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									                                                           6/27/2008




                     Advanced E&M Coding
                     for the Ob/Gyn Practice
                                   July 19, 2008
                              Rebecca L. Massey, CPC




  Advanced Evaluation &
   Management Coding




New vs. Established Patient
• New patient
  – One who has not received professional services from
    the physician or another physician of the same
    specialty who belongs to the same group practice
    within the past three years.
• Established patient
  – One who has received professional services for the
    physician or another physician of the same specialty
    belonging to the same group practice within the past
    three years.




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                  Medical Necessity
• Medical necessity of a service is the overarching
  criterion for payment in addition to the individual
  requirements of a CPT code.
• It would not be medically necessary or
  appropriate to bill a higher level of E&M service
  when a lower level of service is warranted.
• The volume of documentation should not be the
  primary determining factor for choosing a level
  of service.




      Level of Service by Presenting
                 Problem
                            99201/99212

Level of Risk: Minimal

Presenting Problem(s): One self-limited or
  minor problem, e.g., cold, insect bite, tinea
  corporis




      Level of Service by Presenting
                 Problem
                                 99202/99213
Level of Risk: Low

Presenting Problem(s):

•   Two or more self-limited or minor problems;

•   One stable chronic illness, e.g., well controlled hypertension or non-
    insulin dependent diabetes;

•   Acute uncomplicated illness or injury, e.g., cystitis, allergic rhinitis,
    simple sprain




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      Level of Service by Presenting
                 Problem
                          99203 or 99204/99214

Level of Risk: Moderate

Presenting Problem(s):

•   One or more chronic illnesses with mild exacerbation, progression or
    side effects;
•   Two or more stable chronic illnesses;
•   Acute illness with systemic symptoms, e.g., pyelonephritis,
    pneumonitis
•   Acute complicated injury, e.g., head injury with brief loss of
    consciousness




      Level of Service by Presenting
                 Problem
                             99205/99215
Level of Risk: High

Presenting Problem(s):

• One or more chronic illnesses with severe exacerbation,
  progress, or side effect;
• Acute or chronic illnesses or injuries that pose a threat to
  life or bodily function;
• An abrupt change in neurologic status e.g. seizure, TIA,
  weakness, or sensory loss




                         Consultation
               Remember the three R’s
     Request for opinion or advice from one
    provider to another provider
     Render and document consultation
    service
     complete a written Report and forward to
    the requesting physician




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    Consultation Clarification
• Subsequent visits (not performed to complete
  the initial consultation) to manage a portion or all
  of the patient’s condition should be reported as
  established patient office visit or subsequent
  hospital care, depending on the setting.
• A physician consultant may initiate diagnostic
  and/or therapeutic services at an initial or
  subsequent visit.




    Consultation Clarification
  In an emergency department or an inpatient or
  outpatient setting in which the medical record is
  shared between the referring physician and the
  consultant, the request may be documented as
  part of a plan written in the requesting
  physician’s progress note, an order in the
  medical record, or a specific written request for
  the consultation. In these settings, the report
  may consist of an appropriate entry in the
  common medical record.




    Consultation Clarification
  In an office setting, the documentation
  requirement may be met by a specific written
  request for the consultation from the requesting
  physician, or if the consultant’s record shows a
  specific reference to the request. In this setting,
  the consultation report is a separate document
  communicated to the requesting physician.




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   Consultation Clarification
 Consultations requested by members of the
 same group are billable and reimbursable:

 One physician in a group practice may request a
 consultation from another physician in the same
 group practice as long as all of the requirements
 for use of the CPT consultation codes are met.
 (See Medicare Carrier Manual §15506A.)




               Consultation Quiz
Question #1:

If a patient asks for a second opinion, do you code
a consultation?




           Consultation Quiz
Answer: No. Code as an office visit or other
place of service related E/M code.

Guideline: Consults may be requested by a
 physician, PA, NP, doctor of chiropractic,
 physical therapist, occupational therapist,
 speech-language pathologist,
 psychologist, social worker, lawyer, or
 insurance company.




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          Consultation Quiz
Question #2:
 If a physician makes a verbal request for
 an opinion, where should the request be
 documented?




          Consultation Quiz
Answer: The request should be documented
 in the patient’s record at the requesting
 and the consulting provider’s office.

Note: The request can be verbal or written.
 The request should be from provider to
 provider. If the office staff conveys the
 request, it should be documented that
 way.




          Consultation Quiz
Question #3:
 Can diagnostic or therapeutic services be
 started at the consultation visit?




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          Consultation Quiz


Answer: Yes. Treatment may be started at
 the consult or at subsequent visits.




          Consultation Quiz
Question #4:
 If the consultant assumes
  responsibility for management of all
  or part of the patient’s condition, do
  you continue to use the consultation
  codes?




          Consultation Quiz
Answer: No.
Office/outpatient follow-up code
      Established patient (99211-99215)
      Dom/rest home (99334-99337)
      Home (99347-99350)
Inpatient follow-up code
      Subsequent Hospital Care (99231-99233)
      Subsequent Nursing Facility Care (99307-
  99310)




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                Consultation Quiz
Question #5:

     Mrs. Smith has been seeing Dr. Jones in a large group practice.
     She is in a post op period from a gynecological procedure but has
     been recently diagnosed with ovarian cancer. Dr. Jones has
     discussed the case with Dr. Moore who is a part of the same group
     practice and specializes in gynecological oncology. Mrs. Smith is
     scheduled to meet with Dr. Moore for additional treatment options.
     The E/M code for the visit with Dr. Moore would be:

a.   Consultation
b.   New Patient Visit
c.   Established patient visit
d.   Included in the global fee




                Consultation Quiz
Question #6
 Using the previous scenario, modifier -24
 would need to be reported on the visit.

     a. True

     b. False




                     Consultations
Outpatient exception:
  A consultation code may be used again if
  a request for an opinion is received from a
  different physician or the same physician if
  ongoing management of the condition has
  not been provided by the consultant.
Inpatient difference:
  One consult per physician per admission.




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        Preventive Medicine
• Routine evaluation and management of
  patients without presenting complaints.
  – 99381-99387 New Patients
  – 99391-99397 Established Patients


• A head to toe age appropriate
  comprehensive history and exam




        Preventive Medicine
• Includes counseling / anticipatory
  guidance / risk factor reduction
  interventions performed at the time of the
  initial or periodic, comprehensive
  preventive medicine examination.
  – Birth control options etc.
  – Hormone replacement counseling




        Preventive Medicine
• Does not include:
  – Immunizations
  – Ancillary studies such as lab or x-ray

• 9938x and 9939x are NEVER covered by
  Medicare
  – Non-covered does not need waiver
  – Does require modifier –GY reported for non-
    covered service




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     Preventive Medicine Tips
• ACOG template is highly recommended
  – Has successfully withstood audits
  – Can be customized to the provider’s preferences
• Screening services are performed in the
  absence of symptoms, so V codes are more
  appropriate than problem diagnoses
• Examples of screening diagnoses:
  – V72.31 GYN exam with or without Pap
  – V76.47 Encounter for routine Pap Smear
  – V72.32 Encounter to confirm normal findings after
    initial abnormal Pap Smear




Preventive Medicine Tips Cont.
• If possible, do not schedule patients for
  both Well exam and problem visits on
  same day unless physician/provider feels
  it is medically necessary
• If both are performed on same day, then
  append modifier 25 to established patient
  E&M code




Preventive Medicine Tips Cont.
• Medicare Guidelines MCM 15501 E
  – When a physician furnishes a Medicare beneficiary a
    covered visit, at the same place and on the same
    occasion as a preventive medicine service (CPT
    codes 99381 – 99397), consider the covered visit to
    be provided in lieu of a part of the preventive
    medicine service of equal value to the visit.
  – The physician may charge the beneficiary, the
    amount by which the physician’s current established
    charge for the preventive medicine service exceeds
    his/her current established charge for the covered
    visit.




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 Preventive Medicine Tips Cont.
                Example for Medicare Patient

99397-GY V70.0                                   $150.00
99213-25 599.0, 788.43                           $ 60.00

Patient Responsibility: $90.00 for 99397
                        Plus $10 or 20% of allowed
                        charge for 99213 (currently
                        is around $50.00)




 Preventive Medicine Tips Cont.
• Ensure that the following codes are on
  your superbill:
     – G0101 Breast & Pelvic exam
     – Q0091 Collection of Pap Smear
• If unsure as to how long it has been since
  last preventive exam for Medicare patient,
  obtain an ABN.




  ACOG Documentation Recommendations
          for Preventive Exam

                               99385 or 99395
                               18-39 years old

History: Complete or Interval         Counseling & Risk Factor Reduction:
         Review of Systems &                  Birth Control/Pregnancy
         Past History                         Sexually Transmitted Diseases
         Family History                       Diet and exercise
         Social History                       Psycho-social
Exam:    Height, Weight, Blood Pressure       Smoking
         Neck & Thyroid                       Cardiovascular risk factors
         Breasts                              Skin exposure to sun
         Abdomen                              Injury prevention, i.e., seat belts
         Skin                                 General Mental Health
         Pelvic Exam




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    ACOG Documentation Recommendations for
              Preventive Exam

                                 99386 or 99396
                                 40-64 years old
History: Same as 99385 and 99395

Exam: Same as 99385 and 99395 Plus
      Oral exam

Counseling & Risk Factor Reduction: Same as 99385 and 99395 Plus
                                    Self Breast Exam (SBE)
                                    Hormone Replacement Therapy




    ACOG Documentation Recommendations for
              Preventive Exam

                               99387 or 99397
                                 65 years +

History: Same as 99385 or 99395

Exam: Same as 99385 or 99395 Plus
      Oral Exam

Counseling & Risk Factor Reduction: Same as 99385 or 99395 Plus
                                    Hormone Replacement Therapy




    ACOG Documentation Recommendations for
              Preventive Exam
                                      G0101

History: No Review of Systems & Past/ Family/ Social History Required

Exam: Inspection & palpation of Breasts AND
       Perform & Document 6 of 10 elements
       1. Digital Rectal Exam           6. Vagina
       2. External genitalia            7. Cervix
       3. Urethral meatus               8. Uterus
       4. Urethra                       9. Adnexa / parametria
       5. Bladder                    10. Anus and perineum

Counseling & Risk Factor Reduction: No documentation required




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                        G0101
• Screening breast and pelvic exam is payable
  every 2 years.
• High risk patients are payable annually
• High risk defined as:
  –   Sexual activity under 16 yrs old (V69.2)
  –   5+ sexual partners (V69.2)
  –   History of sexually transmitted disease (V13.8)
  –   History of HIV (V08 or 042)
  –   No pap smears for 7 years (no ICD-9-CM)
  –   Prenatal exposure to DES (760.76)




                  G0101 Cont.
• Reimbursement is equal to RVU’s for
  99212
• Deductible does not apply.
• Can be billed with another E/M “sick visit”.
• Requires carve-out when billed with
  complete preventive medicine service.




                  G0101 Cont.
• Payable non high risk diagnosis codes
  – V76.2
  – V76.47 (hysterectomy for non malignant
    condition)
  – V76.49 (patient w/o uterus/cervix)
  – V72.31 Routine gynecological examination




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                   Q0091
• Q0091 billed separately for collection of
  screening pap smear.
• Screening pap smears payable every 2
  years unless considered high risk which is
  payable annually.
• High risk payable annually same as
  G0101.




                   Q0091
• Payable low risk diagnosis per Medicare:
  – V76.2
  – V76.47
  – V76.49
  – V72.31 (when complete gyn exam performed
    with pap)




                   Q0091
• Unacceptable diagnosis codes:
  – V67.01 Follow-up vaginal pap smear status
    post hysterectomy for malignant condition
  – V10.40 – V10.44 PH cancer



  These are diagnostic follow-up services not
   screening services




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                    Q0091
• Q0091 and G0101 may not coincide for
  frequency (i.e., 2003, Q0091 and 2004,
  G0101)
• Deductible does not apply
• Requires waiver if performed more
  frequently
• Should never be reported for collection of
  diagnostic pap smear




                  S Codes
• Well Service Codes
  – S0610 Annual gynecological examination,
    new patient
  – S0612 Annual gynecological examination,
    established patient
  – S0613 Annual gynecological examination;
    clinical breast examination without pelvic
    examination
  – S0622 Physical exam for college, new or
    established patient




Preventive Medicine Risk Areas
• Coding 99204/05 or 99214/15 instead of
  preventive medicine codes
• Combined prevent medicine and “sick visit”
• Never reporting preventive med services,
  G0101, Q0091.
• Incomplete documentation to support billing.
• Here for follow-up on x chronic problems without
  documentation specific to chronic problem.




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 Incomplete Preventive Service
• Patient on menses at time of scheduled visit.
• Options:
     – Reschedule preventive visit
     – Perform all exam outside of gyn and reschedule that
       portion when patient not on menses.
        • AMA recently came out and said the second service should
          not be separately reported with an E/M code. It should be
          considered one service completed at two sessions.
        • If Medicare patient (unlikely) could bill prevent on 1st
          encounter and G0101 and Q0091 at next visit.
        • If BCBS could bill S0610 or S0612 codes for second visit.




     Preventive Medicine Question
A 30 yr old established patient presents for a routine
   physical. The patient is found to be pregnant. The
   physician performs a routine physical including a pap
   smear. The physician writes a prescription for prenatal
   vitamins. The patient is then scheduled for her initial
   OB visit two weeks later. Assign the correct CPT and
   ICD-9 codes according to ACOG recommendations.

a.   99395, Q0091, V72.31, V72.42
b.   99213, V72.42
c.   No code, service is part of global ob package, V22.1
d.   99213, Q0091, V72.31, V72.42




       Documentation Guidelines
• Currently, can still choose between the
  1995 and 1997 Documentation Guidelines
• Differences between the two:
     – 1995 is more general
     – 1997 is very specific (bullets)
     – 1997 contains specialty specific exams




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              Coding by Time
• Use time as the controlling factor when:
   – Greater than 50% of the face-to-face time was
     spent counseling and/or coordinating care
   – Unit/floor time for hospital and nursing facility
     services
   – No time component in ED or confirmatory
     consultations




       Evaluation & Management
         Documentation Tips
• Designate the 1995 or 1997 Documentation Guidelines
  as the standard for the practice. See
  http://www.cms.hhs.gov/medlearn
• See ACOG EM Templates for History, Exam and
  Decision Making at http://www.acog.org
• Be clear in Medical Record Documentation and code
  from this documentation
• Be sure to document all work performed
• Demonstrate medical necessity by utilizing the ICD-9-
  CM code with the highest specificity
• Separate documentation of E/M service, Procedure Note
  and Preventive Medicine Visit




       Evaluation & Management
       Documentation Tips Cont.
• Chief complaint must be documented on every
  encounter
• Make sure that the provider signs off on all
  documentation
• If 50% or more of the encounter is spent
  counseling or coordinating care, code may be
  chosen based on time.
• Total MD time and time spent counseling must
  be documented when coding based on time.




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                                                6/27/2008




                CODE
              EXAMPLES




               Other Issues
• Nationwide Implementation of RAC Audits
• Increased HIPAA Privacy and Security
  Audits
  – OCR is recruiting for additional auditors
• Medicare fee schedule proposed reduction




       Questions & Answers




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                             6/27/2008




       Thank You!

       Please Visit Us at
      www.gatesmoore.com
mfleischman@gatesmoore.com
        (404) 266-9876




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