Provider Evaluation & Management Training

Christi WessonAssistant Director

VMG Coding and Charge Entry

1

NP Billing

There are separate rules for billing Nurse Practitioner’s and nonbilling Nurse Practitioners. Non Billing Nurse Practitioners can not bill for any

services. The attending can only reference their ROS, Past, Family and Social history in order to bill.

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Non Billing Acknowledgement

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NP BILLING

NP billing for the admission service (this includesadmission H&P’s)According to the Vanderbilt Bylaws NP’s can not bill

without the attending provider seeing thepatient(except for CNM). Prior to billing the attending will need to document his own

note or countersign stating that he saw the patient andagrees with the NP’s note.

The preceptor will also need to review 20% of NPcharts.See next slides for appropriate Countersignature.

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NP Countersignature

• For Reviewing 20% of the NP’s notes.

• For billing a shared visit and then documenting Keyfindings.

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NP Billing cont.Nurse Practitioners can bill and see patients for

consults and consulting subsequent visits.The attending does not have to attest or document a note

prior to billing for these services.These services are not shared visits.

If the attending and NP both document a notethese can not be combined in order to bill.

Billing Nurse Practitioners can bill forprocedures if it is within their scope ofpractice.Critical Care cannot be a shared service.

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Evaluation & Management Coding 3 Key Components in an E&M service History ExamMedical Decision Making

The level of service selected is based on the extent of the history &/or exam, and the complexity of the medical decision making required and documented by the provider.

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Elements of HistoryChief Complaint (CC)History of present illness (HPI)Review of systems (ROS)Past medical, family, social history (PFSH)

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History of Present Illness Location – Where is the pain/problem?

Quality – What type of pain? (throbbing, constant, improving, worsening, acute,chronic)

Severity – How bad is the pain? (scale of 1-10, functional status, compared toother types of pain)

Timing – When did you first experience the problem? Specific time of day?Nocturnal?

Duration – How long do the symptoms last? (Onset 3 days ago, since last Monday,yesterday)

Context – What are you doing when the problems occurs? Associated with meals,exercise, or stress?

Modifying factors – What have you tried to alleviate the problem?Medications? What changes/alters the complaint?

Associated signs and symptoms – What else is bothering you when thisoccurs? (Fever w/ chills, headache w/ blurry visions, diaphoresis w/ chest pain)

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History of Present Illness cont.

Tip – 4 HPI needed for admits & consults levels 3-5 Tip – If any part of the history is unobtainable,

you can document history unobtainable due to ______ (state the reason) Ex: pt intubated & sedated

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Review of Systems (ROS)An inventory of body systems obtained through questions seeking to identify signs and/or symptoms which the patient has or has had.

Constitutional symptoms (e.g.fever, weight loss)

Eyes

Ears, Nose, Mouth, Throat

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Musculoskeletal

Integumentary (including breasts)

Neurological

Psychiatric

Endocrine

Hematologic/Lymphatic

Allergic/Immunologic

May be recorded by ancillary staff or on a form completed by the patient

Provider must document that he/she reviewed and confirmed information recorded by others.

If unable to obtain, document why

Pertinent positives and negatives must be referred to in the notes

Review of Systems (ROS)

Unacceptable (ROS) statements

Review of system: negative Review of system: None Review of system Non-contributory Review of system: unremarkable Review of system: Full ROS was notable only for the findings

listed in the HPI 10 point review of systems was completed and is negative unless

otherwise stated Review of systems per HPI otherwise negative

Acceptable (ROS) statements

Review of systems are obtained based on medicalnecessity. Systems with pertinent positive or negativeresponses must be individually documented.

Example: Review of (# of systems reviewed) system is negative except

for: MSK: chronic back pain that is flaring, no HSM Review of (# of systems reviewed) system is negative except

as discussed per HPI Document all pertinent positive and negative findings

and document “All other systems reviewed andnegative”

Past, Family & Social History

Past (past illness, injuries, operations, treatments, current medications, allergies)

Family (medical events of patient’s family, hereditary disease)

Social (living arrangements, level of education)

Tip: DON’T use “noncontributory”Can use negative, but must document negative for

what

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Physical Exam FindingsBody Areas (7)

Head including face

Neck

Chest, including breast

Abdomen

Genitalia, groin

Back including spine

Each extremity

Organ Systems (12)

Constitutional

Eyes

ENMT

Cardiovascular

Respiratory

GI

GU

Musculoskeletal

Skin

Neuro

Psych

Hem/Lymph/Immo

Examples of Organ system exam:

Constitutional: Vital signs and general appearance

Eyes: Pupils: size, shape, equality, reaction to light &accommodation

ENMT: Sinus tenderness, pharynx, tonsils

Cardiovascular: Thrill, Rhythm, Sounds, Murmur, Edema

Respiratory: Breath Sounds, Wheeze, Spoken or Whispered voice. GI: Hepatomegaly, Splenomegaly, Bowel sounds, bruits, rubs GU: Examination of Bladder, Palpation of kidney -enlargement, CVA

tenderness

Physical Exam Findings

Physical Exam Findings

Examples of Organ system exam:

Musculoskeletal: ROM (range of motion), Strength, Stability, Gait Skin: Color, texture, lesions, moles, birthmarks, rashes, dermatitis,

dermatoses, hyperhidrosis, actinic damage, ulcers Neuro: Sensory examination, Reflex Examination Psych: hallucinations, delusions, obsessions, compulsions, Time, place,

person Hem/Lymph/Immo: Palpable cervical, axillary, inguinal nodes

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Medical Decision Making

2 of the 3 elements must be met or exceeded Number of Diagnoses/Treatment Options Amount & Complexity of Data Level of Risk

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Number of Diagnoses/Treatment Options

Each encounter should have an assessment/plan and diagnosis that is documented Self limited/minor = 1Est problem: stable/improved = 1Est problem: worsening = 2New problem: no work-up = 3New problem: add work-up = 4

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Amount & Complexity of Data

If a diagnostic service is ordered, planned, reviewed, or performed at the time of the E/M encounter, the type of service should be documented Lab Test (80000 series) = 1 X-Ray (70000 series) = 1 Medical Test (90000 series) = 1 Discuss test with performing physician = 1 Independent review of images, testing or specimen = 2 Decision to obtain old records and/or hx from

someone other than patient =1 Review/summarize old records and/or obtain hx from someone other

than patient = 2

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Table of RiskHighest level of risk in any category

determines the level of riskPresenting ProblemDiagnostic ProcedureManagement Options

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Score Sheet – Table of Risk

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Score Sheet – Type of Decision Making

To qualify for a given type of decision making, 2 ofthe 3 elements in the table must be either met or exceeded.

Type of Decision Making

Str. Forward Low Moderate High

# of Dx or Mgmt Options

0 or 1 2 3 4+

Amount & Complexity of

Data

0 or 1 2 3 4+

Overall Risk Minimal Low Moderate High

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Evaluation & Management Services

Inpatient Consultation (3 out of 3)

Level HX PE MDM Time

99251 Problem Focused Problem Focused Straightforward 20

99252 Expanded PF Expanded PF Straightforward 40

99253 Detailed Detailed Low 55

99254 Comprehensive Comprehensive Moderate 80

99255 Comprehensive Comprehensive High 110

Initial Hospital Care (3 out of 3)

99221 Detailed/ Comprehensive

Detailed/ Comprehensive

Straightforward/ Low

30

99222 Comprehensive Comprehensive Moderate 50

99223 Comprehensive Comprehensive High 70

Subsequent Hospital Care (2 out of 3)

99231 Problem Focused Problem Focused Straightforward/ Low

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99232 Expanded PF Expanded PF Moderate 25

99233 Detailed Detailed High 35

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Questions

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WESSON BILLING and CODING

New Patient- Outpatient Visit (3 of 3) CPT Code 99201 99202 99203 99204 99205 History (3 of 3)

HPI ROS PFSH

1-3 None None

1-3 1

None

4+ 2-9

1

4+ 10+ All3

4+ 10+

All3

EXAM 1Area/ System

2-4 Area/Sys

5-7 Area/Sy

s

8+ Systems

8+ Systems

Decision (2 of 3) # Dx/Options

Amt Data/Complex Risk level

STFWD 1

STFWD 1

LOW 2

MOD 3

HIGH 4

0- 1 0-1 2 3 4 Minimal Minimal Low Moderate High

Time 10 Mins. 20 Mins. 30 Mins. 45 Mins. 60 Mins.

Est. Patient- Outpatient Visit (2 of 3) CPT Code 99211 99212 99213 99214 99215

H istory(3 of 3) HPI

ROS PFSH

Reserved

for Non-

Hospital·

Based

Practice

1-3 None None

1-3 1

None

4+ 2-9

1

4+ 10+ 2

EXAM 1Area/

System

STFWD 1

2-4 Area/Sys

5-7 Area/Sys

8+ Systems

Decision (2 of 3) # Dx/Options

Amt. Data/ Complex

Risk Level

LOW 2

MOD 3

HIGH 4

0-1 2 3 4

Minimal Low Moderate High

Time N/A. 10 Mins. 15 Mins. 25 Mins. 40 Mins.

In/Outpatient Consult (3 of 3) CPT Code 99251/41 99252/42 99253/43 99254/44 99255/45

History(3 of 3) HPI

ROS PFSH

1-3 None None

1-3 1

None

4+ 2-9 1

4+ 10+

All3

4+ 10+ All 3

EXAM 1Area/ System

2-4 Area/Sys

5-7 Area/Sys

8+ Systems

8+ Systems

Decision (2 of 3) # Dx/Options

Amt. Data/Complex

Risk Level

ST FWD 1

STFWD 1

LOW 2

MOD 3

HIGH 4

0-1 0-1 2 3 4

Minimal Minimal Low Moderate High Time 20/15

Mins. 40/30 Mins.

55/40 Mins.

80/60 Mins.

110/80 Mlns.

Inpatient & Observation Admit (3 of 3) CPT Code 99221/18 99222/19 99223/20

History (3 of 3) HPI ROS PFSH

4+ 2-9

1

4+ 10+ All3

4+ 10+ All 3

EXAM 5-7 Area/Systems

8+ Systems

8+ Systems

Decision (2 of 3) # Dx/Options

Amt. Data/Complex Risk Level

SF/LOW 1-2

MOD 3

HIGH 4

0 - 2 3 4 Minimal/Low Moderate High

Time 30 Mins 50Mins 70 Mins

Subsequent Hospital Care In/Out(2 of 3) CPTCode 99231/99224 99232/99225 99233/99226

History (3 of 3) HPI ROS PFSH

1-3 None None

1- 3 1

None

4+ 2-9 None

EXAM 1 Area/System

2-4 Area/Systems

5+ Area/Systems

Decision (2 of 3) # Dx/Options

Amt. Data/Complex Risk Level

SF/LOW 1-2

MOD 3

High 4

0-2 3 4 Minimal/Low Moderate High

Time 15Mins 25 Mins 35 Mins Hospital Discharge

INCLUDES:FinalExam, Discussionof Stay,Instructions,Prep of Discharge Records 99238 Inpatient Discharge; 30 Minutes or Less 99239 Inpatient Discharge; More than 30 Minutes 99217 Observation Discharge

If more than 50% of the visit is spent counseling the patient. Document total time/counseling time and document summary of counseling performed.

ADM/DC Same Day IN or OBS (3 of 3) CPT Code 99234 99235 99236

History (3 of 3) HPI ROS PFSH

4+ 2-9

1

4+ 10+ All3

4+ 10+ All 3

EXAM 5-7 Area/Systems

8+ Systems

8+ Systems

Decision (2 of 3) # Dx/Options

Amt. Data/Complex Risk Level

SF/LOW 1-2

MOD 3

HIGH 4

0 - 2 3 4 Minimal/Low Moderate High

Time 40 Mins 50Mins 55 Mins *Patient must be admitted and discharged on the same calendar day and stay longer than 8 hrs.

Emergency Service (3 of 3) CPT Code 99281 99282 99283 99284 99285

History (3 of 3) HPI ROS PFSH

1-3 None None

1- 3 1

None

1-3 1

None

4+ 2-9 1

4+ 10+ 2

EXAM 1 Area/ System

2-4 Area/Sys

2-4 Area/Sys

5-7 Area/Sys

8+ Systems

Decision (2 of 3) # Dx/Options

Amt. Data/ Complex

Risk Level

STFWD 1

LOW 2

MOD 3

MOD 3

HIGH 4

0-1 2 3 3 4

Minimal Low Moderate Moderate High

Critical Care Services

TIME CODE CPT AS:

99291 99292

30-74 Minutes 1

75-104 Minutes 1 1

105-134 Minutes 1 2

135- 164 Minutes 1 3

165- 194 Minutes 1 4

Services Included Cardiac Output Measurement Chest X-Rays Blood Gases

Gastric Intubation

Temporary Transcutaneous Pacing Ventilator Management Vascular Access Procedures

Services not listed can be billed

·

Other Requirements Describe Reason and Type of Rx

Must Subtract Time for Billable Procedures

Record Start and Stop Times

No two Physicians can Bill Critical Care at the same hours on the clock

Prolonged Service Coding

TIME Outpatient Inpatient

99354 99355 99356 99357

Under 30 Minutes Covered by

E&M Covered by

E&M

30- 74 Minutes 1 1

75-104Minutes 1 1 1 1

105-134 Minutes 1 2 1 2

Bill In Addition to E&M Code and/or Procedure Code. Report Total Time Per Day.

Time Does Not Have to be Continuous. Time Must be Face to Face.

Elements of HPI Systems for ROS

Location Constitutional (Fever, Weight Loss)

Quality Eyes

Severity Ears, Nose, Mouth, Throat

Duration Cardiovascular

Timing Respiratory

Context Gastrointestinal

Modifying Factors Genitourinary

Assoc. Sings & Symptoms Musculoskeletal

Body Area for Exam Integumentary

Head, Face Neurological

Neck Psychiatric

Chest, Breasts, Axillae Endocrine

Abdomen Hematologic/Lymphatic

Genitalia, Groin, Buttocks Allergic/Immunologic

Back, including Spine

Each Extremity

Organ Systems for Exam

Constitutional (Vital Signs, General Appearance) Genitourinary

Eyes Musculoskeletal

Ears, Nose, Mouth, Throat Skin

Cardiovascular Neurologic

Respiratory Psychiatric

Gastrointestinal Hematologic/Lymph/Immunologic

CPT Codes and descriptions are copyright 2014 American Medical Association, All Rights

Reserved.

VANDERBILT UNIVERSITY MEDICAL CENTER.

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