AAOE-AOC National Residency Curriculum

E&M Coding and DocumentationPreparing Orthopaedic Residents, Fellows, and

New Faculty for What’s Next

John Bonini- Director of Clinical Operations, Duke Orthopaedics

Dametra Arrington- Revenue Manager, Duke Orthopaedics

Presenter

John Bonini

• Director of Clinical Operations, Duke Orthopaedics

• Senior Vice President, AOC

• 33 years Clinic Ops Mgmt. in Private and Academic Orthopaedics

Living In Two Worlds

• For more than 20 years we have been using the guidelines established in 1995 and 1997 to code for E&M services. In January 2021 we had the first major change to the way E&M codes are leveled since 1997, but it doesn’t apply to all visit types. This has created a situation where we need to use 2 different sets of guidelines when coding E&M services depending on the visit type.

Effective 1/1/21

• We will still code Outpatient Consults, Inpatient Initial and Subsequent Care using the same 1997 coding rules we have been using for twenty years.

• We will code New Patient and Established Patient visits using the new 2021 coding guidelines.

Review of 1995/1997 Coding for E&M

This instruction will be for deciding E&M Levels for:

• Outpatient Consults

• Inpatient Initial

• Subsequent Care

E&M Components

E&M Component- History

E&M Component- History Example

Case Example:

Sam Bones is a 45 year old male who is being seen today for bilateral foot pain, especially 2nd toe pain. The patient notes that he has had pain that began back in 10/2018. He believes this was exacerbated by playing football. The patient works as a dog walker and hasthrobbing pain on the planter aspect of his 2nd MTP joint with regular walking. He has tried metatarsal pads but states these exacerbate his pain.

Past Medical Hx: Chronic constipation (2/2016), hammer toes of both feet

Past Surgical Hx: Thyroidectomy (11/2007)

Family Hx: Coronary Artery Disease in his father.

Social Hx: Married with 2 kids, smokes 2 pks of tobacco per day

ROS: Musculoskeletal: Positive for arthritis, foot pain, and joint swelling.

All other systems reviewed and are negative.

E&M Component- 1995 Exam Requirements

E&M Component- Types of Examination

The levels of E/M services are based on four types of examination:

Problem Focused – a limited examination of the affected body area or organ system.

Expanded Problem Focused – a limited examination of the affected body area or organ system and any other symptomatic or related body area(s) or organ system(s).

Detailed – an extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s).

Comprehensive – a Comprehensive exam consists of 2 limbs if you are also charting a multi -system examination

Complete Musculoskeletal Exam

1. Vital Signs- Three of following vital signs- BP, Ht, Wt, Resp, Pulse, Temp

2. Examination of gait

3. Inspection and/or palpation of digits and nails (eg, clubbing, cyanosis, inflammatory conditions, ischemia, infections, nodes)

4. Examination of joints, bones and muscles of one or more of the following six areas: 1) head and neck; 2) spine, ribs and pelvis; 3) right upper extremity; 4) left upper extremity; 5) right lower extremity; and 6) left lower extremity. The examination of a given area (above) includes:

Inspection and/or palpation with notation of presence of any misalignment, asymmetry, defects, tenderness, masses, effusions

Assessment of range of motion with notation, plus documentation of any pain, crepitation or contracture

Assessment of stability with notation of any dislocation (luxation), subluxation or laxity

Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements

Medical Decision Making (MDM)Driving force behind E/M code selection

Determined by 2 of 3:

Number of diagnosis / management options

New vs. established problem

Overall stability of problems/diagnoses – stable vs worsening

Planned work-up

Amount & complexity of data reviewed

Labs, Radiology, Diagnostics, discussions with other providers

Overall patient risk

Chronic conditions, acute exacerbations, prescription management

Table of Risk (MDM)

Assessment/Plan DocumentationAssessment

• List the Diagnosis list in order of importance.

• List any differential diagnosis, from most to least likely, and the thought process behind this list. Example: Problem 1,

Plan

This section details the need for additional testing and consultation with other clinicians to address the patient's illnesses. It also addresses any additional steps being taken to treat the patient. This section helps future physicians understand what needs to be done next. For each problem:

• State which testing is needed and the rationale for choosing each test and what the next step would be if positive or negativ e

• Medications needed

• Therapy needed

• Specialist referral(s) or consults

• Patient education, counseling

• Problems addressed in the visit note each contain a clearly identified status and care plan.

Consultation E&M Requirements When a provider’s (MD/APP) opinion or advice is requested by a referring provider about a specific clinical problem

for which the consulting provider has expertise

Example:

Patient seen in consultation at the request of [list the provider] for the problem of ______. This can be the chief

complaint

Consultations must have:

1) request from a qualified health care professional

2) rendering of consultation

3) written response/letter to provider who requested the consult if he/she is not part of your own organization

Patient self-referrals and transfers of care are not consultations

Do not bill IP Consult when your specialty is managing a patient for the condition.

Time-Based Services

Includes Teaching Physician / APP time only (excludes Resident/Fellow time)

• Inclusive of all E/M codes when counseling / coordination of care dominates (greater than 50%) the provider’s face-to-face ambulatory visit or unit floor time in the inpatient setting

• Discharge management (< 30 mins vs > 30 mins)

• Prolonged care (w/in the Appendix)

Notes must support & document time as well as a summary of the counseling and/or coordination of care discussion and activities.

Of my ‘x’ minute visit with the patient, ‘x’ minutes were spent on counseling and coordination of care activities ______.

E&M Service Level Requirements

Diagnosis Coding

Indicates reason for patient encounter – required for all services

Provides medical necessity of service!

Diagnoses can be linked to E/M services or procedures performed as appropriate

Assigning/sequencing diagnosis codes

Link first the code shown to be chiefly responsible for the services provided during the encounter (use verbiage from E/M)

Sign/symptom codes can be used when a diagnosis has not been confirmed

Do not code diagnoses documented as “probable,” “suspected,” “questionable,” “rule out,” or “working diagnosis” or other similar terms indicating uncertainty

Code all documented conditions that coexist at the time of the encounter and require or affect patient care treatment/management

Review of 2021 Coding for E&M

This instruction will be for deciding E&M Levels for:

• New Patient visits

• Established Patient visits

E&M Changes for 2021 (New/Established Visits Only)

Evaluation & Management 2021

• New and Established Outpatient visit code change only

• Elimination of the documentation requirements of the History and Exam (as medically appropriate)

• Level of Service (LOS) selection now determined by …

• Medical Decision Making (MDM) OR

• Time

• All other E&M documentation and billing codes remain the same as previously outlined.

E&M 2021 Changes

Other changes include:

• Deletion of Level 1 New Outpatient visit (CPT 99201)

• New patient visit with one exam area

• National data supported extremely minimal billing

• Align MDM complexity with unique LOS for each code set

• Same criteria for both new and established codes

• Revision of MDM elements and table

• Represents the biggest change

MDM 2021

Medical Decision Making

Still need 2 of 3 areas to support level

Areas are:

• Number of Diagnoses

• Amount and/or Complexity of Data to be Reviewed

• Risk of Complications and/or Morbidity or Mortality

New MDM Table

MDM- Number/Complexity of Problems

• Multiple new or established conditions may be addressed at the same time and may affect medical decision making.

• Symptoms may cluster around a specific diagnosis and each symptom is not necessarily a unique condition.

• Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless:

• they are addressed, and their presence increases the amount and/or complexity of data to be reviewed and analyzed

• or the risk of complications and/or morbidity or mortality of patient management.

• The final diagnosis for a condition does not in itself determine the complexity or risk, an extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition.

Ortho-Trauma ExampleHPI: Female who presents for evaluation of a right lateral depressed tibial plateau fracture that was sustained on 6/27/20 after she fell five rungs off a ladder.

Past Medical, Surgical and Social History:PMH: OsteoarthritisFH: AsthmaSH: Marital status: Divorced

Review of Systems:A comprehensive 14 point ROS was obtained from the patient today by an ancillary provider and personally reviewed by myself. It is documented in a separate note which includes the pertinent positives/negative.

Exam:Vascular: Mild swelling about the knee Dorsalis pedis pulse is palpable. Capillary refill is normal.Integumentary: No erythema or ecchymosis. No evidence of CRPS. Neuro: Sensation intact to light touch over the deep/superficial peroneal, medial/lateral plantar, sural and saphenous nerve distributions. Musculoskeletal: 5/5 DF/PF/EHL/FHL, patient falls into the depression laterally with valgus stress

Imaging - ReviewedImaging including radiographs and CT reviewed showing a lateral split depressed right tibial plateau fracture with 8mm of lateral joint line depression.

Assessment:Closed fracture of right tibial plateau, initial encounterFemale who presents for evaluation of a right lateral depressed tibial plateau fracture that was sustained on 6/27/20 after she fell five rungs off a ladder. She presented to hospital and was placed in a knee immobilizer. She was initially swollen and this has since improved. She is ambulating NWB with a knee immobilizer.

Plan: Findings are discussed with the patient. Patient/family verbalized understanding. Plan for ORIF of the right plateau fracture on 7/6/20NWB knee immobilizer with ACE wrap in the interimASA daily for DVT PPXTramadol Take 1 tablet (50 mg total) by mouth every 6 (six) hours as needed for up to 10 days

Ordered Lab: Coronavirus (COVID-19) SARS-CoV-2 PCRX-ray pelvis 3 plus views

Applying MDM Table to Ortho-Trauma Example

Problem Acute, uncomplicated illness or injury

OrderedLabs - Covid Test

Imaging –X-ray 3 Views

Review Records

Imaging- CT 6/27 from the EDDocumentation must tell us what image was reviewed and the date of the image.

PrescriptionsASA for DVT PPX

Tramadol

E&M 2021 Changes- Time Used to Level a Service

Time

• 2020

• Currently only considers Face-to-Face time with the patient with counseling and coordination of care dominating 50% of the total time

• 2021

• Includes both Face-to-Face and non-Face-to-Face time on date of encounter

• Eliminates requirement of counseling or coordination of care being dominate factor

• This may be MD and/or APP working together

• Includes Prep and follow up time

Activities Included in Time

• Activities included in time:

• Preparing to see the patient (eg, review of tests)

• Obtaining and/or reviewing separately obtained history

• Performing a medically necessary appropriate examination and/or evaluation

• Counseling and educating the patient/family/caregiver

• Ordering medications, tests, or procedures

• Referring and communicating with other health care professionals (when not reported separately)

• Documenting clinical information in the electronic or other health record

• Independently interpreting results (not reported separately) and communicating results to the patient/family/caregiver

• Care coordination (not reported separately)

E&M 2021 Time Ranges

Time Statement Examples

I spent a total of 38 minutes with the patient. I have performed a medically appropriate examination and evaluation of the patients left heel ulcer. I have personally reviewed the MRI images performed on xx/xx/xxxx and find that ……. I have reviewed the labs from the outside hospital sed rate was high. I have ordered new labs today. I have discussed with the patient and the wife that keeping the wound clean and taking prescribed antibiotics until complete will aid in the healing process. If wound does not improve by the next scheduled appointment in two weeks we will proceed with wound debridement.

Patient is seen in clinic today for a left heel ulcer. I spent 10 minutes preparing to see the patient reviewing medical records and imaging from OSH. I have spent 15 minutes performing a medically appropriate exam of the left heel. Findings are consistent with …… I spent 15 minutes with the patient and his wife explaining proper wound care and the importance of taking the prescribed course of

antibiotics until complete.

New Prolonged Service CPT 99417

• A new code has been created to use for prolonged service provided to a patient during an outpatient new or established patient encounter.

• Code 99417 is used to report prolonged total time (ie, combined time with and without direct patient contact) provided by the physician or other qualified health care professional on the date of office or other outpatient services (ie, 99205, 99215).

Documentation to Support E&M Code

• Indicate the tests that are being order and why

• Communicate the complexity of conditions

• Document when diagnosis or treatment is significantly limited by social determinants of health.

• Risks and Benefits were explained to the patient.

• There should be documentation in the note explaining the risks/benefits

• Document chronic conditions that may influence/impact your treatment plan.

• Patient Referrals: There must be documentation that a discussion occurred with the specialist you’re referring the patient to. If there is no documented discussion no MDM credit can be given.

• Imaging: We need to know what image was reviewed and the date of the image.

Diagnosis Coding

Documentation should be thorough and specific so that the appropriate diagnosis code can be assigned. A specific ICD-10 code should include:

• Anatomic site/Laterality

• Acuity

• Stage/Severity

• Episode of care

• Complications

3 Questions1. Which type of visit can I choose level of service based on total time spent with the patient?

a) New Patient

b) Consult

c) Inpatient visit

d) All of the above

2. During which type of encounter is my level of service determined by taking a comprehensive history and physical?

a) New Patient

b) Consult

c) Established Patient Visit

d) All of the above

3. In the new 2021 coding guidelines you can choose to level your E&M service by:

a) Time or Documenting a Multi-System Exam

b) Time or MDM

c) MDM or Number of Reported Problems