Rational Physician Coding for Emergency Department E/M Services and Critical Care

Rational Physician Coding for Emergency Department

E/M Services and

Critical Care

Peter R. Jensen, MD, CPC www.EMuniversity.com

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Peter R. Jensen, MD, CPC

For clinically driven E/M coding education, go to www.EMuniversity.com

Rational Physician Coding for Emergency E/M

Services

ER E/M Coding

E/M = Evaluation and ManagementHow patient encounters are translated into 5 digit numbers to facilitate billingFor ED E/M services, there are five levels of care:

99281 $19.3099282 $37.1699283 $60.7699284 $110.4799285 $165.70

80%

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Goals

Learn the documentation requirements for ED E/M services and critical careEnsure complianceStreamline the documentation processIdentify the highest ethical level of careMaintain the focus on patient care

ER E/M Documentation

NAHighCompComp99285NAModDetDet99284NAModEPFEPF99283NALowEPFEPF99282NASFPFPF99281

TimeMDMExamHistoryE/M Code

3 out of 3 key components must qualify

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E/M = Cognitive Labor

=

The E/M Guidelines

Developed by the AMA and CMSFirst set released in 1995Second set released in 1997Based on three “Key Components”– History– Physical Exam– Medical Decision-Making

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History Physical

Problem FocusedExpanded Problem FocusedDetailedComprehensive

MDM

StraightforwardLow ComplexityModerate ComplexityHigh Complexity

History

PhysicalMDM

We think of the key components as being random, but they’re really not……

This is how auditors look at the E/M guidelines. They view the history, physical exam and medical decision-making in very concrete terms.

MDMHistory Physical

Straightforward

Problem Focused

Expanded Problem Focused

Detailed

Comprehensive

Problem Focused

Expanded Problem Focused

Detailed

Comprehensive

Low Complexity

Moderate Complexity

High Complexity

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Physical

Physical

ROS

HPI

PMHFH

SH

Exam Bullets

Organ Systems

Diagnoses

Data Reviewed

Risk

Our challenge is to find some way to translate our cognitive labor into the abstruse language of the E/M guidelines without wasting time on over-documentation or getting distracted from our real job of taking care of patients.

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s:

RiskDataProblems

Primacy of Medical Decision-Making

MDM =

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Medical Necessity

“Correct” Level of Care

=

The Importance of Medical Necessity

“Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of E/M service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed.”

RiskDataProblems

The quote above is taken directly from the Medicare carrier manual and it

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Determining the MDM

Moderate ModerateModerateMultiple

Low Complexity

LowLimitedLimited

Straight-Forward

MinimalMinimalMinimal

Level of MDM

RiskData Reviewed

Number of Diagnoses

s

-

“voluntary” basis.

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1Decision to obtain old records

2Independent review of image, tracing, or specimen

2Review and summation of old records

1Discussion of test results with performing MD

1Review/order tests in the medicine section (echo, EKG, LHC, PFTs)

Problem Points

1Self limited or minor (Max 2)

3New problem, no additional work-up planned

2Established problem, worsening

1Established problem, stable

PointsProblems/DDx

The data points are calculated using this table. You only get one data point for reviewing and/or ordering labs and ordering or reviewing X-ray reports. If you personally review any primary data (such as an EKG, an X-ray or a blood smear, etc.), you get two data points, but you must record your findings in the chart.

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Risk Presenting Problem(s) Diagnostic Procedures Management Options Selected

Minimal • One self-limited or minor prob-lem, e.g., cold, insect bite, tinea corporis

• Laboratory tests • Chest X-rays • EKG/EEG • Urinalysis • Ultrasound/

Echocardiogram • KOH prep

• Rest • Gargles • Elastic bandages • Superficial dressings

Low • Two or more self-limited or minor problems

• One stable chronic illness, e.g., well controlled HTN, DM2, cata-ract

• Acute uncomplicated injury or illness, e.g., cystitis, allergic rhini-tis, sprain

• Physiologic tests not under stress, e.g., PFTs

• Non-cardiovascular imag-ing studies with contrast, e.g., barium enema

• Superficial needle biopsy • ABG • Skin biopsies

• Over the counter drugs • Minor surgery, with no identi-

fied risk factors • Physical therapy • Occupational therapy • IV fluids, without additives

Moderate • One or more chronic illness, with mild exacerbation, progression, or side effects of treatment

• Two or more stable chronic ill-nesses

• Undiagnosed new problem, with uncertain prognosis, e.g., lump in breast

• Acute illness, with systemic symptoms, e.g., pyelonephritis, pleuritis, colitis

• Acute complicated injury, e.g., head injury, with brief loss of consciousness

• Physiologic tests under stress, e.g., cardiac stress test, fetal contraction stress test

• Diagnostic endoscopies,

with no identified risk factors

• Deep needle, or incisional biopsies

• Cardiovascular imaging studies, with contrast, with no identified risk factors, e.g., arteriogram, cardiac catheterization

• Obtain fluid from body cavity, (e.g., LP or thora-centesis)

• Minor surgery, with identified risk factors

• Elective major surgery (open, percutaneous, or endoscopic), with no identified risk factors

• Prescription drug manage-ment

• Therapeutic nuclear medicine • IV fluids, with additives • Closed treatment of fracture

or dislocation, without ma-nipulation

High • One or more chronic illness, with severe exacerbation, progression, or side effects of treatment

• Acute or chronic illness or injury, which poses a threat to life or bodily function, e.g., acute MI, pulmonary embolism, severe res-piratory distress, progressive se-vere rheumatoid arthritis, psychi-atric illness, with potential threat to self or others, peritonitis, ARF

• An abrupt change in neurological status, e.g., seizure, TIA, weak-ness, sensory loss

• Cardiovascular imaging, with contrast, with identi-fied risk factors

• Cardiac EP studies • Diagnostic endoscopies,

with identified risk factors • Discography

• Elective major surgery (open, percutaneous, endoscopic), with identified risk factors

• Emergency major surgery (open, percutaneous, endo-scopic)

• Parenteral controlled sub-stances

• Drug therapy requiring inten-sive monitoring for toxicity

• Decision not to resuscitate, or to de-escalate care because of poor prognosis

Table of Risk

This is the official table of risk for both the 1995 and 1997 E/M guidelines. The rules explicitly state that it only takes one element in any of the cate-gories above to qualify for any given level of risk. Use highest level of risk present to stratify the overall level of risk for any encounter.

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Calculating the Overall MDM

Low22Low

Minimal11Straight Forward

RiskData Problems MDM Complexity

f

History Physical Exam

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Problem FocusedExpanded Problem FocusedDetailedComprehensive

CCHPIROSPFSH

History

Levels of History

None1BriefEPF1 out of 32 – 9ExtendedDetailed

NoneNoneBriefPF

3 out of 310ExtendedComp

PFSHROSHPIHistory

For ER E/M encounters, a comprehensive history requires only TWO out of THREE components of PFSH.

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HPI

A narrative of the patient’s symptoms or illnesses since onset or since the previous encounterEvery level of history requires and HPI, which may be referred to as an “interval history” for follow-up encountersThe HPI is the only component of history which MUST be personally obtained and documented by the provider

Elements of HPI

• Location • Duration • Timing • Quality

• Severity • Context • Modifying factors • Associated signs or

symptoms

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HPI Elements

LocationQualitySeverityDurationTimingContextModifying FactorsAssociated Signs/Symptoms

Patient complains of stabbing intermittent chest pain which began 8 hours ago while watching TV. The pain is rated as 8/10 in severity, is worse with exertion and is associated with SOB and nausea.

Location

Severity

Quality

Timing

Modifying Factors

Duration

Context Associated Signs or

Symptoms

Example of an extended HPI using all eight of the HPI elements.

Levels of HPI

Brief HPIRequires only one to three HPI elements

Extended HPIRequires four HPI elements or the status of three chronic or inactive problems

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ROSConstitutional EyesEars, nose, mouth, throatCardiovascularRespiratoryGIGU

MusculoskeletalSkinNeurologicalPsychiatricEndocrineHem/LymphaticAllergic/Immunologic

The ROS may be completed by the physician, ancillary staff or by having the patient fill out a questionnaire.

on the status of three or

more chronic or inactive problems.

What if the patient has no complaints?

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PFSH

Past Medical History– Previously existing illnesses, prior operations,

current medications, allergies, immunizationsFamily History– Health status of parents/siblings/children including

relevant or hereditary diseases Social History– Marital status, employment, DOA, education,

sexual history

The PFSH may be completed by the physician, ancillary staff or by having the patient fill out a questionnaire.

Levels of History

None1BriefEPF1 out of 32 – 9ExtendedDetailed

NoneNoneBriefPF

3 out of 310ExtendedComp

PFSHROSHPIHistory

The documentation requirements for each level of history are very specific. Therefore, the history should be recorded in a purpose-driven manner to ensure compliance while avoiding time-wasting over-documentation.

For ER E/M encounters, a comprehensive history requires

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History Tips and Shortcuts 1. You need a chief

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Physical Exam

1997 Physical Exam 15 Organ Systems and 59 bullets

6 - 11EPF12Detailed

1 - 5PF

18Comp

BulletsExam

1997 Physical Exam Organ Systems

• Constitutional • Eyes • Ears, nose, mouth and throat • Neck • Respiratory • Cardiovascular • Chest (breasts) • Gastrointestinal • GU (male, female) • Musculoskeletal • Lymphatic • Skin • Neurologic • Psychiatric

See individual bullets on next page.

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The 1997 Multi-System Exam Bullets Constitutional

• Three vital signs • General appearance

Eyes • Inspection of conjunctiva and lids • Examination of pupils and irises

(PERRLA) • Ophthalmoscopic discs and posterior

segments

Ears, Nose, Mouth, and Throat

• External appearance of the ears and nose

• Otoscopic examination of the exter-nal auditory canals and tympanic membranes

• Assessment of hearing • Inspection of nasal mucosa, septum

and turbinates • Inspection of lips, teeth and gums • Examination of oropharynx: oral

mucosa, salivary glands, hard and soft palates, tongue, tonsils and pos-terior pharynx

Neck

• Examination of neck (e.g., masses, overall appearance, symmetry, tra-cheal position, crepitus)

• Examination of thyroid

Respiratory

• Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic excursions)

• Percussion of chest • Palpation of chest (e.g., tactile fre-

mitus) • Auscultation of the lungs

Cardiovascular

• Palpation of the heart (PMI) • Auscultation of the heart • Assessment of lower extremity

edema • Examination of the carotid arteries • Examination of abdominal aorta • Examination of the femoral pulses • Examination of the pedal pulses

Chest (Breasts)

• Inspection of the breasts • Palpation of the breasts and axillae

Lymphatic Palpation of lymph nodes two or more areas

• Neck • Axillae • Groin • Other

Skin • Inspection of skin and subcutane-

ous tissue (e.g., rashes, lesions, ulcers)

• Palpation of the skin and subcuta-neous tissue (e.g., induration, subcutaneous nodules, tighten-ing)

Neurologic

• Test cranial nerves with notation of any deficits

• Examination of DTRs with nota-tion of any pathologic reflexes (e.g., Babinksi)

• Examination of sensation (e.g., by touch, pin, vibration, proprio-ception)

Psychiatric

• Description of patient’s judgment and insight

Brief assessment of mental status, which may include:

• Orientation to time, place, and person

• Recent and remote memory

• Mood and affect

Gastrointestinal (Abdomen)

• Examination of the abdomen with notation of presence of masses or ten-derness

• Examination of the liver and spleen • Examination for the presence or ab-

sence of hernias • Examination of anus, perineum, and

rectum, including sphincter tone, pres-ence of hemorrhoids, rectal masses

• Obtain stool for occult blood testing

Genitourinary (Male)

• Examination of the scrotal contents (e.g., tenderness of cord)

• Examination of the penis • DRE of the prostate

Genitourinary (Female)

• Examination of the external genitalia • Examination of the urethra • Examination of the bladder (e.g., full-

ness, masses, tenderness) • Examination of the cervix • Examination of the uterus (e.g., size,

contour, position, mobility) • Examination of the adnexa (e.g., masses,

tenderness, nodularity)

Musculoskeletal

• Examination of gait and station • Inspection and/or palpation of digits and

nails (e.g., clubbing, cyanosis, ischemia)

Examination of the 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 6. Left lower extremity

The examination of a given area includes:

• Inspection and/or palpation with notation of presence of any mis-alignment, asymmetry, crepita-tion, defects, tenderness, masses or effusions

• Assessment of range of motion with notation of any pain, crepi-tation or contracture

• Assessment of stability with notation of any dislocation, sub-luxation, or laxity

• Assessment of muscle strength and tone with notation of any atrophy or abnormal movements

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1995 Exam Rules

♦Head/face ♦Neck ♦Chest/breast/axillae ♦Abdomen ♦Genitalia/groin/buttocks ♦Back/spine ♦Each extremity

♦Constitutional ♦Eyes ♦ENMT ♦Cardiovascular ♦Respiratory ♦GI ♦GU

♦Musculoskeletal ♦Skin ♦Neuro ♦Psychiatric ♦Hematologic-lymphatic

Problem Focused: a limited exam of affected body area or organ system Expanded Problem Focused: a limited exam of the affected body area or organ system and other symptomatic or related organ sys-tems Detailed: an extended exam of the affected body area or organ sys-tem and other symptomatic or related organ systems Comprehensive: a general multi-system exam or complete exam of a single organ system

Organ Systems Body Areas

The 1995 exam rules are included here for the sake of completeness. We recommend using the 1997 physical exam rules because they are

less open to individual interpretation and therefore more likely to stand up against an audit.

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1. What

M

ER E/M Services




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By far frequecode fencouReimbabout

3 out

99281

NASFPFPF99281



99281

NASFPFPF99281


6 – 11 from any systemsEPF

12 from any systemsDet

1 – 5 from any systemsPF

2 from 9 systemsComp

BulletsExam

None1BriefEPF

1/32 – 9ExtDet

NoneNoneBriefPF

3/310ExtComp

PFSHROSHPIHx

High≥4≥4High

Mod33Mod

Low22Low

Min0 - 11SF

RiskData PtsProb PtsMDM

Requires two out of three

Problem Focused History Problem Focused Exam SF/Low Complexity MDM

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What Does a 99281 Look Like?

A 42 year

MDM Points

Self limited or minor

New problem, additiwork-up planned

New problem, no adwork-up planned

Established problemworsening

Established problem

Problems/D

1s

2,

1s

2

1

1

1

Pts

ts = 0Total

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•Parenteral controlled substances•Drug therapy requiring intensive monitoring for toxicity•Obtain DNR or de-escalate care

•Cardiovascular imaging, with contrast, with identified risk factors•Cardiac EP studies•Diagnostic endoscopies, with identified risk factors

•One or more chronic illness, with severe exacerbation•Acute or chronic illness or injury, which poses a threat to life or bodily function•An abrupt change in neurological status

High

•Prescription drug management•IV fluids, with additives

•Cardiac stress test•Cardiovascular imaging studies, with contrast, with no identified risk factors

•One chronic illness, with mild exacerbation, •Two stable chronic illnesses•Undiagnosed new problem, with uncertain prognosis

Moderate


HiMod

LoS

MDComp

Need 2 out of 3 to qualify for given level of MDM

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NA9928NA9928NA9928NA9928NA9928imeE/M Co

3 ou fy

Straightforward MDM

P


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NoneNoneBriefPFPFSHROSHPIHistory

SFPFPF99281MDMExamHistoryTarget Code

HPI

CC:

Location

History

E/M Insight: Problem Focused History The requirements for a problem

which

counts as one HPI element. That’s all you need.

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Physical ExamConstitutional Eyes ENMT Neck

Chest/Breasts

CV

Skin

culoskeletal

eurologic

ychiatric

GI GULungs

ration; wound

1 2

Rbusy

y compone

FPFDMHistory

Exam

ght: Probl

cused histor blem fo-imal, it’s diffi to qualify

one to five b ms.

e included th

That’s all you need.

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Pl

As

Ta

Medical Decision-Making

It litera All you • On• On• Min The elimited

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99281

Requires three out of three qualifying key components

One HPI Element

SF PF PF 99281 MDM Exam History Target

4 cm well heal

clean; no fluct

Plan: No f

Assessment:

HPI: The patie

from a left arm

CC: Follow-up

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SefrecoenReab

3

99282

99282



NALowEPFEPF99282

E/M Co





BulletsExam

None1BriefEPF

1/32 – 9ExtDet

NoneNoneBriefPF

3/310ExtComp

PFSHROSHPIHx

High≥4≥4High

Mod33Mod

Low22Low

Min0 - 11SF



EPF History EPF Exam Low Complexity MDM

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You see a 19 year old college student with

, PRN benadryl and Burrow's solution

MDM Points

Self limited or minor

New problem, additiwork-up planned

New problem, no adwork-up planned

Established problemworsening

Established problem

Problems/D

1

2

1

2

1

1

1

Pts

= 0Total

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•Parenteral controlled substances•Drug therapy requiring intensive monitoring for toxicity•Obtain DNR or de-escalate care

•Cardiovascular imaging, with contrast, with identified risk factors•Cardiac EP studies•Diagnostic endoscopies, with identified risk factors

•One or more chronic illness, with severe exacerbation•Acute or chronic illness or injury, which poses a threat to life or bodily function•An abrupt change in neurological status

High

additivesidentified risk factors•Undiagnosed new problem, with uncertain prognosis

•Rest•Gargles

•Laboratory tests •Chest X-rays

•One self-limited or minor problem, e.g., cold, insect bite, Minimal

Management Options

Diagnostic ProceduresPresenting ProblemsRisk


RiskData Problems MDM Complexity


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Selecting the Target Code


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History

E/M Insight: Expanded

The example qualifies by re-

viewing the CV system.

ROS

ts

HPI: T d intens

CC: “


None1BriefEPFPFSHROSHPIHistory

LowEPFEPF99282MDMExamHistoryTarget Code

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Exam

E/M Insight: Expanded Problem Focused

ms

6

5

General: NAD, conversant, well nourished WF looks stated age

Skin: Warm

7


LowEPFEPF99282MDMExamHistoryTarget Code

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Assessment:


E/M Insight: Low Complexity MDM The acuity of care required for this leve

• Low risk • The example above qualifies b

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99282

Low EPF EPF 99282 MDM Exam History Target

of low risk.

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Third mfrequecode foencounReimbabout

3 out

99283

NAModEPFEPF99283



99283

NAModEPFEPF99283






BulletsExam

None1BriefEPF

1/32 – 9ExtDet

NoneNoneBriefPF

3/310ExtComp

PFSHROSHPIHx

High≥4≥4High

Mod33Mod

Low22Low

Min0 - 11SF



EPF History EPF Exam Moderate Complexity MDM

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You see a 34 YOF

Bactrim DS BID for three

days

MDM Points

Self limited or minor (Max 2)

New problem, additional work-up planned

New problem, no additional work-up planned

Established problem, worsening

Established problem, stable

Problems/DDx

Total Points

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•Over the counter drugs•Minor surgery, with no risk factors

•Physiologic tests not under stress, e.g., PFTs•Non-cardiovascular imaging

•Two or more self-limited or minor problems•One stable chronic illness

•Rest•Gargles•Superficial dressings

•Laboratory tests •Chest X-rays•EKG/EEG, Echocardiogram

•One self-limited or minor problem, e.g., cold, insect bite, tinea corporis.

Minimal

Management Options



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Selecting the Target Code

Comp99285

99283 vs. 99284

The Three Questions

1. 2. 3.

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99283 vs. 99284

“Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of E/M service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed.”

Medicare Carrier Manual

99283 vs. 99284

Detailed

you should

“dial it down a notch” and re-test the documentation.

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Target Code: 99283

NAHighNAModNAModNALowNASF

TimeMDM

must qualify

ntation


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ROS Constitutional: Negative for fevers/chills/anorexiaGU: Negative for flank pain, hematuria

HPI:

MDMExamHistoryTarget Code

One HPI ElementDuration

None1BriefEPFPFSHROSHPIHistory

History

E/M Insight: Expanded Problem Focused History Requires a

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Exam

Physical Exam

Lungs: CTA

Constitutional Eyes ENMT Neck

Chest/Breasts

CV

Skin

Musculoskeletal

• Palpation of the skin

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Assessment: Uncomplica


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Chief Complaint: “Bu

MDM Exam History Target

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SefrecoenRab


99284

NAModDetDet99284


1 .64%2 4.5%3 25.1%4 30.0%5 39.6%


NAModDetDet99284






BulletsExam

None1BriefEPF

1/32 – 9ExtDet

NoneNoneBriefPF

3/310ExtComp

PFSHROSHPIHx

High≥4≥4High

Mod33Mod

Low22Low

Min0 - 11SF



EPF History EPF Exam Moderate Complexity MDM

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You see a 58 YOM

Self limited or

New problem, work-up plann

New problem, work-up plann

Established prworsening

Established pr

Proble

Total Points = 4Total Points = 3

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•Over the counter drugs•Minor surgery, with no risk factors•PT/OT

•Physiologic tests not under stress, e.g., PFTs•Non-cardiovascular imaging studies with contrast

•Two or more self-limited or minor problems•One stable chronic illness•Acute uncomplicated injury or

Low




Minimal

Management Options


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Target Code: 99284

99285

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ROS CV: Negative for

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Physical Exam

Lungs: Clear to auscultation and percussion bilaterally

Constitutional Eyes ENMT Neck

Chest/Breasts

CV

Skin

Musculoskeletal

Neurologic

Psychiatric

G GULungs

Vitals: 148/90, 18, 96, 98.6

CV: RRR, no MRGs

Ext: No peripheral

of peripheral

edema

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Assessment: Acute


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Chief Complaint: Abdominal pain.

HPI: The patient is a pleasant 58 YOWM who presents with intermittent le


1/3 PFSH SH

0.7

137 98

14

24

12 36

101 4.1

UA: No WBCs; RBCs TNTC

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Most

NAHighCompComp*99285






BulletsExam

None1BriefEPF

1/32 – 9ExtDet

NoneNoneBriefPF

3/310ExtComp*

PFSHROSHPIHx

High≥4≥4High

Mod33Mod

Low22Low

Min0 - 11SF



Comprehensive* History Comprehensive Exam High Complexity MDM

*For ER E/M services, only two out of three components of PFSH are needed to qualify for a comprehensive history.

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You see an elderly

1514.0

12488

17 2.1

101

1540

After reviewing the labs and the CXR, y

MDM Points

Self limited or minor (Max 2)

New problem, additional work-up planned

New problem, no additional work-up planned

Established problem, worsening

Established problem, stable

PtsProblems/DDx PtsData Reviewed

Total Points

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•Prescription drug management•IV fluids, with additives

•Cardiac stress test•Cardiovascular imaging studies, with contrast, with no identified risk factors

•One chronic illness, with mild exacerbation, •Two stable chronic illnesses•Undiagnosed new problem, with

Moderate

•Over the counter drugs•Minor surgery, with no risk factors•PT/OT•IV fluids, without additives

•Physiologic tests not under stress, e.g., PFTs•Non-cardiovascular imaging studies with contrast•ABG•Skin biopsies

•Two or more self-limited or minor problems•One stable chronic illness•Acute uncomplicated injury or illness, e.g., cystitis, allergic rhinitis, sprain

Low




Minimal

Management Options


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Target Code: 99285




99285Comprehensive HistoryComprehensive ExamHigh Complexity MDM

Plan Out the Documentation


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HPI: This is a 79 YOWM NH resident with multipl

Current MedicationsLisinopril 10 mg QD Lipitor 20 mg QD Imdur 30 mg QD 70/30 inslulin 20 BID

CC: Altered mental status


PMH: per HPI, plus dyslipidemia and CABG in 1992

HighCompComp*99285MDMExamHistoryTarget Code

2/310ExtendedComp*PFSHROSHPIHistory

History

E/M Insight: Comprehensive* History

Requires an extended HPI (four or

“history caveat” states that this will not be held against the examiner.

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P y ical

MDMExamHistoryTarget Code

Exam

E/M Insight: Comprehensive Exam

Requires at least two bullets from EACH of NINE organ systems.

The example above qualifies based on the following bullets and organ systems:

Constitutional • Three vital si• General app

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E/M Insight: High Complexity MDM Requires data points

• High risk The example above

Min0 - 1




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Chief Complaint: Altered mental status

HPI: 79 YOWM NH resident with multiple medical problems including well-

F M


2/3 PFSH PMH, SH

2.2

151 124

88

17

15 40

101 4.0

CXR: RML infiltrate

Two Bullets from EACH of NINE systems (See bullets on previous page)

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Critical Care

Critical care is the direct delivery

What is a Critical Illness?

“A critical illness

AMA CPT Manual

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Organ System Failure

Critical Care Physician Services

Critical care

frequent, personal

assessment and manipulation by the physician Withdrawal of, o

in the patient's condition

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Services Included with Critical Care

Ganz catheter (93503)

Central line (36556)

Coding for Critical Care

Add’l 30 min $103.00

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99291

Reported for 2,636,587 encounters in

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Critical Care is a Time-Based Service

99291 x 1, f) 165 - 194 minutes

3 or 99251-99255

CPT 4 CodesTotal Duration of Critical Care

Calculating Critical Care Time

side or i

performing es

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Critical Care Documentation

Must document

Critical Care in the EDd document a 992

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Services Provided

ED Visit:

Coding for this Patient

99285 (Level 5

Total Services $783.00

٭25-٭25-

Significant, separately identifiable evaluation and management*٭service by the same physician on the same day of the procedure or other Service”

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Interval HistoryCTSP stat following earlier evaluation for CHF exacerbation. Pt found unresponsive with SBP less than 80

Critical Care Coding Pearls

Add up TOTAL time

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History Physical MDM

Select the “correct” level of careLet the patient s

Peter R. Jensen, MD, CPC

Online and On-site Physician-to-Physician E/MCoding Education

1-888-U-EM-CODE

[email protected]

Practical E/M Coding Education

www.EMuniversity.com

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Documents

Rational Physician Coding for Emergency Department E/M Services and Critical Care