E&M Coding

E&M Coding• Cover office visits

• Hospital visits

• Physicals

• Counseling

99211

• “an office or other outpatient visit that may or may not require the presence of a physician”

• presenting problem is simple• 5 minutes• no documentation needed for hx, px or complexity

of medical decision making. Use a flow sheet!– E.g B-12 shot, suture removal, dressing change, allergy

injections

Depo-Provera Flow Sheet

Name:__________________DOB:_____/_____/_______MRN:__________________

Drs. order to give Depo-Provera 150mg 150mg IM q3 mo:

________________________________________ MD/DO

Date ofInjection

Injectionwithin 3months of lastinjection? (ifno PerformUCG)

UCG resultsIf Positive,do not giveshot)

Billingcompleted bynurse

Lot# Nurse’sinitials

_Yes

__No__Pos

__Neg

___99211___J1055 depo__81025 UCG

You can’t bill for the administration of an injectable medication (90782), or the for the administration of an immunization (90471, 90472) and a nurse visit at the same time. You can either bill for the 99211plus the medications or bill for the injection plus the medication.

99201

• The 99201 code has more specific requirements than the 99211!!!

• 99201 cannot be used for nurse visits.

• 99201 requires a problem focused history, a problem focused exam and straightforward decision making

• e.g. an out of town patient needing a refill of her NSAID.

99201 quick reference

99201

Key components (need all three) Elements Minimum requirements

Problem-focused history HPI 1 1

ROS 0 0

PFSH 0 0

Problem-focused exam Body areas/organ systems 1

Straightforward medical decision making (need at least two)

Diagnoses/management options 1 point (minimal)

Amount/complexity of data 0-1 point (minimal or none)

Risk 1 (minimal)

Unlike code 99211, which has no specific documentation requirements, code 99201 for the evaluation and management of a new patient requires a problem-focused history, a problem-focused examination and straightforward decision making, as outlined in the table at right.

99212

• For the evaluation an management of an established patient, which requires at least 2/3 of these components:– a problem focused history– a problem focused exam– straightforward decision making

10 minutes10 minutes

99202

• Office or other outpatient visit for the evaluation and management of a new patient which requires all three:– expanded problem focused history– expanded problem focused exam and– straightforward decision making

20 minutes20 minutes

99213

• For an established patient and requires 2/3 components of:

• an expanded problem focused history

• expanded problem focused exam

• medical decision making of low complexity

• 15 minutes average

99203

• For new patient and requires all three components:– a detailed history– a detailed examination– low complexity decision making

– 30 minutes

99214

• For the evaluation and management of an established patient and requires 2/3 of:– a detailed history– a detailed examination– medical decision making of moderate

complexity

– 25 minutes

99204

• Evaluation and management of new patient which requires all 3 components:– a comprehensive history– a comprehensive exam– medial decision making of moderate

complexity

– 45 minutes

99215

• Evaluation and management of an established patient which requires 2/3 components:– a comprehensive history– a comprehensive exam– medical decision making of high complexity

– 40 minutes

99205

• Evaluation and management of a new patient which requires all three components:– a comprehensive history– a comprehensive exam– medical decision making of high complexity

– 60 minutes

A point threshold is the minimum Number of documentation points to attain a code level

• CC: No points• HPI: 1 point per element• ROS: 1 point per element• PMH, FH, SH: 1 point for each• PE: 1 point per element• Data from testing/imaging or sources such as reports

and old medical records: 1 point • Diagnosis: 1 point each• Plans/Management options: 1 point for each

Documentation elements include:

• The HPI: 10 possible elements such as location, quality, severity, duration, etc.

• ROS: 15 possible elements based on organ systems reviewed.

• The PMH, FH, SH are each an element.

Data Elements Can Include:

• Test results

• Imaging, ECG, PFT results

• Old Records

Diagnosis can include:

• New Diagnoses

• Chronic problems that are either stable or getting worse.

Management Options Can Include:

• Prescription or OTC meds

• Activity recommendations

• PT, OT, etc

• Referrals

• Immunization other parental needs

Total E&M Point Thresholds

Established NewCode Level Point

ThresholdCode Level Point

Threshold99211 1 99201 399213 2 or 4 99202 999213 5,8, or 9 99203 2299214 12,17, or 19 99204 4099215 22,24, or 34 99205 41

E&M Point Thresholds by Category for Established Patients

Code History Exam Decision Making Total Point Threshold

99211 NA-0 pts. NA – 0 NA – 0 1 (assumes 1 for examor tx.

99212 Problemfocused1 point

Problemfocused1 point

Straightforward3 points

2 or 4

99213 ExpandedProblemFocused2 points

ExpandedProblemFocused6 points

Low Complexity3 points

5,8, or 9

99214 Detailed7 points

Detailed12 points

Mod. Complexity5 points

12,17, or 19

99215 Comprehensive16 points

Comprehensive18 points

High Complexity6 points

22,24, or 34

“2 out of 3 will do”

Established patients

• “Two out of three will do” for established patients• Total points for established patients are less

important than the point thresholds for each category because the point thresholds only need point thresholds only need be met for 2 of the 3 categories.be met for 2 of the 3 categories.– For example, if the history is 2 points (limited), the

examination is less than 6 points (problem focused), but the decision making is 5 points (low complexity), then 99213 may be used even though the total of 13 was not reached.

E&M Point Threshold for New Patients

Code History Examination DecisionMaking

Total points

99201 Problem Focused1 point

Problem Focused1 point

Straightforward1 point

3

99202 ExpandedProblemFocused 2 points

Expanded ProblemFocused 6 points

Straightforward1 point

9

99203 Detailed7 points

Detailed12 points

Low Complexity6 points

22

99204 Comprehensive17 points

Comprehensive18 points

ModerateComplexity6 points

40

99205 Comprehensive17 points

Comprehensive18 points

High Complexity6 points

41 or more

3 are required3 are required

Coding Time

• Three types of time:– face-to-face: physician meets directly with the patient

or family. Outpatient/office visits only.

– Floor/unit time: physician is physically present on the hospital floor delivering bedside service. It includes time spent with the patient & time spent charting, discussing care with nurses/others.

– Non-face-to-face: work related to pt care that occurs before or after face to face time

The greater than 50% rule:

“If a physician spends more than 50% of a face-to-face visit counseling or coordinating a patient’s care, the physician can code the visit on the basis of time, even if the history, exam or medical decision making are lacking.”

Prolonged Services Codes:

Prolonged services codes are reported in addition to the E/M code when the length of time spent with a patient goes at least 30 minutes beyond what is typical for that service.

Use 99354 for the fist 30 - 74 min beyond what is typical, 99355 for each half hour after that.

Prolonged services can also be coded using a modifier-21.*

Document the time:

“Time spent with the individual patient should be recorded in the patient’s chart”

E.g. “20 minutes face-to-face; counseling/coordination of care>50% of visit”

Undercoding and Overcoding:

Family physicians overcode new patient evaluation and management visits 82% of the time and undercode established patients 33% of the time.*

*Journal of the American Board of Family Practice; May/June 2002

Averageand Recommended Code Distributions