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HS 225 Medical Coding I

CPT Evaluationand Management

Unit 2

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E/M Overview

Reflects amount of work involved in providing health care to a patient

Between three and five levels of service

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E/M Section

Codes 99201–99499 First section in CPT Review guidelines at beginning

section Apply applicable notes

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Levels of Service

Organized according to:Place of service

• Physical location where health care is provided to patients (e.g., office, hospital, home, nursing facility)

Type of service• Type of health care services provided to

patients (e.g., new or initial encounter, follow-up or subsequent encounter)

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Example

Dr. Miller completed Jennifer Sullivan’s history and physical on the first day of her inpatient admissionPlace of service: hospitalType of service: initial careE/M category: hospital inpatient

servicesE/M subcategory: initial hospital care

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E/M Section Guidelines

Located at beginning of section Includes:

Classification of E/M servicesDefinitions of commonly used termsUnlisted serviceSpecial reportClinical examplesInstructions for selecting level of E/M

service

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Classification of E/M

Categories (e.g., office, outpatient visits, consultations)

Subcategories (e.g., new and established patients)

Five-digit numerical codes (99201–99499)

(continued)

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Classification of E/M

Code descriptions include:Place and/or type of serviceContent of serviceDetailed history and examinationNature of presenting problemTime required to provide service

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Levels of E/M Service

History Examination Medical decision making Counseling Coordination of care Nature of presenting problem Time

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Key Components

Three components:Extent of historyExtent of examinationComplexity of medical decision making

New patientsThree components required

Established patientsTwo of three components required

Extent of History

Four types: Problem-focused Expanded

problem-focused Detailed Comprehensive

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Extent of History

Includes: History of present

illness (HPI) Review of systems

(ROS) Past/Family/Social

history (PFSH)

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Extent of Examination

Four types: Problem-focused Expanded

problem-focused Detailed Comprehensive

Extent of Examination

Multisystem Exam

Constitutional Eye Ear, Nose and Throat Neck Respiratory Cardiovascular Chest (Breast) Gastrointestinal (Abdomen) Genitourinary Lymphatic Musculoskeletal Skin Neurologic Psychiatric

Single Organ Exam Cardiovascular Ear, Nose and Throat Eye Genitourinary Hematologic/Lymphatic/

Immunologic Musculoskeletal Neurological Psychiatric Respiratory Skin

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Medical Decision Making

Four types of complexity: Straightforward Low Moderate High

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Complexity of Medical Decision Making

Measured by:Number of diagnoses or

management optionsAmount and/or complexity of data

to be reviewedRisk of complications, and/or

morbidity or mortality

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Complexity of Medical Decision Making

Documentation includes:Ancillary test results (e.g.,

laboratory)Known diagnosesOpinions of other physiciansPlanned course of actionReview of previous records

Contributory Components

Counseling Coordination of

Care) Nature of

presenting problem

Time

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Contributing Components

Counseling Diagnostic results Prognosis Risks and benefits of

treatment options Instructions for treatment

and/or follow-up Compliance with treatment

options Risk factor reduction Patient and family education

Coordination of Care Not formally defined in

CPT Represents services that

are completed to organize or direct the patient’s care.

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Nature of the Presenting Problem

Five types:MinimalSelf-limited or minorLow severityModerate severityHigh severity

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Time

Face-to-face timeAmount of time office or outpatient

care provider spends with patient and/or family

Unit/Floor timeAmount of time provider spends at

patient’s bedside and managing patient’s care on unit/floor

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Billing According to Length of Time

Document:Total length of time for the encounterLength of time spent coordinating and/or

counselingIssues discussed Relevant history, exam, and medical

decision makingControlling factor if more than 50% of

time is spent counseling/coordinating care

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Initial Hospital Care 99221-99223

used by the admitting physician to report the first hospital inpatient encounter

only one of these codes should be reported per day All three components of EM should be

met

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Subsequent Hospital Care 99231-99233

Reflect the physician’s work for subsequent days of service performed in the hospital

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Hospital Discharge Services 99238, 99239

Codes are time based Include all services provided to a patient

on the date of discharge Includes:

Final examination of patientDiscussion of hospital stay Instructions for continuing carePreparation of discharge records,

prescriptions, and referral forms

Hospital Observation Services 99217-99220

Subcategories Initial

observation care Observation

care discharge services

Used only once per day

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Initial Observation/inpatient Care

99234-992236Observation or Inpatient Care

Services (including admission and discharge)

Used when a patient is admitted and discharged on the same date of service

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Consultations 99241-99255

Services rendered by providers when their opinion or expertise is requested by another provider

SubcategoriesOffice or other outpatient servicesInitial inpatient consultations

Emergency Department Services 99281-99285

Used for providers who perform services in the emergency department of a hospital based facility, which is open 24 hours a day, 7 days a week

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Critical Care Services 99291, 99292

Physician directly delivers medical care to critically ill or injured patientManages life-threatening conditionsSingle or multiple vital organ system

failure Does not have to be provided in a critical

care unit Time must be spent caring for one

patient at that time

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Pediatric Critical Care Patient Transport 99466-99467

Critically ill pediatric patients transported to facilities, accompanied by a providerPediatric being defined here as 24

months of age or less) Face-to-face care is required and

must be documented

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Inpatient Neonatal and Pediatric Critical Care 99468-99480

Neonate—28 days or younger

Pediatric 29 days to 24 months

Review guidelines at the beginning of the section in regards to the critical services the patients are receiving

VLBW-Less than 1500 g LBS-=1500 g to 2500 g

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Nursing Facility Services 99304-99316

Initial and Subsequent care Includes:

Nursing facility (NF)Skilled nursing facility (SNF)Intermediate care facility

(ICF)/Mentally retardedLong-term care facility (LTCF)Psychiatric residential treatment facility

Domiciliary, Rest Home, and Custodial Care Services 99324-99337

Includes: Boarding homes The facility assists

patients with ADLs but no medical care

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Home Services 99341-99350

Includes:Private residence

Provider must document why the patient was seen at home

Travel time is not billable Only face-to-face time should be

documented

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Prolonged Services 99354-99360

Reported in addition to an E/M service at any level

Physician’s services involving patient contact that are considered beyond the usual service in either an inpatient or outpatient setting

Time must be documented

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Case Management Services 99363-99368

Service provided by an attending physician in which the physician not only supervises but also coordinates direct care received by a patient

Category divided into Anticoagulant Management and Medical Team Conferences

(continued)

Care Plan Oversight Service 99374-99380

Care plan oversight is a service that is billed once a month and includes all care rendered to a patient over a 30-day period

Billed by only one physician in a group practice over the 30 days to reflect services coordinated or rendered by a physician

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Preventive Medicine Services 99381-99429

“Well Visit” or “Physical Exam”

Age driven No HPI is

associated with the visit

Routine check-up Annual

gynecologic examinations

Other examinations whose focus is promoting health

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Newborn Care 99460-99463

Service provided in a variety of health care settings, hospitals, birthing centers, and homes that include:History and examination of normal

infantAttendance at delivery and initial

stabilization of newbornNewborn resuscitation

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Non-Face-to-Face Physician Service 99441-99444

Telephone Service E/M service

provided by a physician using the telephone

E/M service provided by a physician using the internet

(continued)

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Special Evaluation and Management Services 99450–99499 Basic life and/or disability examination

Insurance Work related or medical disability

evaluation services Other evaluation and management

services No other EM code available to

accurately describe services

Questions

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