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Unformatted text preview: Categories of Evaluation & Management Services
A. Office or Other Outpatient Services (99201-99215)
• • New Patient is defined as a patient who has not been seen by the physician, or any
member of the group practice who is of the same specialty, within the past three years.
Established Patient is defined as a patient who has seen the physician, or any member
of the group practice who is of the same specialty, within the past three years.
A physician who is covering or on call for another physician should not classify the
patient's encounter as a new patient unless the patient's attending physician (or any
member of the group who is of the same specialty) has not seen the patient within the
past three years.
Time must be indicated in the medical record when the time factor is used to select a
code from this category. Do not consider the time spent by other staff (e.g., nurse, NP
or PA) as part of the face-to-face time. B. Consultations (99241-99275)
• • •
• Definition: A consultation is a type of service provided by a physician whose opinion
or advice regarding the diagnostic and/or treatment options is requested by another
physician or other appropriate source. The consulting physician may initiate treatment.
Office or Other Outpatient Consultations: Follow-up visits initiated by the
consultant should be reported using the appropriate established patient office visit code.
If the attending physician requests an additional opinion regarding the same or a new
problem, the office consultation codes may be used again.
Initial Inpatient Consultations: A consulting physician should report only one initial
consultation code per hospital or nursing facility admission.
Follow-up Inpatient Consultations: A re-evaluation of a patient in order to finalize an
opinion or advice.
Confirmatory Consultations: A second or third opinion is requested to justify medical
necessity or appropriateness of treatment. A confirmatory consultation can take place in
any setting. C. Hospital E/M Services
1. Hospital Observation Status (99217-99220)(99234-99236)
• These codes are used to report services provided to a patient designated as under
"observation status" in a hospital.
Initial Observation Care (codes 99218-99220): Use the codes from this category to
report services for the first (or additional) day(s) of a multiple-day observation stay. Categories of Evaluation & Management Services 1 •
• • The two higher level codes require a comprehensive history and physical examination.
The lowest level code requires a detailed or comprehensive history and physical
Observation Discharge Care (code 99217): Report this service only for the final day of
a multiple-day stay.
Observation or Inpatient Care Services (codes 99234-99236):use codes to report
observation or inpatient services where the patient is admitted and discharged on the
same date of service. The two higher level codes require a comprehensive history and
physical examination. The lowest level code requires a detailed or comprehensive
history and physical examination.
Typical time has not been yet been established for these services. 2. Hospital Inpatient Services (99221-99239)
• • • •
• Initial Hospital Care: The codes in this category are for reporting services provided
only by the admitting physician. Other physicians providing initial inpatient E/M
services should use consultation or subsequent hospital care codes, as appropriate.
Subsequent Hospital Care: The codes in this category are for reporting inpatient E/M
services provided after the first inpatient encounter (for the admitting physician) or for
services (other than consultative) provided by a physician other than the admitting
A hospitalized patient may require more than one visit per day by the same physician.
Group the visits together and report the level of service based on the total encounters
for the day. Third-party payers vary on their requirements for reporting this service.
Hospital Discharge Services: Use these codes for reporting services provided on the
final day of a multiple-day stay.
Time is the controlling factor for assigning the appropriate hospital discharge services
code. Total duration of time spent by the physician (even if the time
spent is not continuous) should be documented and reported. These codes include: final
examination, discussion of hospital stay, instructions to caregivers, preparation of
discharge records, prescriptions and referral forms. 3. Critical Care Services (99291-99292)
• • • Critical Care Services can be provided in any setting.
The physician must provide constant attendance or constant attention to a critically ill
or injured patient. The physician need not be constantly at bedside per se but is engaged
in physician work directly related to the individual patient's care.
Time is the controlling factor for assigning the appropriate critical care code. Total
duration of time spent by the physician (even if the time spent is not continuous) should
be documented and reported.
Services in critical care units must meet the guidelines to be billed as critical care. Categories of Evaluation & Management Services 2 • The following procedures are considered integral to the performance of critical care,
and should not be reported separately: -- cardiac output evaluation (93561-93562)
-- chest x-ray interpretation (71010-71020)
-- gastric intubation (91105)
-- temporary transcutaneous pacing (92953)
-- ventilation management (94656, 94657, 94660 and 94662)
-- vascular access (36000, 36410, and 36600).
4. Emergency Department Services (99281-99285)
• Services are provided in an organized hospital-based facility for the provision of
unscheduled visits for patients who present for immediate medical attention. The
facility must be available 24 hours per day.
Critical care services should be reported using the appropriate critical care codes.
CPT 2000 Changes: Code 99285 descriptor revised to clarify the patient's clinical
condition and/or mental status may preclude obtaining past pertinent medical history or
other events. 5. Neonatal Intensive Care Services ( 99295-99298)
• Services are provided to neonates (30 days or less) admitted to the intensive care unit.
Infants admitted to an intensive care unit older than one month should be assigned the
appropriate critical care or E/M codes.
Neonatal codes are global 24-hour codes and not reported as hourly services.
Once the neonate is not critically ill and attains a body weight exceeding 1500 grams,
the codes for subsequent hospital visits should be used.
The same definitions for critical care services apply for the adult, child and neonate
The following services are considered integral to the performance of neonatal care, and
should not be reported separately:
o Umbilical venous (36510) and umbilical arterial catheters (36620)
o Central (36488, 36490) or peripheral vessel catheterization (36000)
o Other arterial catheters (36140, 36620)
o Oral or nasogastric tube placement, endotracheal intubation (31500)
o Lumbar puncture (62270)
o Suprapubic bladder aspiration (51000)
o Bladder catheterization (5370)
o Initiation and management of mechanical ventilation (94656, 94657)
o Continuous positive airway pressure (CPAP) (94660)
o Surfactant administration, intravascular fluid administration, transfusion of blood
components (36430, 36440)
o Vascular punctures (36420, 36600) Categories of Evaluation & Management Services 3 o Invasive or non-invasive electronic monitoring of vital signs, bedside pulmonary
function testing, and/or monitoring or interpretation of blood gases or oxygen
saturation (94760-94762). D. E/M Modifiers
Before assigning a final code, it is important to check for potential modifiers that should be
assigned to report an altered service or procedure (e.g., an unusual or special circumstance
that affects the service or procedure). The following is a review of the modifiers used most
often with the codes in the evaluation and management section.
1. Prolonged Evaluation and Management Services
• Modifier - 21 or 09921
Used only with the highest level of each E/M category when the service provided is
greater than that usually designated for that code.
Documentation should be provided to describe the circumstances.
This modifier does not affect reimbursement under Medicare's physician fee schedule. 2. Unrelated Evaluation and Management Service by the Same Physician During a
• Modifier - 24 or 09924
This modifier is used to differentiate between a related and unrelated service during the
post-operative period. (Documentation must be submitted to the carrier when this
modifier is assigned.) The ICD-9-CM code must substantiate that the care was provided
for a condition unrelated to the condition that required surgery. 3. Significant, Separately Identifiable Evaluation and Management Service by the Same
Physician on the Same Day of a Procedure or Other Service
• Modifier - 25 or 09925
This modifier is used to differentiate services associated with global payment from
those to be considered separately for payment. (Sending supporting documentation with
the claim is not required when this modifier is applied.) This modifier should not be
used to indicate that the visit or consultation resulted in the decision to perform major
surgery. 4. Mandated Services
• Modifier - 32 or 09932
Used to inform the third-party payer that the service is required or mandated (e.g.,
PRO, governmental, legislative or regulatory requirement, or third party payer). Categories of Evaluation & Management Services 4 5. Reduced Services
• Modifier - 52 or 09952
In some instances, a service or procedure may be partially reduced or eliminated at the
physician's discretion. 6. Decision for Surgery
• Modifier - 57 or 09957
Identifies an evaluation and management service provided by the physician on the day
before, or the day of a surgery during which the initial decision to perform surgery was
made Categories of Evaluation & Management Services 5 ...
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This note was uploaded on 02/21/2012 for the course CODEING unknown taught by Professor Unknown during the Spring '12 term at Joliet Junior College.
- Spring '12