Guidelines Overview
- office or other outpatient services
- hospital inpatient and observation care services
- consultations
- emergency department services
- nursing facility services
- home or residence services
- prolonged services with or without direct patient contact on the date of an evaluation and management service
Classification
Broad Categories
- office visits
- hospital inpatient or observation care visits
- consultations
Office Visits
- new patient
- established patient
Hospital Inpatient & Observation Care Visits
- initial
- subsequent
Medical Decisions Making (MDM or time)
- 1st a unique code number
- 2nd place and/or type of service is specified defined by location where the face-to- face encounter with the patient and/or/family/caregiver occurs
- 3rd content of the service is defined
- 4th time is specified
New and Established Patients
- A new patient is one who has not received any professional services from the physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group of practice, within the past 3 years
- An established patient is one who has received professional services from the physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group of practice, within the past 3 years
- Emergency department: no distinction is made between new and established patients in the emergency department. It may be reported for any new or established patient who presents for treatment in the emergency department
Initial and Subsequent Services
- An initial service is when the patient has not received any professional services from the physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, during the inpatient, observation, or nursing facility admission and stay
- A subsequent service is when the patient has received professional services from the physician or other qualified health care professional or another physician of the exact same specialty and subspecialty who belongs to the same group practice, during the admission stay
- Hospital Inpatient or observation care services, a stay that includes a transition from observation to inpatient is a single stay
- Nursing facility services, a stay that includes transitions between skilled nursing facility and nursing facility level of care is the same stay
Services Reported Separately
E/M Levels
- Ordering, actual performance, and/or interpretation of diagnostic test/studies during an encounter are not included for E/M level services
- Tests that require results only and are a part of MDM do not count as individual interpretation but may be reviewed for MDM level
- Interpretations of results for tests and studies with preparation written report may be reported separately using CPT modifier 26
History and/or Examination
E/M codes that have levels of services include medical history and/or physical examination when performed. The extent of the history and physical is not an element in the selection of the level of E/M service codes
Level of E/M Services
1.) Level of MDM for each service or
2.) The total time for E/M service performed on the date of the encounter
3 to 5 Levels
- Services are not interchangeable
Guidelines for Selecting Level of Service Based on Medical Decision Making
4 Types - straightforward, low, moderate, and high
1.) The number and complexity of problems that are addressed during the encounter
2.) The amount and/or complexity of data to be reviewed and analyzed
3.) The risk of complications and/or morbidity or mortality of patient management
Number and Complexity of Problems Addressed at the Encounter
- Multiple new or established concitons may be addressed at the same time and may affect MDM
- Cormorbidities/underlying diseases are not considered in selecting a level of E/M services unless they are addressed, and their presence increases the amount and/or complexity of data to be reviewed/analyzed or the risk of complications and/or morbidity/mortality of patient management
- The final diagnosis for a condition does NOT, in and of itself, determine the complexity or risk, as extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition. Highly m orbid conditions may, “drive,” MDM even when the ultimate diagnosis is not highly morbid
** Can see Chronic and Acute definitions here**
Amount and/or Complexity of Data to Be Reviewed and Analyzed
- Tests ordered are presumed to be analyzed when the results are reported. When they are ordered in the encounter, they are counted in the encounter. When they are ordered outside of the encounter it may be counted in the encounter in which they are analyzed.
- Pulse oximetry is not a test
- When multiple results of the same unique test are composed during an E/M service, count it as one unique test
- Tests that have overlapping elements are not unique
- Review of all materials from one unique source counts as one elements to MDM
- Combination of Data Elements is an example of a unique test ordered, tests reviewed, and an independent historian would be a combination of 3 elements
- External records, communications and/or test results from an external physician
- Discussion does not need to be in person, but it does need to happen in a short amount of time, such as a day or two
- Independent historian is a parent, guardian, surrogate, spouse, or witness who provides a history of the patient who is unable to give complete or reliable history
- Independent interpretation of a test for which there is a CPT code or report that is customary
- Apporpriate source is a professional who is not in health care but may be involved in the management of the patient (lawyer, parole officer, case manager, teacher)
Risk of Complications and/or Morbidity or Mortality of Patient Management
- Risk the probability and/or consequences of an event. The assessment level of risk is affected by the nature of the event under consideration.
- For MDM purposes, the level of risk is based on the consequences of the problem(s) addressed at the encounter when appropriately treated
Guidelines for Selecting Level of Service Based on Time
- Critical Care is not time based, emergency services are usually determined on intensity base
- E/M requires face-to-face time with the physician it does not include clinical staff
