Wiki E/M Codes Chapter 19

[KaitlynBerry]

Hello! I am hoping to get insight/advice on coding E/M codes and determining level of service (problem focused, expanded, detailed, comprehensive, etc). I am really struggling with this and need some help in this area. It is specifically Chapter 19 of the CPC course. Any help is greatly appreciated. Thank you!!

 

[TThivierge]

Hi Kaitlyn,
Ok here is the scope.....is the patient new or established? is the patient's illness ongoing or new illness? Is the chief complaint one or 2 dx problems patient coming in for? Is it a follow up or check up? Is it a annual wellness physical? Understand why the patient is seeking care. Is it a laceration needs suturing or blood pressure check up or just need more medications for ongoing illness? Does the patient have one minor dx code problem or more than dx problem during the visit? Did the patient get medication, assign go get a xray or lab or injection; these are the doctor management options. Is the dx problem worsening or stable .....all this helps determine the medical necessity of care.
Now you have read the documentation to think what is going on during treatment. You must look and see if type of medical decision making is.....
Straight forward is minimal care cause probably got one illness or follow up
Low complexity is limited with 2 dx codes
Moderate complexity is multiple dx more than 3 dx and do more managing of meds given, lab test ordered,Etc
High complexity extensive work up and patient really very sick (chronic or acute )with one or more dx codes. and work up or referral or hospitalization.
Now go to CPT manual in Eva Mgnt section to compare CPT code descriptions.(as example CPT 99202 low to moderate care)

Now understand the documentation required in each day s treatment by viewing how many problems patient has with ROS review of 7 body systems and or 13 Organs systems during the examination. Take account of take in time amount on visit of face to face atleast 50% counseling or coordinating care for pt. ,their social and medical history of patient too.
1 body area or system= Problem Focused
2 to 7 Body areas or Systems =Expanded Problem Focused
5 to 7 Body areas=Detailed Problem
8 or more body systems/organs =Comprehensive

Sometimes an annual physical does not have a chief complaint just wanting or needing annual exam
You need three components of history, exam and medical decision making on documentation of treatment
Constitutional is taking pt s vitals taken which is part of the ROS too
I hope I helped you understand a bit better .
Lady T

 

[KaitlynBerry]

Hi Kaitlyn,
Ok here is the scope.....is the patient new or established? is the patient's illness ongoing or new illness? Is the chief complaint one or 2 dx problems patient coming in for? Is it a follow up or check up? Is it a annual wellness physical? Understand why the patient is seeking care. Is it a laceration needs suturing or blood pressure check up or just need more medications for ongoing illness? Does the patient have one minor dx code problem or more than dx problem during the visit? Did the patient get medication, assign go get a xray or lab or injection; these are the doctor management options. Is the dx problem worsening or stable .....all this helps determine the medical necessity of care.
Now you have read the documentation to think what is going on during treatment. You must look and see if type of medical decision making is.....
Straight forward is minimal care cause probably got one illness or follow up
Low complexity is limited with 2 dx codes
Moderate complexity is multiple dx more than 3 dx and do more managing of meds given, lab test ordered,Etc
High complexity extensive work up and patient really very sick (chronic or acute )with one or more dx codes. and work up or referral or hospitalization.
Now go to CPT manual in Eva Mgnt section to compare CPT code descriptions.(as example CPT 99202 low to moderate care)

Now understand the documentation required in each day s treatment by viewing how many problems patient has with ROS review of 7 body systems and or 13 Organs systems duirng the examination. Take account of take in time amount on visit of face to face atleast 50% counseling or coordinating care for pt. ,their social and medical history of patient too.
1 body area or system= Problem Focused
2 to 7 Body areas or Systems =Expanded Problem Focused
5 to 7 Body areas=Detailed Problem
8 or more body systems/organs =Comprehensive

Sometimes an annual physical does not have a chief complaint just wanting or needing annual exam
You need three components of history, exam and medical decision making on documentation of treatment
Constitutional is taking pt s vitals taken which is part of the ROS too
I hope I helped you understand a bit better .
Lady T

Thank you! The part that I am struggling most with is determining when a problem is straightforward, low, moderate, etc. It is hard to decipher from the report sometimes. Also, if I am trying to use the chart...what do I choose if all 3 options are different? For example, the risk is low but the number of diagnoses is straightforward and the other option is moderate. I know that we are supposed to choose based on 2/3 but if they are all different, which would it be?

 

[TThivierge]

Hi Kaitlyn
You will need to read the medical documentation for the day s treatment how provider supports medical care with more labs, xray, an injection Etc.. Also notice what provider documents plus knowing some illness are minimal (such as skin rash or ear problem, or follow up for more meds) vs. chest pain, fever, past critical sins of ongoing chronic problems. Select 2 of 3 History Exam and MDM to ensure have a full visit. Medical Decision Making such as Straightforward could be recheck on getting med refills, or follow up on ongoing problem or treatment of 1 dx problem. Low and Moderate see up above which wrote earlier. So on patient s record read amount of dx treated for day, complexity of more data doctor needs to support the medical need of the patient (med, injection labs or xray or past medical HO, Etc) will help you select right CPT code. Also if a new patient all of these should be met History Exam and MDM not 2 out of 3.
Most CPT visit need to have doctor spent at least 15 minutes with pt. to be billable. (Exceptions are physical therapy treatment 8 minutes and smoking cessation is 5 minutes discussion)
Also most visit providers must estimate time then write time in medical record to help you select proper CPT code.
You will learn there is face to face time, non face to face time( telehealth or phone) and floor unit time on pts. with inpatient status ....all must document in medical record
There is somewhat difference in documentation guidelines (DG )1995 vs DG 1997 . DG 1997 added chronic dx of patient for HPI Extended and added look at pt. s multisystem and organ system. Also differ medical specialties (Ortho, Ophtham.) may use different DG guides.

I hope I helped you a bit more.
Lady T

 

[amyjph]

Do you have a specific example you can provide from the course? Do you have any understanding of evaluation and management coding prior to this at all, or by using the 95/97 guidelines? E&M is one of the hardest concepts for new folks learning in my opinion. If you have an example we could break it down here to help you.