OK, let's continue with Chapter 7 Part 2
We are going to go through the review questions at
the end of the chapter as well as some
other topics that I would like to discuss
and that will be on the exam for this
chapter. (Chapter 7 Review) #2-A new patient was seen
in the physician's office for abdominal
pain.The physician performs a detailed
history and comprehensive exam, medical
decision making is of moderate
complexity. I've answer those questions
that I advised you in the first part of
this podcast, Part 1, that you would ask
as a coder. It is an Office (visit) or other
outpatient service. The fact that it is
initial or subsequent or critical care
does not apply in this case. It takes
place in the physician's office and it is
a new patient, which is what the
documentation tells us. So having
answered those questions, we look up in
our index the main term "evaluation and
management", sub term "Office and other
outpatient" and we get code range of 99201-99215
and when we go
to those codes and read through the
descriptors, we want to find the code
that properly reflects a detailed
history, comprehensive exam and moderate
complexity medical decision making. I
recommend looking at the tables there in
the front of the CPT code book.
There's one for Office and other
outpatient services for a new patient.
Look for those and you see that a new
patient has to have all three key
elements and that means when you look at
that table, you cannot choose 99204
because that would require a
comprehensive history, a comprehensive
exam and moderate medical decision
making. So we cannot choose 99204 so we
drop down a level to 99203 and that
allows us to capture that detailed
history. It was not comprehensive,
so we had to drop down to the 99203
code for new patient. (Chapter 7 Review) #4, New patient again, physician's
office, expanded problem focused history,
a detailed exam and low complexity
medical decision making. Evaluation and
management is the main term, Office and
other outpatient services is the subterm,
the same code range 99201-99215
I would look again at
the E/M tables near the front of CPT
code book under Office or other
outpatient services, for the new patient.
Again, it needs all three elements so we
cannot choose 99203 because our
history is not advanced enough. We would
drop down to level 99202. (Chapter 7 Review) #6
A physician provides E/M services for
a patient in acute hysteria admitted to the
ED (Emergency Department). So the ED is now your place of
service and you're going to be looking
at codes that reflect that. "Evaluation
and management" is the main term with
"Emergency department" as your sub term,
giving you a different code range. Now
you're in 99281 through 99288. Look at
the tables again and the front of cpt
code book under Emergency Department and
you see that it doesn't matter if you
are a new or an established patient, you have
to have all three key elements to assign
a code. Code 99281 is problem focused
history, problem focused exam and
straightforward medical decision making.
(Chapter 7 Review) #8 We're back in the
physician's office, with an established
patient. This is a problem focused
history, expanded problem focused exam,
and low complexity medical decision
making. Go back to the tables, looking at
"Established" patient this time. Established patient,
under the Office or other outpatient
services with an established patient, you
only have to have two of the three
required components to assign a code. We
have two of the required components to assign
99213 so that's the code that
we select.
(Chapter 7 Review) #10. You have a patient being
seen in the doctor's office, again a new
patient. Go back to the same tables. You
can either use the index or the tables.
To me, the tables are the most helpful. You
do not have the comprehensive exam needed
to assign 99204 so we must drop down a
level to 99203. There may be other logic that
you may read about or understand to help
you select the right code but to me when
I see that I have two of three elements to
assign a certain code but I don't have
three (elements), I just drop down a level to the
next lower level and that gives me the
right answer. That may not make sense to
some of you and there may be other ways of
looking at that logic. That seems to work
for me. (Chapter 7 Review) #12 You've got an
established patient, back in the doctor's
office, much more information given in
the documentation with a detailed
history, expanded problem focused exam,
and moderate complexity decision making.
Go back to our tables for an established
patient. You have two of the three
required components and we have two of the 3 (components) to
assign 99214. We have detailed
history and medical decision making of
moderate complexity.
Here's an example not in the textbook.
It's important for you to know this and it
will be on an exam. A patient diagnosed
with hypertension visits her
physician's office on a monthly basis.
The nurse conducted the blood pressure
check under the physician's supervision.
Code the office visit. What we do not
have is the physician seeing the patient.
But we do have a situation where someone,
another qualified healthcare provider, is
providing a service under the physician's
supervision. There's only one code and
in the Office visit range of codes that
fits that description and that is 99211.
It is assigned for a visit that does
not or may not require the presence of a
physician. It is a very low level code and probably
has a low level reimbursement tied to it.
I'm not sure. But it is often a test
question and one that you should be
familiar with. Another example, not in the
textbook, is Nursing Facility Care. You
notice that we have a Skilled Nursing
Home Visit, date of service is 1-9-14 and the
last date of treatment was 12-22-13. The
fact that the last date of treatment is
listed tells us that this is not an initial
visit; this is a subsequent visit. So we look
at the subsequent visits in the nursing
facility. The documentation tells us
it's a detailed interval history,
comprehensive exam and (moderate complexity) medical decision
making. There is a subsequent nursing
facility care table that we can use.
It requires two of three components and we
have those: detailed interval history and
moderate complexity medical decision
making. It takes us to 99309. Here's another
example, not in the textbook, and one
that we often see on exams. Case
management services for anticoagulation
management. I have some history here
for this so you could understand why a
patient might be receiving warfarin. The
drug is called warfarin or coumadin and
either one, it's
the same drug, either
name and it is an anticoagulant that keeps
the blood from being too
thick, meaning clotting too easily. When a
patient has a valve replaced, in this
case, our patient is having an aortic valve
replaced, the consistency of the patient's
blood has to be monitored. You'll
hear someone refer to the blood being
"too thin" or "too thick". "Too thin" means the
patient is bleeding too easily and "too thick" means
the patient's blood is clotting too
easily. So there's a management there of
that level to be sure that the patient is
getting the correct amount of the
anticoagulant. The test that's conducted is
called an INR or a blood coumadin test
because the physician is looking at
those values for the INR to determine
and adjust the patient's Coumadin
medication. The results are evaluated by
the physician, and those needing (it adjusted) is adjusted.
So in this case Mr. Nicholson is seen in
the physician's office for
anticoagulation management since his
aortic valve was replaced. What
CPT code would the physician
bill for the monitoring and management
of the warfarin (Coumadin) therapy for the initial
90 days of therapy? When you look in the
Index, I do not find this code so it's
important for you (if you find
it let me know so I can adjust my slides)
but I could not find it. I instead went
to the E/M chapter, looked in the Table
of Contents because I know it's there.
I found the case management services and
then found those codes for
anticoagulation management. You see that
99363 is for the initial 90 days of
therapy with a minimum of eight INR
measurements and in 99364 is for each
subsequent 90 day period with a minimum
of three INR measurements. There are
guidelines just above these codes in the
CPT code book that tell you exactly how
you would assign these codes.
Another example, not in the textbook, but
one that you will see on exams is
prevention. Preventive Medicine Services.
The case we've been given is an established
patient, 55 years old, was seen for his
annual physical. He has significant pain,
soreness, redness and heat in his right
extremity. The condition requires the
physician to ask additional questions in
his history, do additional examinations
and evaluate through medical decision
making if this patient has phlebitis,
which is like an inflammation of a
vein in his extremity. In a case like
this, both the preventive service code
and the problem oriented service code
are going to be reported.There are
guidelines just in front of these codes
in preventive medicine that tell you
when an abnormality is discovered during a
preventive medicine session, the
appropriate Office Visit code should also
be reported if the condition proves
significant enough to require additional
work up. It did in our scenario.
Modifier -25 is added to the Office Visit
code to indicate that the same physician
provided a significant and separate E&M
service on the same date as a preventive
medicine service. So you have your
preventive medicine service code first,
99396, which is selected based on the
patient's age. Our patient's 55 and that
takes us to 99396 code. Then we know
we're going to use an E/M service code. I
select a problem focused because it's
really all the documentation tells us and
that would take us to 99212 and I
added a modifier -25 to indicate to
the payer, the insurance company, that the
same doctor provided these two services
to the same patient during the same
visit. If you don't add that modifier, the
doctor is not going to get paid for one of
those. The insurance company has software
that's going to pick up on that the fact
that you're billing two E/M codes for the
same date of service
so that -25 modifier alerts the insurance
company this is a different situation.
This modifier indicates that this
physician did indeed provide two services
to the same patient, the same date and
the same episode of care. Let us talk for
a bit about Critical Care services. This
category involves the care of critically
ill patients and a medical emergency
that requires the constant attention of
the physician. The constant attention does
not have to be continuous on a given
date. In other words, he can be in constant
attendance for a four-hour period, walk
away, do something else, come back four
hours later, come back for another two
hours to be in constant attendance with
this patient. So time documentation is so
so important when we're using critical
care codes. The types of emergencies that
might require this kind of service would
be a cardiac arrest, a patient in shock,
bleeding, respiratory failure or severe
post-operative complications. There is a
coding tip in your CPT code book that you
should always be looking for. They're
so helpful and they outline which
services are included in these critical
care service codes. For example, pulse
oximetry where the patient has a little
thing on his finger that's going to
indicate his oxygen level. That's one
thing that would be covered under
critical care services so that you are
billing appropriately. You need to know
for sure what is coming with that code.
If you have services being provided that
are not covered under that code, then
you would want to be coding for those.
You always want to read those coding
tips. If your patient is a neonatal or a
pediatric patient, those are different
codes so be sure that you make a mark
somehow in your code book to know these
are adult codes and these are the
babies, the neonatals and the pediatric
or the patients younger than 24
months. Time is a key factor when you're
selecting a critical care code so you
will always be watching for that
documentation.
Code 99291 is the first 30 minutes
through 74 minutes on a given date.
That's reported only once per date. If
you have additional time after that
first 74 minutes, that would be code 99292
for each additional 30 minutes of
care. So depending on your scenario, you
might have 99292 reported several times
to account for each 30-minute period.
Critical care of less than 30 minutes is
reported with an E&M code. For example, if
it's an inpatient, you'd probably be
coding under a subsequent Hospital
Inpatient services category. Read the
guidelines found just in front of the
critical care services codes. These
address ambulance transport, those doctors
who are in attendance with the people
caring for the patient while the patient
is being transported. As I said earlier,
time spent with the patient is recorded in the
patient's record. Any time spent in
activities that occur outside the unit,
off the floor or elsewhere in the
hospital may not be reported (as) critical
care because in those cases, the
physician is not immediately available
to the patient. Here's an example, not in the
textbook, Critical Care Services, you will
see this on exams. The first hour of
critical care of a 65 year old male with
septic shock following relief of ureteral
obstruction caused by a stone. You
see when you go to the Evaluation and
management as your main term, critical care
is your subterm, takes you to that range
of code either 99291 or 99292. The
selection of the code depends on the
amount of time that's documented in the
patient's record. This documentation
tells us the first hour, which is the
first 60 minutes so that's going to fall
within the range of thirty to seventy
four minutes, which takes us to code 99291.
Same situation, but notice that after the
first hour, the physician left the nursing
floor and went to his office where he
telephoned the patient's family
physician. Can the physician bill
critical care service for the time he
spent talking to the family physician in
the office. The answer is he cannot.
He cannot bill critical care because when
he was talking to the family doctor in
his office, he was not available to the
patient and the guidelines tell us that
time spent in activities that occur
outside of the unit or off the floor may
not be reported at critical care since
the individual is not immediately
available to the patient. Please please
pay attention to these last few slides.
You will see these on the exam and I
want to be sure that you have read about
them in your textbook and in the CPT
code book and be familiar with them. Any
questions related to the Chapter 7 Part 2
Review, please post them in
discussion board and I will answer them.
I hope you have a good day.
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