Chapter 19: CPT® Section Evaluation & Management Practical Application Tips and FAQ

Chapter 19: CPT® Section Evaluation & Management Practical Application Tips and FAQ

Case 1 – There is one E/M code and two ICD-10-CM codes reported. Code selection is based on if the patient is new or established and level of medical decision making determined by 1) Number/Complexity of Problems Addressed, 2) Amount and/or Complexity of Data to be Reviewed and Analyzed and 3) Risk of Complications and/or Morbidity or Mortality of Patient Management. Because this is a follow up patient and a follow up condition, and there is no indication the labs and echocardiogram were ordered by another provider, the tests would have been given credit at the time they were ordered. The risk of complication is not life threatening, but further study is needed to determine the cause of the pulmonary hypertension. Use Table 2 in the EM Guidelines to select the level of service. The two diagnoses are extremity swelling and pulmonary hypertension and are listed in that order. In the ICD-10-CM Alphabetic Index locate Swelling/leg/lower. For the second code locate Hypertension/Pulmonary. Validate codes in the Tabular List.

Case 2 – There is one E/M code and two ICD-10-CM codes reported. Code selection is based on if the patient is new or established and level of medical decision making determined by 1) Number/Complexity of Problems Addressed, 2) Amount and/or Complexity of Data to be Reviewed and Analyzed and 3) Risk of Complications and/or Morbidity or Mortality of Patient Management. This is a new patient so the MRI was ordered and performed by another provider. Use Table 2 in the EM Guidelines to select the level of service. The diagnoses to report are infective synovitis of the left knee and contracture of the left knee reported in this order. Synovitis aka tenosynovitis is further divided into anatomical locations. In ICD-10-CM Alphabetic Index locate Tenosynovitis/infective/lower leg. For the second diagnosis locate Contracture/joint/knee. Select the 6th characters from the Tabular List.

Case 3 – There is one CPT® code and two ICD-10-CM codes reported. This established patient presents with a skin lesion of the arm. A biopsy and shave removal of the skin lesion is performed. In the CPT® Index, look for Shaving/Skin Lesion or Skin/Shaving referring you to the code range. Refer to the Biopsy guidelines in CPT before selecting the procedure code. The indication for the procedure is a suspicious skin lesion and is coded as an unspecified neoplasm. In the ICD-10-CM Table of Neoplasms locate Neoplasm, neoplastic/skin NOS/limb/upper/Unspecified Behavior column. The patient has a personal history of skin cancer and contributes to the necessity of the lesion removal and is the second diagnosis. In the Alphabetic Index locate History/personal(of)/malignant neoplasm/skin.

Case 4 – There is one E/M code and three ICD-10-CM codes reported. Preventive Medicine Services are classified as New or Established and further divided by age range. The primary reason for the visit is an annual exam which is sequenced first. In the ICD-10-CM Alphabetic Index look for Examination/annual (adult) (periodic) (physical). The second diagnosis is for the pelvic exam; look for Examination/pelvic). The third diagnosis is for Hypothyroidism (acquired). For complete information on reporting routine and administrative exams with additional diagnoses, refer to guideline I.C.21.c.13.

Case 5 – There is one E/M code and one ICD-10-CM code reported. Code selection is based on if the patient is new or established and level of medical decision making determined by 1) Number/Complexity of Problems Addressed, 2) Amount and/or Complexity of Data to be Reviewed and Analyzed and 3) Risk of Complications and/or Morbidity or Mortality of Patient Management. Although the provider has two differential diagnoses, neither have a high risk of morbidity so this is not reported as an undiagnosed new problem with an uncertain diagnosis for number and complexity of problems addressed. The amount of data to be reviewed and analyzed is none. The risk of complications and/or morbidity or mortality the patient decides to decrease activity and rest. Use Table 2 in the EM Guidelines to select the level of service. The diagnosis is right lower quadrant abdominal pain. In the Alphabetic Index look for Pain/abdominal/lower/right quadrant.

Case 6 – There is one E/M code and seven ICD-10-CM codes reported. This is a Subsequent hospital visit for the patient in Case 9; the place of service will determine thesubcategory of codes. This E/M subcategory requires 2 of the 3 key components meet or exceed the stated requirements to qualify for a particular level of E/M. The lowest level key component will determine overall E/M level.

There are seven diagnoses to report. Sequence them in this order; use the ICD-10-CM Alphabetic Index to locate:
1.Cholelithiasis: Cholelithiasis – see Calculus, gallbladder. Calculus, calculi, calculous/gallbladder
2. Cystitis: Cystitis (exudative) (hemorrhagic) (septic) (suppurative)
3. Conjunctivitis: Conjunctivitis NOS
4. Hyponatremia: Hyponatremia – there are no other descriptors
5. Hypokalemia: Hypokalemia – there are no other descriptors
6. Diabetes Mellitus type 2: Diabetes, diabetic/type 2
7. Hypertension: Hypertension, hypertensive (accelerated) (benign)

Case 7 – There is one E/M code and seven ICD-10-CM codes reported. This is a Hospital Discharge Service (Discharge Summary) for the patient in Case 6 and 9. These codes are based on time. If no time is documented the lowest time is selected.

There are seven diagnoses to report. Sequence them in this order; use the ICD-10-CM Alphabetic Index to locate:
1. Cholelithiasis: Cholelithiasis – see Calculus, gallbladder. Calculus, calculi, calculous/gallbladder
2. Cystitis: Cystitis (exudative) (hemorrhagic) (septic) (suppurative)
3. Conjunctivitis: Conjunctivitis NOS
4. Hyponatremia: Hyponatremia – there are no other descriptors
5. Diabetes Mellitus type 2: Diabetes, diabetic/type 2
6. Long-term use of Metformin: Long-term (current) (prophylactic) drug therapy (use of)/oral/hypoglycemia.
7. Hypertension: Hypertension, hypertensive (accelerated) (benign)

Case 8 – There is one E/M code and nine ICD-10-CM codes reported. The place of service for this subsequent visit is in a Nursing Home/Facility; this will determine the code category. The E/M subcategory requires 2 of the 3 key components meet or exceed the stated requirements to qualify for a particular level of E/M. The lowest level key component will determine overall E/M level.

There are nine diagnoses to report. Sequence them in this order; use the ICD-10-CM Alphabetic Index to locate:
1. Rib contusion: Contusion/chest (wall) – see Contusion, thorax (wall) front
2. Shoulder pain: Pain(s)/joint/shoulder. Refer to the Tabular List for the appropriate 6th character.
3. Elevated blood pressure: this is not a diagnosis of high blood pressure. Locate Elevated/ elevation/blood pressure/reading.
4. Dementia: Locate Dementia (degenerative) (primary) (old age).
5. CAD: Disease, diseased/coronary – see Disease, heart, ischemic, atherosclerotic.
6. CHF (congestive heart failure): Failure, failed/heart/congestive.
7. Atrial Fibrillation: Fibrillation/atrial or auricular (established).
8. Type II diabetes: Diabetes, diabetic/type 2.
9. Long-term use of Glipizide: Long-term (current) (prophylactic) drug therapy (use of)/oral hypoglycemia.


Case 9 – There is one E/M code and nine ICD-10-CM codes reported. This is a Hospital Admission; the place of service will determine the category of codes. This E/M subcategory requires 3 of the 3 key components meet or exceed the stated requirements to qualify for a particular level of E/M. The lowest level key component will determine overall E/M level.

There are nine diagnoses to report. Sequence them in this order; use the ICD-10-CM Alphabetic Index to locate:
1. Nausea and vomiting: Nausea/with vomiting
2. Diarrhea: Diarrhea, diarrheal
3. Cystitis: Cystitis (exudative) (hemorrhagic) (septic) (suppurative)
4. Hypokalemia: Hypokalemia – there are no other descriptors
5. Hyponatremia: Hyponatremia – there are no other descriptors
6. Cholelithiasis: Cholelithiasis – see Calculus, gallbladder. Calculus, calculi, calculous/gallbladder
7. Diabetes Mellitus type 2: Diabetes, diabetic/type 2
8. Long-term use of Metformin: Long-term (current) (prophylactic) drug therapy (use of)/oral/hypoglycemia.
9. Hypertension: Hypertension, hypertensive (accelerated) (benign)

Case 10 – There are three CPT® codes, one HCPCS Level II code, and four diagnosis codes reported. A significant, separately identifiable E/M was performed on the same day as a procedure. Report the E/M visit first with the modifier to identify a separately identifiable E/M. Code selection is based on if the patient is new or established and level of medical decision making determined by 1) Number/Complexity of Problems Addressed, 2) Amount and/or Complexity of Data to be Reviewed and Analyzed and 3) Risk of Complications and/or Morbidity or Mortality of Patient Management. The number/complexity of problems addressed is one acute problem and two stable chronic illnesses. Use Table 2 in the EM Guidelines to select the level of service.

The procedure is the aspiration of a synovial cyst, left finger. In the Index, Synovial Cyst directs to see Ganglion. Locate Ganglion/Cyst/Aspiration/Injection. A HCPCS Level II modifier is appended to indicate the left second finger.

The provider also performed a DEXA scan in the office to evaluate low bone density. The provider owns the DEXA scan equipment and reported the findings. This is a global radiological service. In the Index locate Dual X-ray Absorptiometry (DXA)/Axial Skeleton.

The synovial cyst was aspirated and 10mg of Depo-Medrol is injected. The Depo-Medrol code is found in the Table of Drugs in HCPCS Level II codebook. Look in the Table of Drugs for Depo-Medrol and you’re directed to see Methylprednisolone Acetate. The smallest dose available is 20mg and the correct code even if the provider only uses 10mg.

There are four diagnoses indicated in the Assessment. Report the diagnosis codes in the order of the Assessment. In the ICD-10-CM Alphabetic Index locate Arthritis/rheumatoid/seronegative/hand joint. Refer to the Tabular List to locate codes for both hands. Report the synovial cyst next. Locate Cyst/synovial and you’re directed to see also Cyst, bursa. Look for Cyst/bursa, bursal NEC/hand. Refer to the Tabular List for the appropriate 6th character. The last diagnosis is senile osteoporosis. In the Index locate Osteoporosis/senile and you’re directed to see Osteoporosis, age-related. Locate Osteoporosis/age-related/with current pathologic fracture/vertebra. Note: the osteoporosis (age related) pathologic compression fracture of the vertebra is receiving continued care and is reported with a 7th character extender on the code to indicate this.

FAQ’s

I get confused in how to find the right Evaluation and Management (E/M) code. Is there an easy way? How do I get started?
Evaluation and Management (E/M) coding can be difficult. The first step in determining which CPT® code to use, is by location and type of service. For example, if a patient goes to see a primary care provider it would be an established patient office visit (99211-99215) or new patient office visit (99202-99205). If the patient goes to the Emergency Room for care you would code from the Emergency Department Services, codes 99281-99285. If a patient is admitted from the ER into the hospital as an inpatient you would code from Initial Hospital Care (99221-99223).

Each E/M Category (Office or Other Outpatient Services, Initial Observation Care, Initial Hospital Care, Critical Care, etc.) have subsection guidelines. A suggestion would be to read each of these subsection guidelines and highlight key information that stands out to you in when and how these categories are coded.

For example, the subsection guidelines for Critical Care Services, there is a paragraph that indicates what services are included in critical care and not reported separately. Highlight those services to indicate to you that these services will not be reported with Critical Care codes 99291 and 99292.

How do you determine a level of service for Office or Other Outpatient Services 99202-99205 and 99211-99215?
Code selection is based on the level of MDM as defined for each service, OR the total time for E/M. There are three elements of MDM in the office or other outpatient service; 1) Number and Complexity of Problems Addressed at the Encounter; 2) Amount and/or Complexity of Date to be Review and Analyzed; 3) Risk of Complications and/or Morbidity or Mortality of Patient Management. The level of MDM is based on 2 out of 3 Elements of MDM. Use Table 2 in your CPT® code book.

For example, an established patient with Low complexity of problems addressed at the encounter, Minimal amount and/or complexity of data to be reviewed and analyzed, and Low risk of complications and/or morbidity or mortality would be 99213.

How do you determine a level of service for Hospital Observation, Hospital Inpatient, Consultations, Emergency Department Nursing Facility, Domiciliary, Rest Home, or Custodial Care and Home E/M Services?
These services are based on History, Exam and Medical Decision Making (key components). For example, Emergency department services (99281-99285) require 3 of the 3 key components while Subsequent Hospital Care requires 2 of the three key components. Review each E/M category and highlight the number of key components required for each E/M level in code descriptor.

You will want to refer to the grids for each key component in your textbook.
When you look at a note, try to separate it between history, exam and medical decision making. This might make it a little easier to determine the levels. For example, Case 6 in your Practical Application workbook, the history is in the Subjective portion of the note. Use this to determine the level of history. The Exam is in Objective and MDM is determined by 1) Number and Complexity of Problems Addressed at the Encounter; 2) Amount and/or Complexity of Date to be Review and Analyzed; 3) Risk of Complications and/or Morbidity or Mortality of Patient Management.

What if E/M codes that require all three key components and they do not exactly match the three key components that is in the code descriptor for that level?
When coding a question or case that does not have all three key components that exactly meet, you report the E/M level that has the lowest key component. Example: you’re coding an office consultation and need 3 of 3 key components. You have a Detailed history, a Comprehensive Exam and Moderate MDM. These three components don’t exactly match any of the consultation levels. You select the code based on the lowest of the three key components. The lowest key component is the Detailed history which is 99243.

What if E/M codes that require two of three key components each have a different key component, what level of service is reported?
E/M categories that only require two of three key components but each component is different you report the second highest component. For example, a Subsequent Nursing Facility visit documents an Expanded Problem Focused History, a Detailed Examination and High Complexity Medical Decision Making. There are no two key components that exactly match. You will report the level that has the second highest key component. In this case the Detailed Examination is the second highest key component reporting 99309.