The Story Behind Evaluation & Management CPT Codes
Today, we have over 38
pages of Evaluation and Management codes in our CPT Manual, well it was not always that way, in 1991, there
was a simple medical billing system that included levels of evaluation and
management medical services that took up only four pages in the CPT Manual.
In 1992, the Health Care
Financing Administration (HCFA),
mandated by congress, introduced a new, and complicated set of
physician billing codes. In May 1997, the version of the Documentation
Guidelines for Evaluation & Management Services included 54 pages covering patient history, clinical exam, family history, decision
complexity, body areas, organ systems, physical exam types, diagnostic tests,
and management options.
There are two different
sets of Evaluation and Management guidelines; 1995 and 1997. The 1997
guidelines were introduced by the Centers for Medicare
& Medicaid Services (CMS) to address some of
the problems that were found with the 1995 guidelines at the time.
The main difference between the two guidelines is in the examination part of the evaluation and management service.
Evaluation and
Management CPT Codes are a medical
billing system that healthcare providers
in the United States use so that they are able to be reimbursed by private insurance
companies and other payers such as Medicare and Medicaid.
Instructions for
Selecting a Level of E/M Service
The CPT codes in the Evaluation &
Management section are 99201-99499. The Evaluation and Management section is
the first section in the CPT Manual.
There are categories and subcategories to the Evaluation and Management codes.
In the Current
Procedural Terminology (CPT®) Manual, the following
instructions are found:
- Review the instructions for the selected category or
subcategory.
- Review the level of E/M
Service Descriptors & examples in the selected category or
subcategory.
- Determine the extent of history obtained.
- Determine the extent
of examination performed.
- Determine the Complexity of medical decision making.
Key Components
There are three key components in choosing an evaluation and management code. The history, examination, and medical decision making.
- Select the appropriate level of E/M service based on all
the key components for initial hospital care, office
consultation, initial inpatient consultation, office new patient, hospital
observation, emergency department, initial nursing facility
care, domiciliary care, new patient & home new patient.
- OR
- Select the appropriate level of E/M service based on two
of the three components for
office established, subsequent hospital;
care, subsequent nursing facility
care, domiciliary care established, & home established
patient.
- OR
- Select the appropriate level of E/M when counseling
and/or coordination of care dominates (more than 50%) the encounter with
the patient and/or family (face-to-face in the office or other outpatient
setting or floor/unit time in the hospital or nursing facility) then time shall
be considered the key or
controlling factor to qualify for a particular level of E/M
services.
Want to read more?
Medical Necessity
"Medical necessity of a service is the overarching criterion for payment in addition to the
individual requirements of a CPT code. It would not be medically necessary or
appropriate to bill a higher level of evaluation and management service when a lower
level of service is warranted. The volume of documentation should not be the primary
influence upon which a specific level of service is billed. Documentation should support
the level of service reported. The service should be documented during, or as soon as
practicable after it is provided in order to maintain an accurate medical record."CMS & MEDICAL NECESSITY
In future post, I will expand upon evaluation and management coding.
ICD-10-CM-Highlight
V97.33XD-Sucked into jet engine, subsequent encounter
Funny
Statistically…. 9 out of 10 injections are in vein.”
No comments:
Post a Comment