1992 as part of Physician Payment Reform, the new Evaluation & Management (E&M) coding for cognitive services was introduced in the CPT Manual. These guidelines were fully implemented in 1995.
1997 Specialty specific Exams were introduced, but not mandated for use. Physicians are to use the 1992 or the 1997 documentation guidelines until the final documentation guidelines are refined and implemented.
The purpose of E&M coding is to:
- Reduce differing interpretations of the contents of the documentation.
- Increase consistency of reporting services with the correct level of service code.
Categories of E&M:
|Office/Outpatient/Emergency Rm. Consults
|New Inpatient Visits
|Subsequent Inpatient Visits (only require an interval history)
|Follow-up Consults (only used to complete an initial consult, in-pt)
|Care Plan Oversight
|Critical Care (if criteria not met, code initial or subsequent hosp. visit)
|In-patient Discharge Services
(if a pt is admitted and discharged on the same day, code 99234-99236 as appropriate)
Consults and office visits have five levels of codes.
Inpatient visits have three levels of codes.
Once you have the right category, the level of code within the category must be assessed.
Seven elements that comprise E&M code selection:
- Medical Decision
- Nature of the presenting problem
- New or Established
- Counseling/Coordination of Care
Three KEY elements are:
- Medical Decision
The assessment of the level of code within the category is based on review of the documentation for the THREE KEY ELEMENTS: History, Exam, and Medical Decision, and the contributing elements.
New patients and consults require that all three key elements have been met or exceeded in the documentation. If all three elements are not met, or exceeded, the lowest level element met will drive the code selection.
Established patients and follow-up consults require that two of the three key elements have been met or exceeded. If two of the three elements are not met, or exceeded, the code selection is based on the second lowest element that is met.
TIME must be documented for all E&M services that are based on the amount of time spent with the patient.
TIME driven codes include:
- Counseling/Coordination of Care (if more than 50% of the visit was spent in counseling, the code selection could be based on time only)
- Prolonged Services
- Care Plan Oversight
- Critical Care
For outpatient visits, time is based on "face to face" time spent by the physician with the patient.
For inpatient visits, time is based on "Unit/floor time", as well as that spent with the patient.
The reimbursement fee schedule is not an element for choosing a code.
Do not use "time" as the ONLY basis for choosing a code. Always consider what other factors are present in the documentation.
Do not use modifier "21" for Medicare Part B services. Use the Prolonged services coding if necessary.
Basics for Documentation:
- Date and time entries
- Physicians should:
- Read notes before signing;
- Document all phone calls;
- Document patient education;
- Document patient’s noncompliance with medical protocol;
- Initial and date all lab results that were reviewed;
- Use approved abbreviations;
- Always support the need for a test or extra service in writing; and’
- Corrections must be made with one line through the error. Do not use liquid paper, or attempt to erase the error.
Addendums while not recommended, must be signed and dated if utilized.
Scribes are not allowed.
The attending must "link" into the resident’s note to have both the resident’s note and the attending’s note assessed together for a charge review. The attending must summarize his findings and either confirm or revise the findings of the resident.
An attending’s note will stand alone, if not linked into a resident’s note.
A resident is any person in a GME approved program, from a PGY 1 to a Fellow.
Components of History:
- Chief Complaint
- History of Present Illness
- Review of systems
- Past, family, and social history
Components of Exam: (See Documentation Guidelines)
Components of medical Decision Making (MDM): (See Documentation Guidelines)
In general, only one service per day will be reimbursed. Concurrent care by two physicians in the same day is usually not reimbursable. If two or more physicians provide service on the same day, additional information must be assessed to indicate the medical necessity of the services. Are the physicians that are providing services of the same or different specialties? Are the services for different diagnoses? If yes to both questions, the services may be reimbursable.