, contour, position, mobility, tenderness, consistency,
     descent, or support)
    · Adnexa/parametria (masses, tenderness, organomegaly, or nodularity)
     Anus and perineum.
Screenings – Blood Occult Routine

   Code G0107 with diagnosis code V76.51

   Annual benefit

   Do not use “82270” in the absence of signs/symptoms or it will reject.
Screenings – Digital Rectal Exam

   Code G0102 with diagnosis code V76.44

   Annual benefit. Note: not covered when billed with annual physical
    (eg. preventive medicine code)

   It is reimburseable if billed with an office visit.
Screenings – Routine Labs

   (eg. 81002, 81000, 82270)

   In the absence of signs/symptoms these services will reject.

   It is critical that you link a diagnosis code (eg. definitive or signs/symptoms)
    when ordering a lab test when applies.

Modifiers are 2 digit codes which accompany a 5 digit CPT code in
order to further describe a situation to support additional payment
when more then one service is being reported in the same session
on the same day.

Primary Care Modifiers

Modifier 25

Modifier –25

Should only be appended to evaluation and management (E/M)
service codes HCPCS codes G0101(Breast & Pelvic Screening)
and Procedures

You do not need a modifier 25 when billing an office visit and
also billing for:

 1) Diagnostics (eg. EKG)
 2) Immunizations
 3) Screenings
Modifier 25 Examples

 Modifier 25 Examples

When the patient presents for a planned procedure and has a different problem
that requires an E/M service (two different diagnoses would be used to distinguish
the services)

the patient presents with a "minor" problem and after evaluation the decision is
made to perform a procedure. In the second example –25 is used if the procedure
is minor in nature, meaning that the post-operative period is less than 90 days
and the primary diagnosis would be the same for both.