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California Medical Bill Reviewer Re-Certification
Unit 2: Official Medical Fee Schedule
Module 3: Evaluation and Management
CA Regulations Training – E & M March 2010
OverviewHi! In this module,
you will learn about evaluation and management
services, how they are classified, and
the difference between new and
established patients.
Then, you will learn about emergency
department codes, the difference
between consultations and referrals, and how same day E & M
services are reimbursed.
Let’s start by discussing how E &
M services are classified...
Classification of Evaluation and Management Services
New and Established Patients Hospital Visits Emergency Department Services Consultations and Referrals Same Day E & M Services
Classification of Evaluation and Management Services
CA Regulations Training – E & M March 2010
Evaluation and Management Guidelines
Evaluation and Management services focus on the initial understanding and diagnosis of an illness or injury, as well as facilitating the necessary treatment to cure the illness or injury.
In the OMFS, the E & M section ranges from
99201-99499.
You might recall from the Physician’s Services module that only physicians can bill for E &
M services.
CA Regulations Training – E & M March 2010
Classification of Services
Evaluation and management services are classified differently depending on the type of service as well as where the service is rendered.
Evaluation and Management can be classified as:
Office visits Hospital visits Consultations
Evaluation and management services can also be classified by intensity.
Let’s take a look…
CA Regulations Training – E & M March 2010
Classification of Services
There are seven different components that can be considered when differentiating levels of service.
The following levels of service can be assigned:
Comprehensive Detailed Expanded Problem focused
Components include: History Examination Medical decision-making Counseling Coordination of Care Nature of Presenting Problem Time
Incr
easi
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nsi
ty
CA Regulations Training – E & M March 2010
Classification of Services
But different levels of service are determined primarily by three key components.
The following levels of service can be assigned:
Comprehensive Detailed Expanded Problem focused
Levels of service are determined
primarily by:
History Examination Medical decision-making
Incr
easi
ng Inte
nsi
ty
Each component of an evaluation is assigned a level of service.
CA Regulations Training – E & M March 2010
Classification of Services
You should be aware that some E & M services only require two of the three key components to meet or exceed the requirements to qualify for a specific level of service.
These services include:
Established patient office visits Subsequent hospital care Follow-up inpatient consultations Subsequent nursing facility care Established patient home visits
CA Regulations Training – E & M March 2010
Example:
Classification of Services
In some instances, a provider spends the majority of the appointment counseling the patient or coordinating care.
If at least 50% of the visit time is taken up in counseling or coordination of care, time
becomes the criteria for service level. Documentation must note
the time spent and a description of the counseling
or care coordination.
CA Regulations Training – E & M March 2010
Classification of Services
Providers are relied upon to code their visits accurately and fairly.
However, during the review of a bill, any office visit on that bill may be evaluated for correctness of the assigned level of service. Also, utilization review
departments working on behalf of the payors and 3rd party administrators will look for patterns of abuse in provider coding.
CA Regulations Training – E & M March 2010
New vs. Established Patients
There are two types of patients within evaluation and management office visits:
New Patients Established Patients
Let’s take a look…
CA Regulations Training – E & M March 2010
New Patients
A new patient is one who is new to the physician, or an established
patient with a new injury or condition.
New Patients
CA Regulations Training – E & M March 2010
New Patients Seen By Multiple Physicians
If a patient sees different specialists within a multi-specialty medical group, each specialist is entitled to use a new patient code on the initial visit.
However, per the fee schedule, only one
physician per specialty may
charge as a new patient visit for the
same injury or condition.
If a different physician within the same specialty is on
call and sees a patient, the visit is billed as it would have been by the regular treating
physician.
CA Regulations Training – E & M March 2010
Established Patients
An established patient is one who has been seen for the same injury or
illness. Established Patients
CA Regulations Training – E & M March 2010
Established Patients
Established patients may return for a follow-up visit regarding the status of the initial illness or injury.
Follow-up visits by established patients are automated in the bill review system.
1. If a second initial visit is billed, the bill review system suspends the bill and prompts the processor to evaluate whether the same provider is billing for a second initial visit.
2. If a second initial visit is billed, the processor should substitute
with a comparable subsequent
visit code.
CA Regulations Training – E & M March 2010
Hospital Visits
Similar to office visits, there are two categories of patients within hospital visits:
Initial Visits Subsequent Visits
Let’s take a look…
CA Regulations Training – E & M March 2010
Initial Hospital Visits
The other services are not to be billed separately.
If a patient is admitted to a hospital in the course of being seen elsewhere,
including... Emergency department Observation Physician’s office Nursing facility
...all E/M services provided for that
condition are included in the initial hospital
visit.
CA Regulations Training – E & M March 2010
Example:
Suppose Mr. Johnson is seen by Dr. Gade in the office for a possible back injury.
The physician sends him to the hospital for x-rays, then sees Mr. Johnson in the ER. Mr. Johnson is admitted to the hospital
for a vertebral fracture.
Dr. Gade can charge for an initial hospital visit, but the office visit and the ER visit are included. The work and time involved in the first two encounters are considered as part of
the initial visit service level.
Initial Hospital Visits
CA Regulations Training – E & M March 2010
Initial Hospital Visits
In some instances, physicians admit patients to the hospital by phone.
If a physician admits a patient by phone, they
report the initial hospital visit code on the day they actually
see the patient.
CA Regulations Training – E & M March 2010
Subsequent Hospital Visits
Subsequent visits occur when the physician visits a hospitalized patient on subsequent days.
If the same physician, or a physician from the same specialty group visits the patient, the visit should
be billed as a subsequent visit.
Hi Mr. Jones, you are looking better today.Reimbursement for
subsequent visits differs depending on
who provides the subsequent visit.
CA Regulations Training – E & M March 2010
Subsequent Hospital Visits
However, if a physician from a different specialty group
visits the patient, the service may be billed with initial
inpatient consultation codes or subsequent hospital care
codes.
Dr. Meyer says that your
symptoms are improving.
This means that only one initial hospital visit
can be billed per patient.
CA Regulations Training – E & M March 2010
Observation Services
Prior to being admitted to the hospital, a patient is occasionally placed under observation. In these cases, observation codes are used.
There are two types of observation services:
Initial Discharge
Let’s take a look…
CA Regulations Training – E & M March 2010
Initial Observation Codes
Like other evaluation and management services, observation codes are not to be charged for post-operative care in connection with a surgical service.
Initial observation services are reported per day. It is expected that a decision will be made within a day to send the patient home or admit him to the hospital.
CA Regulations Training – E & M March 2010
Example
Initial Observation Codes
If the patient is admitted to the hospital, the
observation charges are rolled into the initial
hospital visit. But, if the patient is admitted to observation and discharged on the
same day, the only code used would be an initial admit code from 99218-
99220.
CA Regulations Training – E & M March 2010
Discharge Observation Services
Discharge observation services are only reported when the patient is discharged from the hospital on a different day than they were admitted.
Discharge observation services are indicated by CPT 99217: Observation care discharge.
CA Regulations Training – E & M March 2010
Emergency Department Services
Emergency Department Services: services rendered in a 24-hour hospital-based facility designed to accommodate immediate medical care to patients requiring unscheduled treatments.
There is no distinction between new or
established patients in the emergency department.
Emergency department (ED) codes are only to be billed for services in the ED. Services
provided elsewhere, including an urgent care center, are not eligible for emergency room
coding. In addition, for any single ED patient visit, only one
physician can report an ED E/M code. If two physicians see the patient, one may code for an ED visit and the other for
another appropriate visit.
CA Regulations Training – E & M March 2010
Emergency Department Services
Like other types of evaluation and management services, emergency department visits tend to vary with intensity.
Because of the extensive variability, time is not a descriptive component of an emergency department visit.
Emergency department visits vary with:
The number of patient encounters
Time waiting for test results
Medication Patient observation Care of other patients
CA Regulations Training – E & M March 2010
Emergency Department Codes
Instead, emergency department visits are coded by key components and the nature of the presenting problem.
Let’s take a look…
Emergency department codes vary by:
The severity of the injury or illness.
The extent of treatment.
As a result, like evaluation and management codes, emergency department codes also vary.
CA Regulations Training – E & M March 2010
Example 2Example 1 CPT 99285
CPT 99281
Emergency Department Codes
Corresponds to minor injuries or illnesses that require straightforward
examination and treatment, such as:
Emergency department visit for the treatment of poison
ivy.
Emergency department visit for the diagnosis and wrap of a sprained ankle.
Corresponds to severe injuries or illnesses that
pose an immediate threat to the patient’s life, such
as:
Emergency department visit for internal bleeding.
Emergency department visit for severe chest pain.
CA Regulations Training – E & M March 2010
Critical Care Services
If services provided in the emergency department are of a critical nature, and meet certain criteria, a critical service code may be billed in addition to the appropriate evaluation and management code(s).
Critical care services may be billed for direct delivery of
care in the ED to a critically ill or injured patient.
Critical care service criteria:
Total time delivering critical care services must be greater than 30 minutes.
Physician must be in constant attendance, or involved in treatment directly.
Separate documentation of critical care services must be included.
Separate documentation is important because unlike other ED services, critical care services are paid by
time rather than key components and the presenting problem.
CA Regulations Training – E & M March 2010
Consultations and Referrals
Evaluation and Management services are also distinguished by:
Consultations Referrals
Let’s take a look…
CA Regulations Training – E & M March 2010
Consultations
A consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.
Consultations
The physician may order diagnostic tests in order to form an opinion regarding the
patient’s diagnosis.
CA Regulations Training – E & M March 2010
Consultations
In order for a visit to be classified as a consultation, the three “ROs” must be met.
pinion
equest for an pinion endering an pinion
eport of an
CA Regulations Training – E & M March 2010
Referrals
A referral constitutes the transfer of the total or specific care of a patient from one physician to another.
Referrals do not constitute a consultation.
Referrals
CA Regulations Training – E & M March 2010
Referrals
If the referring physician writes “eval and treat” they are, in essence, referring the patient to the other physician and not asking for an opinion.
This is true even if the specialist sends a report to the referring physician, which is considered only a professional courtesy.
CA Regulations Training – E & M March 2010
Where might you find documentation of the
referral?
Referrals
Sometimes, a physician refers a patient to another physician without a written or verbal request for a consultation.
The patient referral should be documented in
the patient’s records.
In these instances, the referral should be reported using office codes, outpatient codes (99201-99215), or subsequent hospital care codes.
CA Regulations Training – E & M March 2010
Same Day E & M Services
There are instances when a provider bills for an E&M twice on the same day.
Let’s take a look…
Before denying the charge as a
duplicate, you must check the provider’s
documentation carefully. There are instances when the
charges are allowable.
CA Regulations Training – E & M March 2010
Same Day E & M Visits
“I am glad he came in
again…we should be able to repair the damage…”
“You should be fine…come back in if you continue
to experience symptoms…”
Subsequent E & M visits are allowable if:
Charges are for different specialists in the same group.
The patient experienced difficulties or complications that required a second trip to the office or emergency room.
CA Regulations Training – E & M March 2010
Same Day E & M Visits
A modifier indicates subsequent E & M services on the same calendar day.
Modifier –19: Subsequent E & M services within the same calendar day.
This modifier must be used with the associated E & M
code to bill for subsequent visits.
An explanation An explanation that documents that documents
the the circumstances circumstances must also be must also be included with included with
the bill.the bill.
CA Regulations Training – E & M March 2010
Summary
How E & M services are classified and who can bill them.
The difference between new and established patients.
Emergency department service codes.
Same day E & M services: What is allowable?
The difference between consultations and referrals.
Patients seen by multiple physicians.