Today we're going to begin looking at
Chapter 7 which are the Evaluation and
Management Services codes. There's quite
a bit to cover so there are two podcasts,
Parts 1 and 2. As with other
chapters, I won't be covering all of the
codes or all of the guidelines within
this chapter but you are expected to read
them as well as work the exercises that
apply these codes. For the format of the
E/M codes, they begin with 99. Why it is
they are always in the front of the CPT
code book, I cannot explain nor can I
explain why with all the different
curricula I looked at, E&M codes are
never covered first when teaching CPT.
They are unique. They're designed to
capture the physician's time and/or
expertise when he or she is
performing their jobs as doctors. The
codes are differentiated by place (the
physician office, nursing facility, the
Emergency Department). They are also
differentiated by the type of service as
an "initial" or is it "subsequent", the
extent or the level of service you will
see codes broken out by "problem-focused
history and/or examination", "expanded
problem focused", "detailed" and
"comprehensive" for both the history and
examination. You'll see the medical
decision making or the patient's, the
severity of the patient's condition come
into play. Some codes include the amount
of time the physician spends with the
patient or spends doing certain service
or performing a certain procedure. There
are 1995 and 1997 E/M Service
guidelines. There are PDFs of both of
them on the Content page in your D2L
course. The physicians can decide by their
practice which one they want to use. You
cannot mix and match. You either have to go
by '95 or '97 guidelines.
I find most physicians go by '95 (Guidelines) but
they really they don't have to. They can
easily go by '97. This is a reminder
when you are selecting E&M codes, you are
coding for the physician. If you are
a hospital coder, you're not going to
be using E/M codes. They are just to
capture the physician's time and
expertise. A coder should answer the
following questions: What type of service
did the patient receive? Was the encounter
an initial or subsequent episode of
care? Did the patient receive a
critical care service? These will be
defined a little bit further as we move
forward. Where was the service provided,
the physician's office or clinic, a
hospital inpatient or outpatient
department, the observation unit, the
emergency department, a nursing facility
or rehab unit? Was the recipient a new
patient or one of the physician's
established patients? These, all these
questions, the answers to these questions,
help you select the correct code. When
you start reading code descriptions, they
will be covering these various elements.
The first thing we are going to look at is:
Is the patient "new" or "established"? The key
number to remember here is "three years."
I won't read the entire definition but
basically, if you've not been seen in
that practice for three years, by anyone
in the practice, any specialty in the
practice, you are considered a "new"
patient. If you have been seen within
the last three years, by the same
physician, you're an "established" patient.
Now it is possible on a given billing date
(for a patient) to be a "new" and an "established" patient
if the physician you're seeing is for the
first time. Here's an example of that.
Here's an example. Mr. Stevens was seen
last week by his family doctor Dr.
Groves and is seen for the first time
today of a neurologist, Dr. Newman. Dr.
Groves and Dr. Newman are in the same
multi-specialty practice.
When the bill was processed last week
for the visit with Dr. Groves, Mr.
Stevens was considered an established patient
because he had been seen within the last
three years. He was seen today by Dr.
Newman, a neurologist within the same
multi-specialty practice but for the
first time. For the purposes of billing
today's visit, Mr. Stevens is considered
a new patient of Dr. Newman's. You
really have to look at the individual
scenarios and cases as far as when a
patient was seen. You also have to watch
the date when you're looking at test
items to select an appropriate status,
new or established. You really have to look
at those dates and this would not be
uncommon in any testing situation,
whether it was in this course, for the
RHIT or for one of the coding
specialties. This is an office visit. The
date of service is 1-3-14 and the last
date of treatment was 2-12-11. You
see in my explanation in purple (boldface) if the
patient is seen any time before 2-12-14
(and I got that date by adding three
years to the last date of treatment), the
patient is still an established patient.
By definition, within three years, is an
established patient so when this office
visit is billed, it it would be as an
established patient. It's a similar case
but you see the date of service is 2-23-14
and the last day of treatment was 2-12-11.
If you add three years, you're going
to get 2-12-14. This patient was not
seen until 2-23-14, which is later than 2-12 14.
Therefore, she would be billed as a new
patient for this date of service. You
have to watch the dates to determine if
a patient is new or established.
Concurrent care and transfer of care are
two different things. Concurrent care
is when one or more physicians is
seeing the same patient on the same day.
Depending on the insurance, some health plans
limit reimbursement to one physician per
day unless the physicians have different
specialties and the services of more than
one are medically necessary. If that is
the case, the physicians involved in the
concurrent care episode must identify
which ICD10 code justifies the medical
necessity of that patient seeing that
specialist. Assigning the same ICD-10-CM
code could result in one of those physicians
being denied payment, usually the one who
submitted the claim last. So let's look at
an example that makes that real . Patient is
admitted to the hospital complaining of
unstable angina and uncontrolled type 2
diabetes mellitus. Dr. Smith, Cardiology
Service is the attending physician and
treats the patient's angina. Dr. Reynolds,
Endocrinology Service was consulted to
manage the patient's diabetes. The
diagnosis codes that were assigned to
this chart are I20.0 for intermediate
coronary syndrome and E11.65 for the
diabetes mellitus, uncontrolled. Dr. Smith
will report the I20.0 and the
appropriate E/M level of service
code from the Hospital Inpatient
Services category in this chapter. Dr.
Reynolds would report the E11.65 code
and the appropriate E/M level of
service code from the Hospital Inpatient
Services category. If both doctors tried
to go with the same diagnosis code, one
of them would be denied, probably the one
who submitted his claim last.
As a reminder, (there are two) types of coders-
there's facility coders where you're
going to be actually coding for the
hospital, ambulatory care center,
long-term care center, hospice, etc. and a
pro-fee or the professional fee coders.
These are the coders who select codes for
physicians or other qualified healthcare
providers. E/M codes are designed to
account both for the physician's time and
the professional expertise. For the most part,
a coder does not select the E/M codes.
These codes are selected by the physician,
either on paper or electronically as he
or she knows the level of decision making
and the severity of the patient's
condition. If software is capturing the
physician services like the E/M codes in
these settings, the coder will then code
the procedure that the physician is
performing. When a covered service
exists in the coding and billing software, it
is known as being "hard coded". That means
a code is automatically selected and
cannot be changed except by the person
in charge of the chargemaster or the
billing software.
So if that's the case, you may be asking yourself, why
do I have to learn E/M coding if it's
done for me on the chargemaster.
What I have listed here are all the exams
that you may be looking at in your
future that include coding on them.
AHIMA offers all of the exams there on
the left and AAPC which is a
professional coders' organization
offers those on the right. The RHIT exam, for
which you are eligible to sit once
you've graduated from this program, is
not a coding credential but there are
coding questions on that exam. All
the other exams that are listed are
coding exams leading to coding
credentials. So that is why you have to
learn all about E&M coding. What I've done
here I've answered some of the questions
in your textbook using the tables that
are indicated in the instructions. In
purple (boldface type) I have highlighted those parts of
the scenario that are applicable in this
situation. The chief complaint is also
abbreviated "CC". Do not get that confused
with the ICD-10 coding "CC" which means
"comorbidity and complication". That
affects the DRG assignment that is (covered) in
the coding course, the ICD 10 CM coding
course. It's important for you to
recognize that "CC" is a common acronym
and depending on the context in which
you see it, will determine what it means.
When you are looking at a History and
Physical and you see "CC" that means
chief complaint, what is the main reason
the patient is being seen.
What I've done here is I've taken the
different elements of the HPI (the
location, the quality, the modifying
factors, the duration, the context,
associated signs and symptoms, the
severity and the timing. You see that
in the documentation the physician
addressed the majority of those, so the
question was for the student to assign
the level of HPI and when you look at
the definitions there on Table 7.3,
Detailed: four or more HPI elements were
addressed .I see seven here in my
chart. So that's the logic behind how the
"detailed" level was captured. Four or more
HPI elements were addressed in the
physician documentation. The next example
is Exercise 7.2 #2, we're using
Table 7.4 in CPT textbook and I've got
the scenario where the physician has
dictated all this information about his
examination. Then I went through the
different components of the examination,
both by body areas and by organ systems
and checked them off. By definition,
this would be a detailed level where 6 organ
systems were examined but I do want you
to read the small print that's under the
table there (7.4). I did not reproduce
it in the slide but it basically says
that it depends on how your
setting or your institution or your
physician practice is telling you to
code. Sometimes they would say between
two and five or two and six organ system
is going to be this and more than that's
going to be "comprehensive" so it really
depends on where you're working, how this
would be assigned. What I'm trying to do
in these slides is just go through the
logic of how you would arrive at that
detailed setting, that detailed level when
you're selecting a code . All I'm trying
to get you to look at is that the
physician is addressing several elements
within the examination when he or she
completes that part
of the history and physical examination.
Exercise 7.3 #2 is looking at
the level of decision-making and you're
using the logic on Figure 7.1 in your
textbook. I've reproduced a table
here or I would come up with for this
particular scenario, low complexity level
of decision making. All this particular
exercise is asking you to do is address
the level of decision making so what the
authors of the textbook have done is
separate out the elements of the HPI, the
elements of the exam and now the element
level of decision making so that the
student sees that there's different
areas that are covered in each of those
levels. Exercise 7.5 Evaluation and
Management. There are two true/false
statements. The first one, the AMA and the
CMS developed documentation guidelines
for use with the CPT code book. That is
true. The review of systems is a
chronological description of the
development of symptoms. That is false.
Review of symptoms is what's going on
today, right now, while I, the physician, am
examining you. Exercise 7.5 Evaluation
and Management #6 instructs the
students who use the 1995 E/M guidelines
to determine if this documentation of
past family and/or social history meets
a definition of "pertinent" or "complete".
Both the 1995 and the 1997 guidelines
are available to you on the Content page
in this week in the D2L course. The
instructions are to use the 1995 E/M
guidelines and you are specifically
looking at the definition of "pertinent"
and "complete" PFSH.
This is a screenshot of those guidelines
where this defines what it means. PFSH is a
review of three areas: past history,
family history, and social history. By
definition, the "pertinent" is a review of
the history area directly related to the
problem identified. I scroll down a
little bit in that document and the
"complete" PFSH is review of two or all
three of those history areas. Looking
back, I selected the answer as pertinent.
The physician's documentation talks about
the past history, doesn't really go into
a family history nor a social history.
Exercise 7.5 Evaluation and Management
#8. The student is again
instructed to use the 1995 E/M
guidelines and determine if this HPI is
brief or extended. Here's a screenshot of
the 1995 definition of HPI where you
have these elements that must be
addressed and by definition, the brief
HPI is 1-3 elements and
extended its 4 or more elements of the
HPI. So I went to the correct answer as
extended because four elements were
reviewed and I give those four elements
here in purple (boldface font).
Evaluation and management #10. The
student is instructed to identify the
body system explored in the review of
systems. I have in purple (boldface type) the chest pain,
the palpitations and the shortness of breath.
I think with the respiratory and
cardiovascular (body systems). If you have any questions about
this first Part 1 of Chapter 7, please
post them in the discussion board and I
will do my best to answer them. Please
post along with your question the path
that you use to try and find your code.
Thank you so much and have a good evening.