Basic Inpatient E/M Coding Training Office of Regulatory Affairs & Compliance.
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Transcript of Basic Inpatient E/M Coding Training Office of Regulatory Affairs & Compliance.
Basic Inpatient E/M Coding Training
Office of Regulatory Affairs & Compliance
2
Outline
This training only covers the basic elements of coding for inpatient evaluation and management (E/M) services, specifically initial hospital visits, subsequent hospital visits, discharge services, observations, inpatient consultations, coding based on time, and prolonged services.
Components of E/M Services Inpatient E/M Inpatient Services
Initial Hospital Visits Subsequent Hospital Visits Hospital Discharge Services Hospital Observation Services Inpatient Consultations When to Use Time Based Coding Prolonged Services
Most Frequently Used Modifiers Selecting, Sequencing and Linking Diagnosis Codes Completing Fee Tickets Teaching Physician Attestations for E/M Services
3
Components of E/M Inpatient Services
Inpatient E/M services have the same basic components as outpatient E/M.
Below are the basic components:
History Chief Complaint History of Present Illness (HPI) Review of Systems (ROS) Past Medical, Family, Social History (PFSH)
Examination
Medical Decision-Making (MDM) Number of diagnoses or management options Amount and/or complexity of data reviewed or ordered Risk of complications and/or morbidity or mortality
4
Overview of Inpatient E/M Leveling
The codes listed in the left hand column require 3 of 3 components be met or exceeded.
History Exam Medical Decision-Making Time Based
Code Type PF EPF Detailed Comp PF EPF Detailed Comp S L M H Avg. Time
99221 Initial
Hospital
Visit
X X X X 30
99222 X X X 50
99223 X X X 70
99218 Observation
Services
X X X X NA
99219 X X X NA
99220 X X X NA
99234 Hospital Observation or Inpatient Care Services
(Including Same Day Admission and
Discharge)
X X X X NA
99235 X X X NA
99236 X X X NA
99251 Inpatient
Consultations
X X X 20
99252 X X X 40
99253 X X X 55
99254 X X X 80
99255 X X X 110
PF = Problem Focused EPF = Expanded Problem Focused C = Comprehensive S = Straightforward L = Low M = Moderate H = High
Notes: Codes 99221, 99218, and 99234 can either have straightforward or low medical decision-making. See slide 21 for information on when and how to code based on time.
5
Overview of Inpatient E/M Leveling
The codes listed in the left hand column require 2 of 3 components be met or exceeded; 1 of the 2 must be medical decision-making.
History Exam Medical Decision-Making Time Based
Code Type PF EPF Detailed Comp PF EPF Detailed Comp S L M H Avg. Time
99231 Subsequent (Follow-up)
Visit
X X X X 15
99232 X X X 25
99233 X X X 35
PF = Problem Focused EPF = Expanded Problem Focused C = Comprehensive S = Straightforward L = Low M = Moderate H = High
Notes:
Code 99231 can either have straightforward or low medical decision-making.
See slide 31 for information on when and how to code based on time.
6
Overview of Inpatient Visits
Initial hospital care:
*Code 99221, 99222 or 99223
Subsequent follow-up or encounter by provider other than admitting
physician:
Code 99231, 99232 or 99233
Inpatient consults:
Code 99251, 99252, 99253, 99254, or
99255
Hospital Discharge Day Management:
Code 99238 or 99239
Notes: See slides 4-5 and 8-17 for more information on when and how to use these codes. *For Medicare and CareLink patients, see slides 7 and 16 for information on when and how to use these codes because these payors have different coding guidelines. Prior to admission, patient may have been evaluated at another site of service (e.g., outpatient hospital, office, emergency department, or nursing facility).
Admission & discharged on same calendar date:
*Code 99234, 99235 or 99236
Admit to hospital as inpatient
7
Overview of Inpatient Visits - Medicare & CareLink
Admit to hospital as inpatient
Admission < 8 hours:
Code 99221, 99222 or 99223
Admission > 8 hours but < 24 hours & discharged on same calendar date as
admission:
Code 99234, 99235 or 99236
Admission > 24 hours:
Code 99221, 99222 or 99223
Subsequent visit by admitting physician or visit by provider other
than admitting physician:
Code 99231, 99232 or 99233
Inpatient consults:
Code 99251, 99252, 99253, 99254, or 99255
Hospital Discharge Day Management:
Code 99238 or 99239
Notes: See slides 4-5 and 8-17 for more information on when and how to use these codes.
Prior to admission, patient may have been evaluated at another site of service (e.g., outpatient hospital, office, emergency department, or nursing facility).
8
Initial Hospital Visits
Codes 99221-99223 are used by the admitting physician to report initial services to hospital inpatients. These codes are often referred to as the “Admit” codes.
Notes: Only one physician can be the admitting physician and only the admitting physician
can use codes 99221-99223. All other providers should bill the inpatient E/M codes that describe their participation
in the patient’s care (i.e., subsequent hospital visit or inpatient consultation). When performed on the same date as the admission, all other outpatient services
provided by the physician in conjunction with that admission are considered part of the initial hospital care.
If the patient is seen in the office on one day, and admitted on the next day (even if <24 hours have elapsed) by the same physician, code both the office visit and initial hospital visit.
Code 99221-99223 +
99238-99239
99221-99223 +
99231-99233 +
99238-99239
Type Initial Hospital Visit +
Hospital Discharge Day Management
Initial Hospital Visit +
Subsequent Hospital Visit +
Hospital Discharge Day Management
Duration of Service 1st calendar day - admitted
+
3rd calendar day - discharged
1st calendar day - admitted
+
2nd or subsequent calendar days
+
3rd calendar day - discharged
Comments Code both services Code all services
9
Initial Hospital Visits
History, exam, and medical decision-making must meet or exceed the same level in order to assign a specific code (i.e., 3 out of 3 same level or higher).
Code History Exam Medical Decision Making Comments
99221 Detailed or comprehensive
Detailed or comprehensive
Straightforward or low Usually presenting problem(s) are of low severity
99222 Comprehensive Comprehensive Moderate Usually presenting problem(s) are of moderate severity
99223 Comprehensive Comprehensive High Usually presenting problem(s) are of high severity
10
Initial Hospital Visit - Clinical Example
The below clinical example was taken from the current CPT manual and does not encompass the entire scope of medical practice or the documentation required to support the code.
The intent of the example is to assign a code level for an initial hospital visit based on patient’s presenting problem.
Initial hospital visit for a 50 year old patient with lower quadrant abdominal pain and increased temperature, but without septic picture.
Based on this example, what code should be assigned? For the answer, see the next slide.
11
Initial Hospital Visit - Clinical Example
Based on the example in the preceding slide, the service provided and
documented should support initial hospital visit code 99222.
12
Subsequent Hospital Visits
Codes 99231-99233 can be used by any provider to report subsequent inpatient services.
Two out of 3 components of history, exam, and medical decision-making must meet or exceed the same level to assign a code (1 of the 2 has to be medical decision-making).
Code History Exam Medical Decision Making Comments
99231 Problem focused Problem focused Straightforward or low Usually patient is stable, recovering, or improving
99232 Expanded problem-focused
Expanded problem-focused
Moderate Usually patient is responding inadequately to therapy or experiencing a minor complication
99233 Detailed Detailed High Usually patient is unstable or has developed a significant complication or significant new problem
Notes: The descriptors for these codes include the phrase “per day,” meaning care for the
day. If Provider A sees the patient in the morning and Provider B, who is covering for
A, sees the same patient in the evening, the notes for both services are combined and only one subsequent hospital visit is coded.
If two physicians see the patient and they are in different specialties and are seeing the patient for different reasons (i.e., different diagnosis), then both may bill a subsequent hospital visit based on that physician’s note and the medical necessity of the service.
Select a code that reflects all services provided during the date of service.
13
Subsequent Hospital Visits - Clinical Example
The below clinical example was taken from the current CPT manual and does not encompass the entire scope of medical practice or the documentation required to support the code.
The intent of the example is to assign a code level for an initial hospital visit based on patient’s presenting problem.
Subsequent hospital visit for 55 year old male with severe chronic obstructive pulmonary disease and bronchospasm; initially admitted for acuter respiratory distress requiring ventilator support in the ICU. The patient was stabilized, extubated and transferred to the floor, but has not developed acute fever, dyspnea, left lower lobe rhonchi and laboratory evidence of carbon dioxide retention and hypoxemia.
Based on this example, what code should be assigned. For the answer, see the next slide.
14
Subsequent Hospital Visits - Clinical Example
Based on the example in the preceding slide, the service provided and
documented should support initial hospital visit code 99233.
15
Observation or Inpatient Hospital Care(Including Admission and Discharge Services)
Codes 99234-99236 are used by a provider to report observation or inpatient hospital care
services provided to patients admitted and discharged on the same date of service.
Code History Exam Medical Decision Making Comments
99234 Detailed or comprehensive
Detailed or comprehensive
Straightforward or low Usually problem(s) requiring admission are of low severity
99235 Comprehensive Comprehensive Moderate Usually problem(s) requiring admission are of moderate severity
99236 Comprehensive Comprehensive High Usually problem(s) requiring admission are of high severity
Notes: When performed on the same date as the admission, all other outpatient services
provided by the physician in conjunction with that admission are considered part of the initial hospital or observation care.
When a patient is admitted to observation or inpatient care and discharged on a different date, see slides 4, 6-11 and 17 for information on when and how to use the initial hospital care codes 99221-99223 and discharge management codes 99238-99239, or slides 18-25 on when and how to use hospital observation codes 99218-99220 and observation care discharge code 99217.
16
Observation or Inpatient Hospital Care – Medicare and CareLink
Codes 99234-99236 are used by a provider to report: Admitting and discharging a patient on the same calendar day for >8 hours but <24 hours, or Placing a patient under observation and discharging the patient on the same calendar date for >8 hours but <24 hours
Code History Exam Medical Decision Making Comments
99234 Detailed or comprehensive
Detailed or comprehensive
Straightforward or low Usually problem(s) requiring admission are of low severity
99235 Comprehensive Comprehensive Moderate Usually problem(s) requiring admission are of moderate severity
99236 Comprehensive Comprehensive High Usually problem(s) requiring admission are of high severity
Notes: In addition to meeting the documentation requirements for history, exam and medical
decision-making, documentation in the medical record should include: Statement that the stay for observation care or inpatient hospital care involved
eight hours, but less than 24 hours. Admission and discharge notes written by the billing provider. Personal documentation by the billing provider indicating presence and face-to-
face services were provided.
17
Hospital Discharge Day Management
Codes 99238-99239 are used to report the total duration of time spent by the provider for final hospital discharge services.
History Comments
99238 Hospital discharge day management, 30 minutes or less Face-to-face time between the attending and the patient
99239 Hospital discharge day management, more than 30 minutes
Notes: Only one hospital discharge service is coded per patient, per hospital stay. Only the attending physician of record reports the discharge day code. Discharge service is billed on the date of the actual visit by the provider even if the
patient is discharged on a different calendar date. Includes, as appropriate:
Final patient exam Discussion of the hospital stay Instructions for continuing care Preparation of discharge records, prescriptions, and referral forms
Total time of the visit must be documented to support code assigned. All other providers performing a final visit should code subsequent hospital care
(99231–99233).
18
Hospital Observation Services
Initial observation care:
Codes 99218, 99219 or 99220
Then use discharge code
99217
Then admit as inpatient:
Code 99221-99223 (see slides 8-11)
Notes: See slides 20-25 for more information on when and how to use these codes. *For Medicare and CareLink patients, see slides 19 and 21 for information on when and how to use these codes because these payors have different coding guidelines. Prior to observation, patient may have been evaluated at another site of service (e.g., outpatient hospital, office, emergency department, or nursing facility).
Admit to Observation
Status*
Subsequent visit by admitting physician or
visit by another provider
Code 99212, 99213, 99214, or 99215
Outpatient consultation: Code
99241, 99242, 99243, 99244, or
99245Admission & discharged on same calendar date:
*Code 99234, 99235 or 99236
19
Hospital Observation Services – Medicare and CareLink
In Observation < 8 hours and discharged same calendar date:
Code 99218, 99219 or 99220
In Observation > 8 hours but < 24 hours and discharged
same calendar date: Code 99234, 99235 or 99236
(see slide 15)
In Observation > 24 hours: Code 99218, 99219 or 99220
In Observation > 48 hours: Code 99218, 99219 or 99220
then 99212-99215
When discharged, use observation care
discharge day management: Code
99217
If admitted, use initial hospital visit:
Code 99221, 99222 or 99223 (see slides 8-11)
Notes: See slides 20-25 for more information on when and how to use these codes. Prior to observation, patient may have been evaluated at another site of service (e.g., outpatient hospital, office, emergency department, or nursing facility).
Admit to Observation
Status
20
Hospital Observation Services
These codes are used to report a patient placed under observation and include initiation of observation status, supervision of care, and periodic assessments.
Notes: Billed only by the physician who admitted the patient to observation and was responsible for the
patient during his/her stay. All other providers should bill the outpatient E/M codes that describe their participation in the
patient’s care (i.e., office and other outpatient service codes or outpatient consultation codes).
Code 99218-99220 +
99217
99218-99220 +
99212-99215 +
99217
99218-99220 +
99212-99215 +
99221-99223
Type Initial Observation Care
+
Observation Care Discharge Services
Initial Observation Care
+
Established Patient, Office or other Outpatient Visit
+
Observation Care Discharge Services
Initial Observation Care
+
Established Patient, Office or other Outpatient Visit
+
Initial Hospital Visit
Duration of Service 1st calendar day - placed under observation
+
2nd calendar day - discharged
1st calendar day - placed under observation
+
2nd calendar day - subsequent service
+
3rd calendar day - discharged
1st calendar day - placed under observation
+
2nd calendar day - subsequent service
+
3rd calendar day - admitted to inpatient status
Comments Code both services Code all services Code all services
22
Hospital Observation ServicesHistory, exam, and medical decision-making must meet or exceed the same level in order to assign a specific code (i.e., 3 out of 3 same level or higher).
Notes: The descriptors for these codes include the phrase “per day”, meaning care for the
day. Select a code that reflects all services provided during the date of the service. The observation record for the patient must contain dated and timed physician’s
admitting orders regarding the care the patient is to receive while in observation, and progress notes prepared by the physician while the patient was in observation status. This information is in addition to any record prepared as a result of an emergency department, outpatient clinic, or nursing facility encounter.
In rare instances when a patient is held in observation status for more than two calendar dates, the physician must code subsequent services before the discharge date using outpatient/office visit codes (99212-99215).
Code History Exam Medical Decision Making Comments
99218 Problem focused Problem focused Straightforward or low Usually patient is stable, recovering, or improving
99219 Expanded problem-focused
Expanded problem-focused
Moderate Usually patient is responding inadequately to therapy or experiencing a minor complication
99220 Detailed Detailed High Usually patient is unstable or has developed a significant complication or significant new problem
23
Observation Care Discharge Services
Code 99217 is used to report discharge services of a patient in observation status.
History Comments
99217 Observation care discharge day management Face-to-face time between the attending and the patient
Notes: Billed only by the physician who was responsible for observation care during this stay. Discharge service is billed on the date of the actual visit by the provider . Includes:
Final patient exam Discussion of the hospital stay Instructions for continuing care Preparation of discharge records, prescriptions, and referral forms
All other providers performing a final visit should use outpatient/office visit codes (99212-99215).
Do not bill the hospital observation discharge management code (99217) if patient was Admitted to inpatient status, use codes 99221-99223. See slide 8-11 for more
information on when and how when and how to use these codes. Placed under observation and discharged on the same calendar date, use codes
99234-99236. See slide 15-16 for information when and how to use these codes.
24
Hospital Observation During A Global Surgical Period The global surgical fee includes payment for hospital observation (codes 99217,
99218, 99219, 99220, 99234, 99235 and 99236) services unless specific requirements are met.
Observation services may be paid in addition to the global surgical fee only if both of the following requirements are met: The hospital observation service meets the criteria needed to justify billing it with
modifiers: 24 - Unrelated E/M service by the same physician during a post-operative
period 25 - Significant, separately identifiable E/M service by the same physician on
the same day of a procedure or other service 57 - Decision for major surgery
The hospital observation service furnished by the surgeon meets all the criteria for the hospital observation code billed.
See slide 35 for information on when and how to use modifiers with E/M services.
25
How to Use Observation Codes - Examples
Date 9/189/18
Medicare & CareLink9/19 9/20
Admitted to Observation by Provider A on 9/18 at 1AM; seen and discharged by Provider A at 7 AM on 9/18
99234-99236
(Provider A)
99218-99220
(Provider A)
Admitted to Observation by Provider A on 9/18 at 1AM; seen and discharged by Provider A at 9/18 4PM
99234-99236
(Provider A)
99234-99236
(Provider A)
Admitted to Observation by Provider A on 9/18 at 1AM; seen by Provider B 9/18 at 3 PM; seen and discharged on 9/19 at 7 AM by Provider A
Note: Provider A is from a different specialty than Provider B and the service was not a consultation.
99218-99220 (Provider A)
99212-99215 (Provider B)
99218-99220 (Provider A)
99212-99215 (Provider B)
99217
(Provider A)
Admitted to Observation by Provider A on 9/18 at 1AM; seen by Provider A on 9/19; and, seen and discharged by Provider A on 9/20
99218-99220
(Provider A)99218-99220
(Provider A)
99212-99215
(Provider A)
99217
(Provider A)
Admitted to Observation by Provider A on 9/18 at 1AM; seen by Provider A on 9/19; and, admitted by Provider A to inpatient status 9/20
99218-99220
(Provider A)99218-99220
(Provider A)
99212-99215
(Provider A)
99221-99223
(Provider A)
26
Inpatient Consultations
Codes 99241-99245 are used to report consultations provided to hospital inpatients.
History, exam, and medical decision-making must meet or exceed the same level in order to assign a specific code (i.e., 3 out of 3 same level or higher).
Code History Exam Medical Decision Making Comments
99251 Problem focused Problem focused Straightforward Usually presenting problem(s) are self limited or minor
99252 Expanded problem-focused Expanded problem-focused Straightforward Usually presenting problem(s) are of low severity
99253 Detailed Detailed Low Usually presenting problem(s) are of moderate severity
99254 Comprehensive Comprehensive Moderate Usually presenting problem(s) are of moderate to high severity
92255 Comprehensive Comprehensive High Usually presenting problem(s) are of moderate to high severity
Notes: An inpatient consultation may only be billed once per consultant, per admission. Additional follow-up visits after the initial inpatient consultation are billed using the
subsequent hospital care codes (99231-99233). See slide 12-14 for information on when and how to use these codes.
A request to take care of the problem is a referral, and should be coded with subsequent hospital care code 99231-99233. See slide 12-14 for more information on when and how to use these codes.
27
Inpatient Consultations
These requirements must be met and supported by documentation in the patient’s inpatient medical record to code and bill a consultation. The service is provided by a physician or qualified non-physician provider whose
opinion or advice regarding evaluation and/or management of a specific problem is requested by provider (excludes residents, fellows, and interns) due to the consultant’s expertise in a specific medical area beyond the requesting provider’s knowledge; and,
The request for a consultation including the name of the requestor and the need or reason for the consultation must be documented by the consultant in the inpatient’s medical record; and,
After the consultation is provided, a written report of the consultant’s findings, opinions, and recommendations is documented in the inpatient record for the requesting provider to use in the management of and/or decision making for the patient; and,
Intent is to return the patient to requesting provider for ongoing care of the problem. During the service, the consultant may:
Perform or order diagnostic tests, or Initiate a treatment plan, including performing emergent procedures.
28
Examples of Disposition Boxes for Consultation Services Templates
Here are examples that you may include in your documentation templates to support your intent to return the patient to the requestor.
❑ Return to requesting provider with recommendations and treatment options.
❑ Return to requesting provider’s care with final recommendations after completion of
additional diagnostic testing.
❑ Return to requesting provider’s care with final recommendations after evaluation of
trial of therapeutic regimen.
❑ Will follow for X problems in parallel with requesting provider if provider agrees.
29
Inpatient Consultations - Clinical Example
The below clinical example was taken from the current CPT manual and does not encompass the entire scope of medical practice or the documentation required to support the code.
The intent of the example is to assign a code level for an initial hospital visit based on patient’s presenting problem.
Initial inpatient consultation for a 72 year old male with emergency admission for possible bowel obstruction.
Based on this example, what code should be assigned. For the answer, see the next slide.
30
Inpatient Consultations - Clinical Example
Based on the example in the preceding slide, the service provided and
documented should support initial hospital visit code 99254.
31
When to Use Time Based Coding In an inpatient setting, when more than 50% of the total visit time by the teaching
physician is counseling and/or coordinating the patient’s care, the time used to code must be provided at the patient’s bedside and/or on the patient’s hospital floor or unit.
When coding based on time, the teaching physician may not: Add time spent by the resident in the absence of teaching physician to face-to-
face time spent with the patient by the teaching physician with or without the resident present .
Count time counseling or coordinating the patient’s care after leaving the patient’s floor or after beginning to care for another patient.
In addition to documenting history and/or physical exam provided, the documentation should include: Total visit time and time spent counseling and coordinating care, and, Description of the medical decision making and counseling discussion and/or
activities coordinated. Examples of documenting support for coding based on time based:
“I spent a total of 30 of 45 minutes on the floor coordinating David’s care and in discussion with David regarding…”
“30 of 40 minutes of visit at Mary’s beside discussing ….with Mary and her family was spent discussing…”
32
Prolonged Services
Codes 99356 and 99357 can be used to report inpatient services involving direct (face-to-face) care provided beyond the usual E/M service.
Code E/M Type Typical Time for Code Threshold Time to Bill Code 99356 Threshold Time to Bill Code 99357
99221
Initial Hospital Visit
30 60 105
99222 50 80 125
99223 70 100 145
99231
Subsequent Visit
15 45 90
99232 25 55 100
99233 35 65 110
99251
Inpatient Consultation
20 50 95
99252 40 70 115
99253 55 85 130
99254 80 110 155
99255 110 140 185
Note: See slides 33-36 for information on when and how to use these codes.
33
When to Use Prolonged Service Codes
Only count the duration of direct face-to-face contact between the physician and the patient (whether the service was continuous or not) beyond the typical/average time of the E/M visit code billed for the same date of service. See slide 32 for typical and threshold times and applicable E/M services.
Must be 30 minutes or more beyond the typical time assigned to the E/M level coded Example: Average time for 99232 = 25 minutes, so a minimum of 55 minutes would be
required to also bill 99356. Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes
beyond the final 30 minutes is not reported separately. Prolonged service of less than 30 minutes total duration on a given date is not separately
reported because the work involved is included in the total work of the E/M codes. Cannot bill prolonged services:
Based on time spent reviewing charts or discussing a patient with house medical staff without direct face-to-face contact with the patient, waiting for test results, changes in the patient’s condition, end of a therapy, or use of facilities
Without first coding an inpatient E/M service on the same date of service If the total duration of direct face-to-face time does not equal or exceed the threshold time
for the level of E/M service the provider is billing When the E/M service is selected based on time, prolonged services may only be reported as the
companion code with the highest code level in that family of codes (i.e., 99223, 99233, or 99255). See slide 8-14 and 26-30 for information on when and how to bill codes based on time.
34
Documentation for Prolonged Services
Documentation is required in the medical record about the duration and content of the medically necessary E/M service and prolonged services billed.
The start and end times of the visit must be documented in the medical record along with the date of service.
The medical record must be appropriately and sufficiently documented by the physician or qualified NPP to show that the provider personally furnished the direct face-to-face time with the patient specified in the CPT code definitions.
35
Prolonged Services - Clinical Example
The below clinical example was taken from the current CPT manual and does not encompass the entire scope of medical practice or the documentation required to support the code.
The intent of the example is to assign a code level for an initial hospital visit based on patient’s presenting problem.
A 34 year old primigravida presents to hospital in early labor. Admission history and physical reveals severe preeclampsia. Physician supervised management for preeclampsia, IV magnesium initiation and maintenance, labor augmentation with pitocin, and close maternal-fetal monitoring. Physician face-to-face involvement includes 40 minutes of continuous bedside care until the patient is stable, then is intermittent over several hours until the delivery.
Based on this example, what code should be assigned. For the answer, see the next slide.
36
Prolonged Services - Clinical Example
Based on the example in the preceding slide, the service provided and
documented should support initial hospital visit code 99356.
37
Inpatient Modifiers
These are the most frequently used modifiers with inpatient E/M services. However, there may be others. See TrailBlazers’ Modifier manual for a complete listing of other modifiers at http://www.trailblazerhealth.com/Publications/Manuals/.
24 - Unrelated E/M service by the same physician during a post-operative period.
25 - Significant, separately identifiable E/M service by the same physician on the same day of a procedure.
57 - Decision for major surgery.
GC - Service performed in part by a resident under direction of a teaching physician.
38
Tips on Selecting Diagnosis Codes
This information will assist in the selection of diagnosis codes used to bill an E/M service.
Diagnosis codes: Describe the condition(s) that prompted the visit and support the medical necessity
and level of service coded. Must be supported by documentation in the current note. Are coded to the highest degree of specificity (e.g. renal failure vs. chronic kidney
disease, Stage III). May be taken from final assessment or chief complaint. Can be based on signs/symptoms if unable to make definitive diagnosis during the
visit. Cannot be coded for conditions documented as “rule out… probable... possible…
questionable…”. Include secondary conditions affecting treatment during the current visit. Diagnosis codes are not assigned when a diagnosis is mentioned in the history and is
not addressed, or there is no indication in the current visit note that the diagnosis affected care.
39
Tips on Sequencing Diagnosis Codes
All diagnosis codes must be sequenced (1,2,3, etc.) on the fee ticket. Sequencing on the fee ticket should follow the same sequence as the diagnosis are
documented in the current visit note. First-listed code:
Chief complaint (i.e., diagnosis, condition, problem, or other reason for the visit such as chemotherapy) chiefly responsible for the service provided.
If the reason for the visit was for multiple complaints and each was addressed as supported by documentation,
The complaint that was most time consuming due to evaluation and/or management is sequenced first; and,
The remaining complaints are sequenced thereafter based on evaluation and/or management.
Additional codes: Newly diagnosed codes that were evaluated and/or treated during the current
service. Co-morbid conditions that coexist at the time of the service and influence,
require, or affect patient-care or treatment as supported in documentation. Selecting a diagnosis without sequencing the code is not acceptable.
40
Example of Linking Diagnosis Codesto E/M Services and Procedures
Assessment: Codes:
1.Asthma with acute exacerbation2.Native vessel coronary artery disease3.Pilondial cyst without abscess
1.493.022.414.013.685.1
E/M Service: Subsequent hospital visit 99232-25 1. 493.022. 414.043. 685.1
Procedures: • Incision and drainage of pilondial cyst, simple
10080 3. 685.1
Notes: When an E/M service and a procedure are coded for the same visit, diagnosis codes
must be linked to both the E/M service and the procedure. Applying the appropriate modifier to the E/M and procedure code support the medical
necessity of both services. See slide 37 for information on when and how to assign E/M modifiers.
The patient was admitted 2 days ago with acute exacerbation of asthma and native vessel CAD. Today, a painful pilondial cyst was also evaluated and the cyst was incised and drained. Notes supporting the subsequent hospital visit and I&D were fully documented in the patient’s medical record.
41
Completing A Fee Ticket
Select E/M level
Select additional service or procedure codes as applicable
Select, sequence, and link diagnosis codes for each E/M and procedure coded
Select modifiers
Sign the paper fee ticket or authenticate the electronic fee ticket
42
Documenting a Teaching Physician Attestation for E/M ServicesThe teaching physician does not have to re-perform and re-document the entire E/M
service to bill. However, the teaching physician, at minimum, must personally document
an attestation to supplement the resident’s documentation.
The attestation includes a statement that the teaching physician: Personally performed the service, or was physically present during the key or
critical portions of the service when performed by a resident; Participated in the management of the patient; and, Reviewed the resident’s note. The name of the resident should be included in
the attestation.
When properly attested, the resident’s documentation and the faculty’s documentation can be used by the teaching physician to determine the level of E/M service billed and support medical necessity.
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Examples of Teaching Physician Attestations for E/M Services Examples of acceptable attestations:
“I saw and evaluated the patient. I agree with the findings and plan of care documented in Dr. Resident’s note.”
“I saw the patient with Dr. Resident and agree with his findings and plan.” “I saw the patient and discussed the patient with Dr. Resident and agree with the
note except that the findings are more consistent with…. Will begin ….”
Examples of unacceptable attestations: “Discussed with resident and agree.” “Patient seen and evaluated.” “Agree with the above.”
It is also unacceptable for a resident to attest to a teaching physician’s presence and participation in an E/M service. For example, “I saw and evaluated the patient with Dr. Faculty who agrees with
my findings and plan of care.”
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Questions
If you have any questions, please contact:
Your UT Medicine Coder Educator
or
Office of Regulatory Affairs & Compliance at 567-2014