2013 Psychiatry E/M Coding Guide

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Evaluation and Management Documentation Guidelines
Focus of Todays Program

Rationale for using E/M coding Benefits of E/M coding Key differences between the 1995 and 1997 CMS documentation guidelines for E/M services. Documentation guidelines for select Evaluation and Management (E/M) codes available for use by prescribers
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Where Do I Find Information About E/M Documentation Requirements?

Current CPT Manual CMS Website 1995 Guidelines: http://www.cms.hhs.gov/MLNProducts/downloads/1995d g.pdf 1997 Guidelines: http://www.cms.hhs.gov/MLNProducts/downloads/maste r1.pdf HCFA Draft worksheet: http://www.aafp.org/online/en/home/publications/journal s/fpm/collections/fpmmedicare/meddecisions.html
Key CPT Codes Available for Psychiatric Medication Clinic Visits by Prescribers

Pharmacologic Management (90862) Therapy with E/M (90805, 90807, 90809 as well as 90811, 90813, 90815) E/M Codes

New Outpatient Office Visit

(99201, 99202, 99203, 99204, 99205)
Established Outpatient Office Visit

(99211, 99212, 99213, 99214, 99215)
Outpatient Consultation
(99241, 99242, 99243, 99244, 99245)
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Why Use the E/M Codes?

Accurately capture work value of sessions Accommodate prescriber services beyond the scope of a typical 90862 Reimbursement rate higher than 90862 for 99214 and 99215
1995 Versus 1997 Guidelines

CMS allows prescribers to use EITHER the 1995 or 1997 guidelines. Elements of 1995 CANNOT be intermixed with elements of 1997 guidelines in a single service note.
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Key Differences Between 1995 and 1997 Guidelines

1995 Guidelines
History Only elements are counted
1997 Guidelines
Status of chronic conditions may substitute for elements Highly defined examination bullets Same in 1995 and 1997
Examination
Somewhat subjective Same in 1995 and 1997
Medical Decision Making
When KHS Reviews E/M Documentation

Auditors will score the service by both 1995 and 1997 guidelines The score that is most advantageous to the Provider will be used
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CMS-Defined Core Components of E/M Documentation

History Examination Medical Decision Making Counseling and Coordination of Care Nature of Presenting Problem Time
E/M Coding: Key Components in Selecting Which Service was Rendered

History Examination Medical Decision Making
OR
Documentation based on time, but ONLY IF counseling or coordination of care dominated the session
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Counseling and Coordination of Care

Counseling, in this context, is NOT psychotherapy In an outpatient encounter, the Counseling and Coordination of Care MUST occur during the face-toface portion of the encounter
Counseling and Coordination of Care Would Include: Education (diagnosis, prognosis, treatment options)
Discussion of potential risks and benefits of proposed treatments Education about self-management techniques Review of laboratory results, recommended interventions (i.e., diet, exercise, referral) Work with family or other care providers to facilitate Members treatment Etc.
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To Code by Time Spent Counseling and Coordinating Care

Start and Duration must be documented Notation must be included that more than 50% of the face-to-face visit was spent in Counseling or Coordination of Care Key topics of Counseling or Coordination must be documented Select the proper code based on the time of the full face-to-face portion of the encounter
Typical Time Spent Face-ToFace

New Outpatient
visit
99201 99202 99203 99204 99205 10 minutes 20 minutes 30 minutes 45 minutes 60 minutes 99211 99212 99213 99214 99215 5 minutes 10 minutes 15 minutes 25 minutes 40 minutes
Established Outpatient visit
(For typical times spent face-to-face during an outpatient consultation, refer to the current CPT manual.)
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Mr. X
6/12/09 Face-to-face time: 30 minutes
Start time: 11:15am
Goal: Mr. X will have an euthymic mood 90% of the time.
CC: Mr. X returns for routine follow-up. He notes I cant sleep.
HPI:Mr. X said he had been sleeping poorly for the past 8 days with racing thoughts and excessive energy. He noted impulsivity in terms of unplanned travel and spending sprees. He said he had been taking his lithium as prescribed and denied side effects. He denied any suicidal thoughts, citing religion and family as chief deterrents. He presented no evidence of dangerousness.
MSE: Mr. X was meticulously groomed and was dressed extravagantly for the occasion. He maintained good eye contact and was cooperative. He noted a wonderful mood and displayed a bright and expansive affect. He denied SI/HI/AH/VH, and there was no overt attention to internal stimuli. His speech was increased in volume and amount with marked flight of ideas.
Lab: Li level on 6/10/09 was 0.3
Impression: Bipolar I Disorder, Most Recent Episode Manic, Severe, without Psychotic Features; acute decompensation
Plan: Over 50% of the time was spent in counseling and coordination of care. Topics included education
Established Outpatient visit, typical time face-toface:

99211 99212 99213 99214 99215 5 minutes 10 minutes 15 minutes 25 minutes 40 minutes
Which is the Correct Code to Bill?
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If Coding is NOT Based on Counseling and Coordination of Care

Key components to determine level of service
History Examination Medical Decision Making
For Consultations and New Patient, all 3 components are used to determine level of service For Office or other Outpatient visits for ESTABLISHED patients, the TWO highest scoring components determine level of service
Extent of History and Examination History

Problem Focused Expanded Problem Focused Detailed Comprehensive
Examination
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Straightforward Low complexity Moderate complexity High complexity
Example: Established Outpatient Coding

CPT Code
99211 99212 99213
History
N/A Problem Focused Expanded Problem Focused Detailed Comprehensive
Examination
MDM
N/A
Typical Time
5 minutes
Straightforward 10 minutes Low Complexity 15 minutes
99214 99215
Moderate Complexity High Complexity
25 minutes 40 minutes
For Established Outpatient Office Visits, 2 of 3 components (history, exam, MDM) must be met or exceeded. For Consultations and New Outpatient Office Visits, all 3 components must be met. Coding based on time (Counseling or Coordination of Care) is the exception.
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Coding the History
Components of History
Chief Complaint History of Present Illness
Brief Extended
Past, Family, and/or Social History

None Pertinent Complete
Review of Systems
None Problem Pertinent Extended Complete
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Measuring the History

Level of History
Problem Focused Expanded Problem Focused Detailed
HPI
Brief Brief
ROS
PFSH
None None
Extended
Pertinent Complete
Comprehensiv Extended e
The Extent of the History

A Chief Complaint is required for every level of service. The 8 recognized elements of HPI include: Location, Quality, Severity, Duration, Timing, Context, Modifying Factors, and Associated Signs and Symptoms. 1997 guidelines allow status of chronic conditions to be substituted for elements of HPI. 1995 guidelines do not allow substitution.
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Recognized Elements of HPI
Location Quality Severity Duration
Timing Context Modifying Factors Associated Signs and Symptoms
Scoring the HPI

Level of HPI
Brief
1995 Guidelines
Chief Complaint + 1-3 Elements
1997 Guidelines
Chief Complaint + 1-3 Elements or status of 1-2 chronic conditions*
Extended
Chief Complaint Chief Complaint + + (*Use of chronic conditions or more 4 for the 1997 Brief HPI ismore interpretation; 4 or a KHS other managed care organizations may or may not subscribe to this Elements Elements or Interpretation.) status of 3 or more chronic conditions
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Review of Systems
Systems Recognized by 1995 and 1997 Guidelines
Constitutional Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Level of ROS None
GI GU Musculoskeletal Skin and/or breast Neurological
Psychiatric Endocrine Hematologic/Lymphatic Allergic/Immunologic
Number of Systems Reviewed 0 1 system 2-9 systems 10 or more systems (or some systems and a statement all others negative)
Problem Pertinent Extended Complete
Past, Family, and/or Social History

Three history components recognized:
Patients Past History Family History Social History
At least one specific item in a particular area must be documented for a Pertinent PFSH At least one specific item 2 or 3 of the areas must be documented for a Complete PFSH
2 areas required for an established outpatient
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Scoring the PFSH

Level of PFSH Areas of PFSH for Established Outpatients Areas of PFSH for New Outpatients or New/Established Consults 0 1 or more 3
0 1 or more 2 or more
Putting the History Together
Level of History Problem Focused Expanded Problem Focused Detailed Comprehensive
HPI Brief Brief Extended Extended
ROS None
PFSH None
Problem Pertinent None Extended Complete Pertinent Complete
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Mr. X Start time: 11:15am
6/12/09 Face-to-face time: 30 minutes
Goal: Mr. X will have an euthymic mood 90% of the time. CC: Mr. X returns for routine follow-up. He notes I cant sleep. HPI: Mr. X reported severely worsening sleep for the past 8 days including no sleep at all for at least 72 hours. He said this had occurred in the context of stress over an upcoming family reunion. He noted associated symptoms of starting excessive numbers of projects, racing thoughts, shopping sprees, an unplanned 3-day trip, and friends commenting he talks too much. He reported using lithium as prescribed with tremor as his only side effect. Collateral: Mr. X case manager indicated that over the past week, he had noticed that Mr. X had persistently pressured speech, grandiose business plans, and occasional irritability that is unusual for him. PFSH: Mr. X had elevated transaminases with divalproex sodium in the past. He and his wife have recently separated. ROS: GI: Denied any nausea, vomiting, or diarrhea since on Li Endocrine: Denied any weight gain, constipation, or cold intolerance since on Li
Scoring the HPI

Elements of HPI Location Quality Severity Duration Timing Context Modifying Factors Associated Signs and Symptoms
Extended
Level of HPI
Brief
1997 Guidelines
Chief Complaint + 1-3 Elements or status of 1-2 chronic conditions* Chief Complaint + 4 or more Elements or status of 3 or more chronic conditions*
(*Use of chronic conditions for the 1997 Brief HPI is a KHS interpretation; other managed care organizations may or may not subscribe to this Interpretation.)
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Scoring the ROS

Level of ROS Number of Systems Reviewed
0 1 system 2-9 systems 10 or more systems (or some systems and a statement all others negative)
Scoring the PFSH
Level of PFSH None
Areas of PFSH for Established Outpatients 0
Pertinent 1 or more Complete 2 or more (PMH, SH)
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ROS None
PFSH None
Coding the Examination
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Levels of Examination
Types of Examination
Type of Examination General Multi-System Single System 1995 Guidelines Available at all levels Subjective scoring Available for only Problem Focused Comprehensive 1997 Guidelines Available at all levels Objective scoring Specialty examination available for all levels Specific psychiatric exam
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1995 Guidelines Examination

Level of Examination
Problem Focused Expanded Problem Focused
Documentation Requirements
A limited examination of the affected body area or organ system A limited examination of the affected body area or organ system and other symptomatic or related organ system(s) An extended examination of the affected body area(s) and other symptomatic or related organ system(s)
Detailed
Comprehensive
A general multi-system examination or complete examination of a single organ system (Must include 8 or more organ systems) Quotations are from the CMS 1995 documentation guidelines: http://www.cms.hhs.gov/MLNProducts/downloads/1995dg.pdf
1995 Documentation Recognized Body Areas Guidelines

Head and face Neck Chest, breasts, axillae Abdomen Genitalia, groin, buttocks Back and spine Each extremity
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1995 Documentation Guidelines

Recognized Organ Systems
Constitutional Eyes Ears, nose, mouth, throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic, lymphatic, immunologic
Problem Focused Expanded Problem Focused
KHS Scoring of Examination by 1995 Guidelines
Documentation Requirement
1 element in any body area or organ system
1 element in any body area or organ system AND 1 element in any additional organ system Extended examination of the affected area or organ system AND extended examination of 1 additional organ system Documentation of examination of 8 organ systems OR a complete psychiatric specialty examination
Detailed
Comprehensive
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KHS Scoring by 1995 Guidelines: Complete Psychiatric Specialty Exam

All of the following must be documented
Speech Thought Processes Associations Abnormal or psychotic thoughts or lack thereof Insight and Judgment Memory (remote and recent) Attention and Concentration Language Fund of Knowledge Mood and Affect
Orientation (time, place, person)
1997 Guidelines: General Multisystem Examination

Level of Examination Problem Focused Expanded Problem Focused Detailed Documentation Requirements 1-5 bulleted elements 6 bulleted elements 2 bulleted elements from each of six areas/systems OR 12 bulleted elements from 2 areas/systems 2 bulleted areas from each of 9 areas/systems
Comprehensive
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1997 Documentation Guidelines

Recognized Body Areas and Organ Systems
Constitutional Eyes Ears, nose, mouth, throat Neck Respiratory Cardiovascular Chest, breasts Gastrointestinal/Abdo men Genitourinary Lymphatic Musculoskeletal Skin Neurologic Psychiatric
1997 Guidelines Psychiatric Specialty Examination
Reproduced from the CMS 1997 documentation guidelines: http://www.cms.hhs.gov/MLNProducts/downloads/master1.pdf
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Scoring the 1997 Psychiatric Specialty Examination

Documentation Requirements
1-5 bulleted elements 6-8 bulleted elements 9 bulleted elements Each element in a shaded box (the psychiatric and constitutional areas) + At least one element in the unshaded box (the musculoskeletal area)
Vitals: Weight: 220 lbs Pulse: 78 and regular Blood Pressure: 123/76 Appearance: Well developed and well nourished white male in no apparent physical distress. He was well groomed and overdressed for the occasion. Musculoskeletal: Muscle strength was 5/5 throughout with normal tone. There was a moderate postural tremor noted in both hands with increased intention tremor. Psychiatric: Speech was increased in volume and rate. Thought content was logical and abstraction was intact by testing with pairs (apple + banana = fruit). Marked flight of ideas was present. There were no loose associations noted. He denied SI/HI/AH/VH and there was no overt attention to internal stimuli. Judgment appeared impaired in terms of unplanned travel and spending sprees but insight into his mania appeared intact. Mr. X was A&O X 4. Immediate and 5 minute recall were 3/3. He was able to name the past 4 United States presidents. He had difficulty attending to the interview but responded well to redirection. He was able to name 3 common items. He discussed recent events related to the economy. He noted a wonderful mood and demonstrated a bright and expansive affect.
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1995 versus 1997 Guidelines: Medical Decision Making

Medical Decision Making (MDM) is scored identically for 1995 and 1997 guidelines
Levels of Medical Decision Making
Straightforward Low Complexity Moderate Complexity High Complexity
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Components of MDM
Scoring Medical Decision Making

Number of diagnoses considered and/or management options considered Amount and/or complexity of data ordered or reviewed Level of risk for complications, including morbidity and mortality
Each component is individually scored Level of MDM defined by the highest scores in 2 of the 3 MDM components
Medical Decision Making: Must Meet or Exceed 2 of the Number of Amount and/or Risk of Type of 3 diagnoses or complexity of complications decision making
management options Minimal Limited Multiple Extensive data to be reviewed Minimal or none Limited Moderate Extensive and/or morbidity or mortality Minimal Low Moderate High Straightforward Low Complexity Moderate Complexity High Complexity
CMS 1997 documentation guidelines: http://www.cms.hhs.gov/MLNProducts/downloads/master1.pdf
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Scoring is addressed in a concrete manner in neither the 1995 nor the 1997 documentation guidelines A draft score sheet had been released by HCFA in the past. Draft score sheet contents referenced at: http://www.aafp.org/online/en/home/publications/journals/fpm/collectio ns/fpmmedicare/meddecisions.html
KHS: Scoring Diagnoses and Treatment Options

Self-limiting and/or minor problem, maximum of 2 problems Condition already diagnosed by provider and improved and/or stable Condition already diagnosed by provider and worsening 1 point each 1 point each 2 points each
Condition that is new to the provider 3 points without further work-up planned, maximum of 1 problem Minimal 1 point Condition that is new to the provider and 4 points each Limited 2 points further work-up is planned Multiple Extensive 3 points 4 points
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KHS: Scoring Amount and/or Complexity of Data

Laboratory testing ordered and/or reviewed Radiology testing ordered and/or reviewed Medical testing ordered and/or reviewed Discussion of results with physician who performed or interpreted the test Direct and independent review and interpretation of a specimen, tracing, or image Decision to obtain old records and/or collateral information 1 point 1 point 1 point 1 point 1 point each 1 point
Minimal or none 1 point Review and written summary of old records and/or 2 collateral information points Limited 2 points Moderate Extensive 3 points 4 points
Reproduced from the CMS 1997 documentation guidelines: http://www.cms.hhs.gov/ MLNProducts/downl oads/master1.pdf
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Mr. X (continued) Laboratory: Li level 0.3 on 6/10/09 ECG: Received from PCP Dr. Y, done on 6/04/09 and noted by Dr. Y to be normal. The ECG was reviewed today, and I concur with Dr. Y. Impression: Bipolar I Disorder, Most Recent Episode Manic, Severe, Without Psychotic Features Acute decompensation Plan: We reviewed the potential risks and benefits of increase in LiCO3 to target mania, including discussion of the risk of lithium toxicity and symptoms that would warrant an immediate phone call to the clinic or trip to the emergency room. We also reviewed lifestyle modifications for safe use of lithium. He expressed understanding and gave consent, so the LiCO3 dose will be increased to 600mg po BID. He will RTC 1 week, sooner prn.
Mr. X: Scoring Diagnoses and Treatment Options

Condition that is new to the provider 3 points without further work-up planned, maximum of 1 problem Minimal 1 point Condition that is new to the provider and 4 points each Limited 2 points further work-up is planned Multiple 3 points Extensive 4 points
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Mr. X: Scoring Amount and/or Complexity of Data

Review and written summary of old records and/or 2 Minimal or none 1 point collateral information points Limited 2 points Moderate Extensive 3 points 4 points

?
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Summarizing Medical Decision Making forAmount and/or Risk of Mr. X Number of Type of
diagnoses or management options Minimal Limited Multiple Extensive complexity of data to be reviewed Minimal or none Limited Moderate Extensive complications and/or morbidity or mortality Minimal Low Moderate High decision making
Must meet or exceed 2 of the 3 items for a given level
Summary: Established Outpatient Coding

CPT Code
99211 99212 99213
History
Examination
MDM
N/A
Typical Time
5 minutes
99214 99215
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Coding Mr. X Outpatient Visit

CPT Code
99211 99212 99213
History
Examination
MDM
N/A
Typical Time
5 minutes
99214 99215
What if.
What if no ECG had been done or reviewed?
Amount and/or complexity of data would be scored as moderate Medical Decision Making would be scored as moderate complexity The visit would be properly coded as a 99214
Medical Necessity will determine if the ECG should be done

An ECG wouldnt be ordered simply to allow a higher code. If the ECG was needed, though, take credit for it!
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Mr. X: Scoring Amount and/or Complexity of Data

Summarizing Medical Decision Making forAmount and/or Risk of Mr. X Number of Type of
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Coding Mr. X Outpatient Visit

CPT Code
99211 99212 99213
History
Examination
MDM
N/A
Typical Time
5 minutes
99214 99215
Summary
E/M Services may be coded by time, BUT ONLY IF over 50% of the face-to-face part of the visit involved counseling and coordination of care.
Must document in note that over 50% of time was in counseling and coordination of care Must document key points of counseling and/or coordination of care
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If the Service Is NOT Being Coded by Time:

Key Components include
Level of history Level of examination Complexity of medical decision making
For established outpatient visits, the highest 2 of the 3 components define the service rendered. For new outpatient visits or outpatitnet consultations (new or established), all 3 components
Ms. Z. Start Time: 9:20am
7/25/08 Duration: 20 minutes
Goal: Ms. Z. will have well managed anxiety 90% of the time. CC: Ms. Z. presents for f/u of anxiety. She notes my nerves are bad. HPI: Ms. Z. notes a 1 week exacerbation of her anxiety, which she attributes to her sons military deployment. She rates anxiety as 9/10 (10=worst) and believes her level of anxiety is out of proportion to event. She also reports muscular tension, sleep disturbance, and poor concentration. She denies any SI, citing her children as strong deterrents. PFSH: Ms. Z. has longstanding GAD. Her meds include sertraline 100mg daily as well as lisinopril 10mg daily from her PCP. She has family support from her husband, adult daughter, and mother. ROS: Constitutional: Ms. Z. reports a reduced appetite but denies any recent weight change GI: Ms. Z. denies any nausea, vomiting, or diarrhea since starting sertraline MSE: Appearance/Behavior: WD WN WF in NAD. Well groomed, good eye contact, cooperative. Thought/Speech: Denies SI/HI/AH/VH; no overt attention to internal stimuli. Thought processes demonstrate rumination on sons deployment. Speech RRR and goal-directed with normal volume, articulation, and initiation. Mood/Affect: Anxiety 9/10, denies depression, congruent and tearful affect. Orientation: A&O X 4 Attention span was interrupted by ruminations related to her son and required frequent redirection. Insight and judgment appear intact, as she recognizes her anxiety and is utilizing her support system. Imp: Generalized Anxiety Disorder, Severe exacerbation Plan: We discussed treatment options, including no change, increase in sertraline, or addition of psychotherapy to target recently increased anxiety. Since she had previously done very well on the current sertraline dose, and since there is a clear stressor that has triggered her exacerbation, she and I agreed that psychotherapy is the best choice at present. No change to the sertraline. I will order a referral for psychotherapy. RTC 2 weeks, sooner prn.
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Ms. Z. Start Time: 9:20am
7/25/08 Duration: 20 minutes
Goal: Ms. Z. will have well managed anxiety 90% of the time. CC: Ms. Z. presents for f/u of anxiety. She notes my nerves are bad. HPI: Ms. Z. notes a 1 week exacerbation of her anxiety, which she attributes to her sons military deployment. She rates anxiety as 9/10 (10=worst) and believes her level of anxiety is out of proportion to event. She also reports muscular tension, sleep disturbance, and poor concentration. She denies any SI, citing her children as Strong deterrents. PFSH: Ms. Z. has longstanding GAD. Her meds include sertraline 100mg daily as well as lisinopril 10mg daily from her PCP. She has family support from her husband, adult daughter, and mother. ROS: Constitutional: Ms. Z. reports a reduced appetite but denies any recent weight change GI: Ms. Z. denies any nausea, vomiting, or diarrhea since starting sertraline MSE: Appearance/Behavior: WD WN WF in NAD. Well groomed, good eye contact, cooperative. Thought/Speech: Denies SI/HI/AH/VH; no overt attention to internal stimuli. Thought processes demonstrate rumination on sons deployment. Speech RRR and goal-directed with normal volume, articulation, and initiation. Mood/Affect: Anxiety 9/10, denies depression, congruent and tearful affect. Orientation: A&O X 4 Attention span was interrupted by ruminations related to her son and required frequent redirection. Insight and judgment appear intact, as she recognizes her anxiety and is utilizing her support system. Imp: Generalized Anxiety Disorder, Severe exacerbation Plan: We discussed treatment options, including no change, increase in sertraline, or addition of psychotherapy to target recently increased anxiety. Since she had previously done very well on the current sertraline dose, and since there is a clear stressor that has triggered her exacerbation, she and I agreed that psychotherapy is the best choice at present. No change to the sertraline. I will order a referral for psychotherapy. RTC 2 weeks, sooner prn.
Scoring the HPI for Ms. Z.

Level of HPI
Brief
1997 Guidelines
Chief Complaint + 1-3 Elements or status of 1-2 chronic conditions* Chief Complaint + 4 or more Elements or status of 3 or more chronic conditions
Extended
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Review of Systems
Scoring the PFSH

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Putting the History Together: Ms. Z

Level of History Problem Focused Expanded Problem Focused Detailed Comprehensive HPI Brief Brief Extended Extended ROS None PFSH None
1997 Guidelines Psychiatric Specialty Examination for Ms. Z.

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KHS: Scoring Diagnoses and Treatment Options for Ms. Z.

Condition that is new to the provider 3 points without further work-up planned, maximum of 1 problem Minimal 1 point Condition that is new to the provider and 4 points each Limited 2 points further work-up is planned Multiple 3 points Extensive 4 points
KHS: Scoring Amount and/or Complexity of Data for Ms. Z.

1 2 Review and written Minimal orof old records and/or point summary none collateral information points Limited 2 points Moderate Extensive 3 points 4 points
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Summarizing Medical Decision Making for Ms. Z

Number of diagnoses or management options Minimal Limited Multiple Extensive Amount and/or complexity of data to be reviewed Minimal or none Limited Moderate Extensive Risk of complications and/or morbidity or mortality Minimal Low Moderate High Type of decision making
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Established Outpatient Coding for Ms. Z.

CPT Code
99211 99212 99213
History
Examination
MDM
N/A
Typical Time
5 minutes
99214 99215
Mr. B. 07/02/09 Start time: 3:15pm Face-to-face time: 25 minutes Goal: Mr. B. will be able to manage his daily routine without interruption by hallucinations 95% of the time. CC: Mr. B. said he was here to get my prescription refilled. HPI: Mr. B. notes his Schizophrenia remains at baseline, with no interval hallucinations or delusions. He indicated he had good concentration but had difficulty motivating himself to perform hygiene and household chores. He indicated he remained fairly inactive, spending most of his time inside watching TV. He noted he primarily consumes prepackaged food or inexpensive fast food. His case manager was present and said it was difficult to interest Mr. B. in activities and that he preferred solitary projects. The case manager indicated Mr. B. was managing his finances on his own and remembered to refill his prescription on time. PFSH: Mr. B has a longstanding history of Schizophrenia as well as recent dyslipidemia. He is taking only risperidone 1mg po am and 2mg po q hs at this time. ROS: Constitutional: Intact sleep and energy, stable weight Musculoskeletal: Denied tremors and dystonia MSE: Appearance/Behavior: WD WN BM in NAD. He appeared disheveled with ungroomed hair and beard and disarrayed clothing. He maintained intermittent eye contact. Thought/Speech: He denied SI/HI/AH/VH; there was no overt attention to internal stimuli. Speech was RRR with normal volume and articulation. There was minimal initiation and moderate loosening of associations. Mood/Affect: He noted a good mood and demonstrated a blunted affect. Orientation: He was A&O X 4 Insight/Judgment: He continues to display limited insight into his negative symptoms but judgment appears intact. Labs: 6/25/09: Chol 245, LDL 142, HDL 35, Trig 324 (essentially unchanged from 2 months ago) Impression: Schizophrenia, disorganized type; at baseline Dyslipidemia Plan: Over 50% of the session was spent in Counseling and Coordination of Care. We reviewed option to try a different antipsychotic or different dose of the current medication to address residual negative symptoms. We reviewed that his current medication could be causing or worsening his dyslipidemia and that other options might not do this. He expressed understanding and politely declined any change to medication, so no changes were made. We also discussed his dyslipidemia. We discussed, at length, dietary options that are more heart-healthy than his current diet. We also discussed a walking regimen that might help with weight and lipids. He expressed he would try this for 3 months, and if not successful, we will need to have him see his PCP about the lipids. RTC 1 month, sooner prn.
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Coding Options
Code by time (Counseling and Coordination of Care) since this consumed over 50% of the visit
OR
Code by History, Exam, and Medical Decision Making since these are all present
Mr. B. 07/02/09 Start time: 3:15pm Face-to-face time: 25 minutes Goal: Mr. B. will be able to manage his daily routine without interruption by hallucinations 95% of the time. CC: Mr. B. said he was here to get my prescription refilled. HPI: Mr. B. notes his Schizophrenia remains at baseline, with no interval hallucinations or delusions. He indicated he had good concentration but had difficulty motivating himself to perform hygiene and household chores. He indicated he remained fairly inactive, spending most of his time inside watching TV. He noted he primarily consumes prepackaged food or inexpensive fast food. His case manager was present and said it was difficult to interest Mr. B. in activities and that he preferred solitary projects. The case manager indicated Mr. B. was managing his finances on his own and remembered to refill his prescription on time. PFSH: Mr. B has a longstanding history of Schizophrenia as well as recent dyslipidemia. He is taking only risperidone 1mg po am and 2mg po q hs at this time. ROS: Constitutional: Intact sleep and energy, stable weight Musculoskeletal: Denied tremors and dystonia MSE: Appearance/Behavior: WD WN BM in NAD. He appeared disheveled with ungroomed hair and beard and disarrayed clothing. He maintained intermittent eye contact. Thought/Speech: He denied SI/HI/AH/VH; there was no overt attention to internal stimuli. Speech was RRR with normal volume and articulation. There was minimal initiation and moderate loosening of associations. Mood/Affect: He noted a good mood and demonstrated a blunted affect. Orientation: He was A&O X 4 Insight/Judgment: He continues to display limited insight into his negative symptoms but judgment appears intact. Labs: 6/25/09: Chol 245, LDL 142, HDL 35, Trig 324 (essentially unchanged from 2 months ago) Impression: Schizophrenia, disorganized type; at baseline Dyslipidemia Plan: Over 50% of the session was spent in Counseling and Coordination of Care. We reviewed option to try a different antipsychotic or different dose of the current medication to address residual negative symptoms. We reviewed that his current medication could be causing or worsening his dyslipidemia and that other options might not do this. He expressed understanding and politely declined any change to medication, so no changes were made. We also discussed his dyslipidemia. We discussed, at length, dietary options that are more hearthealthy than his current diet. We also discussed a walking regimen that might help with weight and lipids. He expressed he would try this for 3 months, and if not successful, we will need to have him see his PCP about the lipids. RTC 1 month, sooner prn.
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Scoring the HPI for Mr. B.

Level of HPI
Brief
1997 Guidelines
Extended
*(Use of chronic conditions for the 1997 Brief HPI is a KHS interpretation; other managed care organizations may or may not subscribe to this Interpretation.)
Review of Systems for Mr. B.

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Scoring the PFSH for Mr. B.

Putting the History Together: Mr. B.

Level of History Problem Focused Expanded Problem Focused Detailed Comprehensive HPI Brief Brief Extended Extended ROS None PFSH None
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1997 Guidelines Psychiatric Specialty Examination for Mr. B.

KHS: Scoring Diagnoses and Treatment Options for Mr. B.

Self-limiting and/or minor problem, maximum of 2 problems Condition already diagnosed by provider and improved and/or stable
(Schizophrenia, Disorganized, at baseline)
1 point each 1 point each
Condition already diagnosed by provider and worsening

(Uncontrolled dyslipidemia)
2 points each
Condition that is new to the provider 3 points without further work-up planned, Minimal 1 point maximum of 1 problem Limited 2 points Condition that is new to the provider and 4 points each Multiple 3 points further work-up is planned Extensive 4 points (This slide updated 05/04/09)
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KHS: Scoring Amount and/or Complexity of Data for Mr. B.

1 2 Review and written Minimal orof old records and/or point summary none collateral information points Limited 2 points Moderate Extensive 3 points 4 points
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Summarizing Medical Decision Making for Mr. B

Number of diagnoses or management options Minimal Limited Multiple Extensive Amount and/or complexity of data to be reviewed Minimal or none Limited Moderate Extensive Risk of complications and/or morbidity or mortality Minimal Low Moderate High Type of decision making

(This slide updated 05/04/09)
Established Outpatient Coding: Mr. B.

CPT Code
99211 99212 99213
History
Examination
MDM
N/A
Typical Time
5 minutes
99214 99215
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What About Coding by Time?
Mr. B. 07/02/09 Start time: 3:15pm Face-to-face time: 25 minutes Goal: Mr. B. will be able to manage his daily routine without interruption by hallucinations 95% of the time. CC: Mr. B. said he was here to get my prescription refilled. HPI: Mr. B. notes his Schizophrenia remains at baseline, with no interval hallucinations or delusions. He indicated he had good concentration but had difficulty motivating himself to perform hygiene and household chores. He indicated he remained fairly inactive, spending most of his time inside watching TV. He noted he primarily consumes prepackaged food or inexpensive fast food. His case manager was present and said it was difficult to interest Mr. B. in activities and that he preferred solitary projects. The case manager indicated Mr. B. was managing his finances on his own and remembered to refill his prescription on time. PFSH: Mr. B has a longstanding history of Schizophrenia as well as recent dyslipidemia. He is taking only risperidone 1mg po am and 2mg po q hs at this time. ROS: Constitutional: Intact sleep and energy, stable weight Musculoskeletal: Denied tremors and dystonia MSE: Appearance/Behavior: WD WN BM in NAD. He appeared disheveled with ungroomed hair and beard and disarrayed clothing. He maintained intermittent eye contact. Thought/Speech: He denied SI/HI/AH/VH; there was no overt attention to internal stimuli. Speech was RRR with normal volume and articulation. There was minimal initiation and moderate loosening of associations. Mood/Affect: He noted a good mood and demonstrated a blunted affect. Orientation: He was A&O X 4 Insight/Judgment: He continues to display limited insight into his negative symptoms but judgment appears intact. Labs: 6/25/09: Chol 245, LDL 142, HDL 35, Trig 324 (essentially unchanged from 2 months ago) Impression: Schizophrenia, disorganized type; at baseline Dyslipidemia Plan: Over 50% of the session was spent in Counseling and Coordination of Care. We reviewed option to try a different antipsychotic or different dose of the current medication to address residual negative symptoms. We reviewed that his current medication could be causing or worsening his dyslipidemia and that other options might not do this. He expressed understanding and politely declined any change to medication, so no changes were made. We also discussed his dyslipidemia. We discussed, at length, dietary options that are more heart-healthy than his current diet. We also discussed a walking regimen that might help with weight and lipids. He expressed he would try this for 3 months, and if not successful, we will need to have him see his PCP about the lipids. RTC 1 month, sooner prn.
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Summary: Established Outpatient Coding

CPT Code
99211 99212 99213
History
Examination
MDM
N/A
Typical Time
5 minutes
99214 99215
Established Outpatient Coding by Time for Mr. B.

CPT Code
99211 99212 99213
History
Examination
MDM
N/A
Typical Time
5 minutes
99214 99215
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Questions?
References
Current CPT Manual CMS Website 1995 Guidelines: http://www.cms.hhs.gov/MLNProducts/downloads/1995d g.pdf 1997 Guidelines: http://www.cms.hhs.gov/MLNProducts/downloads/maste r1.pdf HCFA Draft worksheet: http://www.aafp.org/online/en/home/publications/journal s/fpm/collections/fpmmedicare/meddecisions.html
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Blank Scoring Templates

(For an Established Patient Outpatient Visit, using 1997 guidelines)
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Elements of HPI
Location Quality Severity Duration
Timing Context Modifying Factors Associated Signs and Symptoms
Scoring the HPI

Level of HPI
Brief
1997 Guidelines
Extended
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Review of Systems
Scoring the PFSH

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ROS None
PFSH None
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KHS: Scoring Diagnoses and Treatment Options

Condition that is new to the provider 3 points without further work-up planned, maximum of 1 problem Minimal 1 point Condition that is new to the provider and 4 points each Limited 2 points further work-up is planned Multiple Extensive 3 points 4 points
KHS: Scoring Amount and/or Complexity of Data

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Summarizing Medical Decision Making Amount and/or Risk of Number of Type of

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Established Outpatient Coding

CPT Code
99211 99212 99213
History
Examination
MDM
N/A
Typical Time
5 minutes
99214 99215
58

2013 Psychiatry E/M Coding Guide

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1/17/2013

Evaluation and Management Documentation Guidelines

Focus of Todays Program

Where Do I Find Information About E/M Documentation Requirements?

New Outpatient Office Visit

Established Outpatient Office Visit

Why Use the E/M Codes?

1995 Versus 1997 Guidelines

Key Differences Between 1995 and 1997 Guidelines

Somewhat subjective Same in 1995 and 1997

Medical Decision Making

When KHS Reviews E/M Documentation

CMS-Defined Core Components of E/M Documentation

E/M Coding: Key Components in Selecting Which Service was Rendered

Counseling and Coordination of Care

To Code by Time Spent Counseling and Coordinating Care

Typical Time Spent Face-ToFace

Established Outpatient visit

6/12/09 Face-to-face time: 30 minutes

Start time: 11:15am

Goal: Mr. X will have an euthymic mood 90% of the time.

CC: Mr. X returns for routine follow-up. He notes I cant sleep.

Lab: Li level on 6/10/09 was 0.3

Established Outpatient visit, typical time face-toface:

Which is the Correct Code to Bill?

If Coding is NOT Based on Counseling and Coordination of Care

Extent of History and Examination History

Medical Decision Making

Example: Established Outpatient Coding

Straightforward 10 minutes Low Complexity 15 minutes

Moderate Complexity High Complexity

Coding the History

Past, Family, and/or Social History

Measuring the History

The Extent of the History

Recognized Elements of HPI

Location Quality Severity Duration

Timing Context Modifying Factors Associated Signs and Symptoms

Scoring the HPI

GI GU Musculoskeletal Skin and/or breast Neurological

Psychiatric Endocrine Hematologic/Lymphatic Allergic/Immunologic

Problem Pertinent Extended Complete

Past, Family, and/or Social History

Scoring the PFSH

None Pertinent Complete

Putting the History Together

Level of History Problem Focused Expanded Problem Focused Detailed Comprehensive

HPI Brief Brief Extended Extended

Problem Pertinent None Extended Complete Pertinent Complete

Mr. X Start time: 11:15am

6/12/09 Face-to-face time: 30 minutes

Scoring the HPI

Scoring the ROS

None Problem Pertinent Extended Complete

Scoring the PFSH

Level of PFSH None

Areas of PFSH for Established Outpatients 0

Pertinent 1 or more Complete 2 or more (PMH, SH)

Putting the History Together

Level of History Problem Focused Expanded Problem Focused Detailed Comprehensive

HPI Brief Brief Extended Extended

Problem Pertinent None Extended Complete Pertinent Complete