MCCG 240 Week 7 Portfolio Project Final Submission- Ciara Santos
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Ciara Santos
12/10/2023
MCCG 240
Week 7: Portfolio Project Final Submission
Chapter 1: New and Established Patients
Evaluation and management coding is a medical coding process in support of medical
billing. E/M codes were designed to classify services provided by physicians in evaluating
patients and managing their medical care. E/M services represent a category of CPT codes used
in the billing process. It is important to remember that most patient visits require an E/M code
for billing. E/M codes are contributing components of a physician’s service to determine the
level of services that are provided. According to CMS all E/M codes must contain Place of
Service and Type of Service codes. Place of Service codes are two-digit codes placed on health
care professional claims to indicate the setting in which a service was provided. Some examples
of these types of codes are physician’s office, hospital, emergency department, and nursing
home. Type of Services codes are the reasons the service is requested or performed. Some
examples of these codes are hospital admission, office visit, consultation, and observation.
Evaluation and management coding is a medical coding process in support of medical billing.
E/M codes were designed to classify services provided by physicians in evaluating patients and
managing their medical care. E/M services represent a category of CPT codes used in the billing
process. It is important to remember that most patient visits require an E/M code for billing.
E/M codes are contributing components of a physician’s service to determine the level of
services that are provided.
Evaluation and management punctuation is a system of symbols and abbreviations used
to streamline medical documentation. The system includes symbols for common medical terms
and abbreviations for common diagnoses, medications, and procedures that are performed. The
E/M punctuation system was created by CMS to help improve the consistency and clarity of
physician documentation. Use of E/M codes help to systemize the medical record. Following a
standardized system of punctuation and abbreviations helps to make it easier to understand the
medical record in general. Common E/M punctuation marks include parentheses, dashes, and
brackets. Parentheses are used to enclose information that may not be essential to the main
documentation. Common E/M punctuation marks include parentheses, brackets, and dashes.
Parentheses are used to enclose information that is not essential to the main documentation,
such as the date of a procedure or the patient's weight. The E/M punctuation system was
developed by the CMS to improve clarity but is not mandatory. Abbreviations are often used in
medical coding to reduce medical transcription. Using an abbreviation such as E/M for
Evaluation and management helps to shorten commonly used words within physician notes.
An Add-On code is a HCPCS and CPT code that describes a service that is performed in
conjunction with the primary service by the same physician. An Add-On code is very seldom
eligible for payment or reimbursement if it is the only procedure reported by a physician. CMS
divided Add-On codes into three types of Add-On codes to help differentiate the payment
model for each. Type one AOC has a limited number of identifiable primary procedure codes.
Type one is eligible for payment if one of the listed primary codes is also eligible for payment to
the same physician for the same patient on the same date of service. Type two AOC can be
listed without any primary procedure codes and is eligible for payment if an acceptable primary
procedure code is used for the same physician for the same patient on the same date of service.
Type 3 AOC can be listed only with the primary procedure codes that are specifically identifiable
is eligible for payment if used for the same physician for the same patient on the same date of
service. CPT symbols are the symbols commonly used in CPT reference coding books. The bullet
to the left of the code indicates this is a new code that has never been used before. Triangle
located to the left of the code indicates the code description has been revised in the current
edition of the CPT. These are just a few examples of CPT code symbols that may be found in the
current edition of the CPT. It is imperative that coders pay attention to CPT code symbols and
Add-On codes to avoid having a claim denied and loss of revenue.
The difference between a new patient and an established patient is that an established
patient is an individual who has received professional services from his or her physician or
another physician within the same specialty from the same group practice, within the past three
years. A new patient is an individual who has not received any professional services from a
physician within a certain specialty group, within the past three years. Place of Service is a two-
digit code used on medical claims to indicate the setting in which a service was provided. Type
of Services codes refer to the procedures and/or service the patient experienced. Types of
Service codes are used mainly to collect data that may affect payment at times. Place of Services
codes tells insurance companies where the patient received services and Types of Services
codes tell insurance companies what services were performed.
Evaluation and management punctuation is a system of symbols and abbreviations used
to streamline medical documentation. The system includes symbols for common medical terms
and abbreviations for common diagnoses, medications, and procedures that are performed.
Symbols for add on codes are important because add on codes are reimbursable services when
reported in addition to the appropriate primary service by the same individual physician or
other health care professional. It is important to note that add on codes reported as stand-
alone codes are not reimbursable services in accordance with CPT and the Centers for Medicare
and Medicaid Guidelines. The E/M punctuation system was created by CMS to help improve the
consistency and clarity of physician documentation. Use of E/M codes help to systemize the
medical record. Following a standardized system of punctuation and abbreviations helps to
make it easier to understand the medical record in general. Common E/M punctuation marks
include parentheses, dashes, semi colons, and brackets. Parentheses are used to enclose
information that is not essential to the main documentation, such as the date of a procedure or
the patient's weight. Dashes are used for setting off additional information such as examples,
descriptive phrases, or supplemental facts. Semi colons are used for saving time and space to
avoid having to type the entire description each time. Brackets, another common E/M
punctuation mark, is used in addition to the disease or condition to identify an associated
manifestation. It is important to remember there are special meanings for stand-alone codes
and indented codes. Indented codes have important variations on the code above them and
denote different methods, outcomes, and/or approaches. The E/M punctuation system was
developed by the CMS to improve clarity but is not mandatory. Abbreviations are often used in
medical coding to reduce medical transcription. Using an abbreviation such as E/M for
Evaluation and management helps to shorten commonly used words within physician notes.
Some examples of typical abbreviations within the E/M section of CPT are MDM (Medical
Decision Making), HPI (History of Present Illness), PFSH (Past Family Social History), Chief
Complaint (CC), and Review of Systems (ROS) to name just a few. Using abbreviations within the
health care field helps standardize the use of medical language in order to avoid errors when
documenting a patient’s condition and/or medical needs.
An Add-On code is a HCPCS and CPT code that describes a service that is performed in
conjunction with the primary service by the same physician. An Add-On code is very seldom
eligible for payment or reimbursement if it is the only procedure reported by a physician. CMS
divided Add-On codes into three types of Add-On codes to help differentiate the payment
model for each. Type one AOC has a limited number of identifiable primary procedure codes.
Type one is eligible for payment if one of the listed primary codes is also eligible for payment to
the same physician for the same patient on the same date of service. Type two AOC can be
listed without any primary procedure codes and is eligible for payment if an acceptable primary
procedure code is used for the same physician for the same patient on the same date of service.
Type 3 AOC can be listed only with the primary procedure codes that are specifically identifiable
is eligible for payment if used for the same physician for the same patient on the same date of
service. CPT symbols are the symbols commonly used in CPT reference coding books. Bullet to
the left of the code indicates this is a new code that has never been used before. Triangle
located to the left of the code indicates the code description has been revised in the current
edition of the CPT. These are just a few examples of CPT code symbols that may be found in the
current edition of the CPT. It is imperative that coders pay attention to CPT code symbols and
Add-On codes to avoid having a claim denied and loss of revenue.
Prolonged Evaluation and Management Service code 99358 is a code used to describe a
prolonged E/M service involving ongoing patient management of a service or patient face-
toface patient care has been performed or will be performed in the future. It is important to
note that E/M Service code 99358 cannot be used to bill for patient wait time. Always
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remember that E/M Service code 99358 is for the first hour of non-face-to-face services and
may only be billed before or after direct patient care. The difference between a new patient and
an established patient is that an established patient is an individual who has received
professional services from his or her physician or another physician within the same specialty
from the same group practice, within the past three years. A new patient is an individual who
has not received any professional services from a physician within a certain specialty group,
within the past three years. Both new and established patients share the same key elements
such as patient history, physical examination, and medical decision making. However, time is the
exception between these two as new patients require three of the three key elements be met
whereas established patients only need two of the three elements to be met. Why is time the
exception you ask? An exception to this rule is the case of visits which consist predominantly of
counseling and/or coordination of care; for these services time is the key factor to qualify for a
particular level of E/M service.
References:
Why accurate spelling and pronunciation of medical terms are important in healthcare settings?
(urhelpmate.com)
CBHC-2013-Billing-Add-on-codes-Handout-3.pdf
Place of Service Codes | CMS
Evaluation and Management Coding, E/M Codes - AAPC
New Vs Established Patient (aap.org)
Home - Centers for Medicare & Medicaid Services | CMS
Medical Coding - Medical Billing - Medical Auditing – AAPC
Chapter 2: Medical Decision-Making
The levels of Evaluation and Management Services recognize four types of medical
decision-making. These four types are known as straightforward, low complexity, moderate
complexity, and high complexity. To determine the type of MDM needed we must first consider
three factors. The first factor is the number of diagnoses and/or management options the
provider must consider. The next factor is the complexity of medical records, diagnostic tests,
and other data the provider must obtain to review and analyze the patient. The third and final
factor is the risk of complications, morbidity, comorbidities, and/or mortality associated with
the patient’s presenting problem, diagnostic procedures required, and management options for
treatment. When determining MDM elements required for each type of MDM in E/M coding
must meet or exceed two of the three factors previously listed. Straightforward MDM is minimal
number of diagnoses or management options, minimal or no complexity of data required, and
minimal risk of complications and/or morbidity. Low complexity MDM is limited number of
diagnoses or management options, limited amount of data required, and low risk of
complications and/or morbidity is required. Moderate complexity MDM is multiple number of
diagnoses or management options, moderate amount of data to be reviewed, and moderate
risk of complications and/or morbidity is required. High complexity MDM is extensive number of
diagnoses or management options, extensive amount of data required to be reviewed, and high
risk of complications and/or morbidity is required.
With the first element the importance is the number of diagnoses and/or management
options that the provider has to offer the patient. Certain guidelines must be followed and/or
met to determine how complex a patient problem is. The main guideline is to offer general
advice, indicating that a diagnosis is less complex than an undiagnosed problem or one that is
getting worse. Providers tend to use the Marshfield tool to provide a more definitive approach
to selecting a level of MDM. The Marshfield tool uses a point system to assist providers in
selecting a level of MDM. After adding up the points the provider will translate them to levels
identified in the column for the number of diagnoses and/or management options. One point
equals minimal, two points equal limited, three points equal multiple, and four points equal
extensive. An example of this element might be established problem, improving, 1 point each.
The second element that is used when determining MDM type is the complexity of data
related to the encounter. Each point tool is used to provide a list to help calculate the MDM
element. The score will help determine the correct level for this element. 0-1 point equals
minimal, 2 points equal limited, 3 points equal moderate, and 4 points equal extensive. An
example of the second element point system is reviewing of old records or obtaining history
from someone other than the patient and then discussing that data with another healthcare
professional would count as 2 points.
The third element, also known as the level of risk, involves three categories. These three
categories are presenting problem(s), diagnostic procedures ordered, and management options.
For this element, it is advised that the MDM Table of Risk for E/M coding is used. The four levels
of risk are minimal, low, moderate, and high. An example of a moderate risk according to the
MDM table may be two or more stable chronic illnesses, diagnostic endoscopies with no
identified risk factors, and elective major surgery with no identified risk factors.
Modifiers are important to coding to clarify what occurred during an encounter. The use
of a modifier allows a code to be altered by a specific circumstance without changing the
definition of the actual code. Using a modifier also allows for more coding accuracy and
specificity. Some examples of modifiers coders use are modifier 25, 27, 24 and 57. Modifier 25 is
used to code an E/M service that occurs when another service is performed by the same
provider, on the same day. Modifier 27 is used to code multiple outpatient hospital E/M
encounters that occur for the same patient on the same day. Unlike modifier 25, modifier 27 is
used only for hospital outpatient E/M services such as emergency room visits. Modifier 24 is
used to indicate that an unrelated E/M Service was provided by the same physician during a
postoperative period. It is also important to note that with modifier 24, Other “same-specialty
physicians” are included in the definition of “same physician” for the purpose of using this
modifier. Modifier 57 is used to code an E/M service performed on the same day or the day
before a major surgery that resulted in the decision to perform the procedure. The key
difference between modifiers 25 and 57 is that modifier 25 is used for coding for minor
procedures whereas 57 is used for coding for major procedures. A great case scenario example
for appropriate use of modifier 25 would be as follows, “A patient visits the cardiologist for an
appointment complaining of occasional chest discomfort during exercise. The patient has a
history of hypertension and high cholesterol. After the physician completes an office visit it is
determined that the patient needs a cardiovascular stress test that is performed that day by the
same physician.”
References:
Appropriate Use of Modifier 25 - American College of Cardiology (acc.org)
Using Modifier 24: Understand the Rules of the Game (physicianspractice.com)
Thinking on Paper: Documenting Decision Making | AAFP
Medical Decision Making | ACS (facs.org)
Chapter 3: Evaluation and Management Guidelines Review
In the Evaluation and Management Services section of the CPT code book, sections
99202-99499, there are many code categories with specific details and/or guidelines. These
specific guidelines were written for seven categories. These seven categories include Office or
Other Outpatient Services, Hospital Inpatient and Observation Care Services, Consultations,
Emergency Department Services, Nursing Facility Services, Home or Residence Services, and
Prolonged Service with or without Direct Patient Contact on the Date of an Evaluation and
Management Service. Keep in mind that even though the E/M Section is divided into broad
categories as previously listed, it is important to note that most of these seven E/M categories
have subcategories as well. These subcategories are further classified into levels of services that
are identified with specific and identifiable codes. It is imperative that we remember that when
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coding for any E/M service, we must consider the place of service (where), the type of service
(what), and the patient’s status (new or established).
The first category of E/M services is Office or Other Outpatient Services (99202-99215).
The subcategory for this category is used in determining whether the patient is a new or
established patient. A new patient is a patient that has not received any services from the
physician or other qualified health care professional or another physician or other qualified
health care professional of the same specialty or subspecialty who belongs to the same
practice, within the past three years. An established patient is the exact opposite as it refers to a
patient that has received services from the physician or other qualified health care professional
or another physician or other qualified health care professional of the same specialty or
subspecialty who belongs to the same practice, within the past three years.
The next category is Hospital Inpatient and Observation Care Services (99217-99239).
Hospital observation services are a set of specific services which include ongoing short-term
treatment, assessment, and re-assessment before a decision is made regarding whether a
patient requires further treatment as an inpatient status. The patient is considered outpatient if
they are receiving emergency room services, observation services, lab tests, surgery, or x-rays
and will remain in outpatient status until a physician writes an order to admit you to a hospital
as an inpatient. One important factor to keep in mind is that a patient is still considered an
outpatient even if the patient stays overnight in the hospital. When coding for this category it is
important to remember that “total time” on the date of the encounter is by calendar date.
When using total time for code selection, a continuous service that spans the transition of two
calendar dates is a single service and should be reported as such.
Consultations is the next category and is a type of E/M service provided at the request of
another physician, other qualified health care professional, or appropriate source to
recommend care for a specific condition or problem with the patient (99241-99255). It is
important to note that a consultation initiated by the patient and/or the patient’s family and
does not meet the criteria mentioned previously, is not reported using the consultations
category. The results of the consultation must be communicated by a written report to either
the requesting physician or other qualified health care professional. This report must contain
the consultant’s opinion and any services that were ordered or performed by the consultant.
The Emergency Department Services section contains codes that are used to report E/M
service codes provided in the emergency department (99281-99288). Within the emergency
department services section there is no distinction between new and/or established patients. It
is important to note that time is not a descriptive component for the emergency department
levels of E/M services coding. Emergency department services are typically provided on a
variable basis that often involve multiple encounters with several patients over an extended
period. Other Emergency Services (99288) may include Critical Care Services (99291-99292).
Critical care is the direct delivery by a physician and/or other qualified health care professional
of medical care for a critically ill or critically injured patient. Total duration of critical care (in
minutes) is used when reporting E/M service Critical Care Services.
Nursing Facility Services (99304-99316) are codes used to report E/M services of
patients in nursing facilities and/or skilled nursing facilities. It is important to note that these
codes should also be used when coding patients in psychiatric residential treatment centers
and/or immediate care facilities for individuals with intellectual disabilities. Two major
subcategories of this section of the E/M services are Initial Nursing Facility Care and Subsequent
Nursing Facility Care. This E/M Services section does recognize new versus established patient
care. The key difference between Initial and Subsequent Nursing Facility Care is that an Initial
Nursing Facility Care service can occur on a different date than the admission date and occur in
a physician’s office, hospital, and/or Skilled Nursing Facility. Whereas a Subsequent Nursing
Facility Care is per day, for the evaluation and management of the patient and also requires 2 of
the 3 key components: An expanded problem focused interval history, an expanded problem
focused interval history, an expanded problem focused examination, and medical decision
making of low complexity.
Home or Residence Services section (99324-99350) are codes used to report E/M
services of patients that are provided in a home or residence setting. It is important to
remember that the term “home” may be defined as any private residence, temporary lodging,
or short-term accommodation that the patient is living in. It is also important to note that this
section of E/M services does recognize new patient versus established patient for coding
purposes. Domiciliary, Rest Home, Custodial Care Services, and Home Services all fall under the
Home or Residence Services section of evaluation and management. When selecting code level
it is important to remember that travel time does not count. This means that only the time
spent in the home or residence may be used to determine the appropriate code used.
The last category to discuss is Prolonged Service with or Without Direct Patient Contact
on the Date of an E/M Service (99358-99418). This service is to be coded with other physician
or other qualified health care professional services, including but not limited to, E/M services at
any level, on a date other than the face-to-face service to which it is related. It is important to
remember that Prolonged Service with or without direct patient contact may only be reported
when it occurs on a date other than the date of the evaluation and management service. Time
spent performing separately reported services other than the primary E/M service and
prolonged E/M service is not counted toward the primary E/M service and prolonged services
time.
Initial Services are services reported on the date of admission by the admitting
physician. Any other services performed on other dates occurring after the date of admission
are reported with Subsequent service codes. With Initial Services three out of three component
requirements must be exceeded or met whereas with Subsequent services only two of the
three components are required to be met. The E/M service coding based on key components
are types of history, types of examination, and four types of MDM (medical decision making).
History entails problem focused, expanded problem focused, detailed, and comprehensive.
Examination also entails problem focused, expanded problem focused, detailed, and
comprehensive. MDM is listed from lowest to highest as straightforward, low complexity,
moderate complexity, and high complexity.
References:
Evaluation and Management Coding, E/M Codes - AAPC
Observation Care Codes – BIG Changes for 2023 - American Institute of Healthcare Compliance
(aihc-assn.org)
https://www.cgsmedicare.com/partb/pubs/news/2013/0313/cope21584.html
Chapter 4: Level of E/M Service – Medical Decision Making and Time
Now that we have a much better understanding of Evaluation and Management coding
principles and guidelines let’s look at a patient case. I have chosen Patient Case Number
OPC120-Giles, Roderick to use as my coding example for this part of the training. Patient Giles is
a 53-year-old male being seen in the office with a chief complaint of Bilateral Hand Pain. Patient
Giles was last seen by this provider 3 months prior. This patient has a history of Rheumatoid
Arthritis and is currently on two different medications for his RA. Patient Giles states that one of
his medications, Humira is currently not helping with his condition. This patient also has a
known history of lung lesions that is being closely monitored by his pulmonary physician. The
patient is requesting the medication for his RA be changed. It is also important to note that this
patient was seen in this office 3 months prior by another physician and this is a requested visit
by said physician of the same specialty.
The first thing we want code for this patient is Rheumatoid Arthritis, unspecified which is
ICD-10-CM code M06.9. The next step is to code M51.36 to specify a medical diagnosis for the
intervertebral disc degeneration, lumbar region. This ICD-10-CM code is the correct code
needed for this scenario as the case scenario lists DDD of lumbar spine as a secondary
diagnoses code. Key point for this code is degenerative disc disease of lower back. This case
scenario requires we code the medications as well. Medications are coded to ensure that coders
are always coding to the highest specificity. The most important part of a medical coders job is
to ensure that all the coding and billing information is accurate and correct. The next three ICD-
10-CM codes for this case scenario are Z79.1 (Long-term (current) use of non-steroidal anti-
inflammatories (NSAID), Z79.620 (Long-term (current) use of immunosuppressant), and Z79.899
(Other Long-term (current) use of immunosuppressive biologic (etanercept). The last code
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needed for this scenario is the Evaluation and Management code. We know this patient was
seen 3 months prior by another physician in the same specialty/practice. The key points with
the E/M code are time spent, more than 60 minutes, and medically appropriate history and/or
examination of high level of medical decision making. The correct E/M code for this case
scenario should be 99245 Outpatient visit of a new patient, estimated time between 60-74
minutes, extensive examination and adjustment of medications, plus documented Time, helps
support the highest E/M Service code 99245.
References:
Humira: Uses, Dosage, Side Effects, Warnings - Drugs.com
Search Page 1/1: enbrel (icd10data.com)
Medical Coding: A Critical Role in Healthcare Today (imbc.edu)
Importance of Accurate Medical Coding in Healthcare – InsuranceNewsNet
Chapter 5: Level of E/M Services – Medical Decision Making
For this case scenario we have Estel Capleton who is a new patient being seen in the
office for a hospital follow up. Patient Capleton has a large ovarian mass that appears to be
malignant but is causing said patient moderate to severe pain in left lower abdomen. The E/M
code we would use for this patient would be 99204-57. This CPT code requires a medical
decision-making level of moderate with a medically appropriate history or examination. An
average session length for an initial 99204 E/M session such as this scenario, is around 45-59
minutes. 99204-57 Office, New Patient, Moderate medical decision-making, prescription for
Norco, and plan for laparotomy. The use of the required modifier is explained in further detail
below.
Now that the MDM has been determined for this patient, we must determine the
diagnoses code(s) needed for this case scenario as well. In the ICD-10-CM Index to Diseases and
Injuries we should reference Cystic with sub term Ovary. There we will see the ICD-10-CM
codeN83.20 with the symbol for additional character needed. The next step we would need to
take is to verify code N83.20 in the Tabular List. The Tabular List states that this case scenario
would require code N83.209 for unspecified ovarian cyst, unspecified side.
Next, we would go back to the ICD-10-CM Index to Disease and Injuries and reference
Pain with sub term Chronic. The code we are given would be G89.29. Next, we would verify
G89.29 in the Tabular List which states G89.29 Other Chronic Pain is the correct code for this
patient case scenario.
The next step for this patient case scenario would be to visit the ICD-10-CM Index to
Disease and Injuries once again to reference Drug with sub term Therapy. The code given is Z79
Long term, current drug therapy. To verify this code, we would need to turn to the Tabular List
which states code Z79.1 Long term use of non-steroidal anti-inflammatory would be the correct
code for this patient case scenario.
The final step for completion of this assignment is to determine whether this case
scenario requires a modifier or not. We have learned previously that Level I modifiers are used
to supplement the information provided or to adjust care descriptions in order to provide extra
details concerning a procedure or service provided by a physician. We use modifiers to help
further describe a procedure code without changing its definition entirely. The modifier I
believe to be the correct choice for this patient case scenario is Level I modifier 57. Modifier 57
is used when a decision of surgery has been determined on an E/M service. Adding modifier 57
to an appropriate E/M service verifies that an initial decision to perform surgery on a patient
has been determined.
References:
CPT® code 99204: New patient office visit, 45-59 minutes | American Medical Association
(ama-assn.org)
Procedure Coding: When to Use The 57 Modifier - Continuum (carecloud.com)
List of CPT/HCPCS Codes | CMS
The Web's Free 2023 ICD-10-CM/PCS Medical Coding Reference (icd10data.com)