Table of Contents
Evaluation and Management Services
General Coding and Billing
Q: Why is it important to understand coding and billing?
A: Accurate coding and billing can result in more appropriate and timely reimbursement, while also protecting against claims denials and audits. Understanding coding and billing is an essential component of advancing ID physician compensation.
Q: What is “QHCP”?
A “QHCP” is a qualified healthcare professional, defined by the American Medical Association (AMA) as “is an individual who is qualified by education, training, licensure/ regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his or her scope of practice and independently reports that professional service.”
Q: What is a “NPP”?
A: “NPP” is used by Medicare and other payers to describe a non-physician practitioner, such as a physician assistant and nurse practitioner.
Q: Are split or shared visits the same as “incident to” visits?
A: No. Split or shared visits are visits in the outpatient setting that are shared between a physician and NPP within the same group practice. This means that both a physician and an NPP have face-to-face contact with the patient during the same visit. "Incident to" services are those that are furnished as an integral, although incidental, part of a physician's professional service in the course of diagnosis or treatment of an injury or illness. These services must be performed in a non-hospital setting and under the direct supervision of a physician. The services are typically performed by NPPs. Please see Split or Shared Visits (insert hyperlink) and “Incident To” (insert hyperlink) for specific information regarding these types of visits.
Q: With the new coding rules, I thought that I no longer needed to document a history or physical exam? Isn’t the level of service based on medical decision making (MDM) or time?
A: Level of service selection is based on MDM or time, but it is important to document an appropriate history and physical examination, when performed, as this documentation can also support the level of service selected. It is also important to appropriately document the patient encounter, including history and physical examination, when performed, to convey information and plan of care in the medical record to other clinicians.
Q: What is considered a “new” patient”
A: A patient is considered “new” to the provider if that patient has not received any professional service from that provider or any other provider in the same group within the previous three years.
Q: I am covering a physician in another group. Can I bill these patients as “new” since I have never seen them before?
When a physician or QHCP is covering for another physician/ QHCP, then the encounter would be billed as if the unavailable provider is doing the encounter (i.e., it would not count as a new patient or visit).
Evaluation and Management Services
Q: What are the two ways of billing an evaluation and management service:
A: Evaluation and management services may be billed by using either medical decision making (MDM) or total time on the date of the encounter.
Q: What is medical decision making (MDM)?
A: MDM is composed of three elements: number and complexity of problems addressed at encounter, amount and/or complexity of data reviewed/analyzed at the encounter, and level of risk associated with care of the patient
Q: What are considered problems addressed at an encounter?
A: For a problem to be considered “addressed” at the encounter if it is evaluated or treated during the encounter or there was consideration for treatment. A problem can include signs, symptoms, findings, complaints, illnesses, conditions, or diseases.
Q: What is a self-limited or minor problem?
A: This is a problem that has a definite and prescribed course, is transient in nature, and is likely not to permanently alter the patient’s health status. An example would be a patient evaluated for upper respiratory symptoms and diagnosed with a viral upper respiratory tract infection and no further evaluation, treatment, or monitoring is indicated.
Q: What is considered a chronic illness?
A: An illness is considered to be chronic if it has an expected duration of at least one year or until the death of the patient (e.g., diabetes, hypertension, HIV). The term “chronic” does not relate to the stage or severity of the illness.
Q: What does the term “stable” mean with regards to a chronic illness?
A: “Stable” refers to being at treatment goal. A patient with HIV who is on treatment with an undetectable HIV viral load is stable, but a patient with HIV on treatment who is not undetectable (treatment goal) would not be stable.
Q: What is considered data reviewed or analyzed?
A: Data are considered analyzed when the practitioner reviews medical data in determining the level of MDM. These data can include medical records, laboratory tests, imaging results, medical tests that were ordered, reviewed, or analyzed during the encounter.
Q: I am seeing a patient in the office that was seen by another physician in my practice two weeks prior, and I reviewed the note from that visit. Does this review count towards MDM?
A: No. Since the two physicians are in the same practice, review of the prior medical record note would not be counted toward the MDM.
Q: I ordered a complete blood count during a patient’s visit last week, but did not review the results with the patient until the follow-up visit today. How does this fit into selecting today’s E/M visit based on MDM?
A: Including the test order and its review in different visits for MDM credit is not allowed. When a test is ordered during a visit, it's considered part of the MDM for that day. If you discuss the results with the patient during a follow-up visit, you can't count this separately because it's included in the visit where it was ordered. However, if a test is ordered separately from any visit and the results are then reviewed during a subsequent visit, this can be included in the MDM for that visit.
Q: I have recurring laboratory orders for weekly labs that were ordered at their initial visit. How do account for reviewing these lab results?
A: Recurring orders that have previously been ordered may be counted during the encounter in which they were analyzed. If weekly lab orders for a complete blood count and a comprehensive metabolic panel were ordered to be done weekly for four weeks while on outpatient intravenous antibiotics, then those lab data can be used for the MDM determination during the encounter in which they were considered.
Q: I reviewed three blood culture results obtained over three different days. How many data reviewed can I count for these three blood cultures?
A: For MDM determination for tests reviewed or ordered it refers to “unique test”. An unique test is defined by the CPT code set (e.g., basic metabolic panel [80047]) and is considered a single test despite possibly having multiple laboratory values included. Reviewing multiple results of the same unique test when compared during an E/M service counts as one unique test. Therefore, the three blood cultures reviewed would count as one test reviewed for MDM determination purposes. Tests that have overlapping elements are not considered unique even if those tests are identified by distinct CPT codes. Some examples include if both a basic metabolic panel (BMP) and comprehensive metabolic panel (CMP) are reviewed, this only counts as a single test due to overlapping values of the BMP being encompassed in the CMP. Review of a molecular panel counts as a single test even though multiple targets are reported.
Q: I ordered an ECG to be done in the office and I billed for reading the ECG. Can I also use the ECG as part of data ordered and reviewed for MDM determination?
A: No. If the data are a service for which a professional component is separately reported by the physician or other QHCP, such as an ECG performed in the office and the ECG with interpretation were separately billed, then that cannot be used as an element for MDM determination.
Q: The patient’s spouse was in the room with the patient and gave all of the history for the patient although the patient was able to relate a good history. Can I still use the spouse as an “independent historian”?
No. An “independent historian” such as a parent, guardian, surrogate, spouse or witness provides additional history to the history provided by the patient who is unable to provide a complete or reliable history or because a confirmatory history is judged to be necessary. Since the patient is able to relate a good history, no confirmatory history is needed and the spouse would not meet the definition of an “independent historian.” If an independent historian is used, then it is important to clearly document the historian and why they were specifically needed to provide history (i.e., why the patient is unable to provide his/her own history).
Q: What counts as “independent interpretation of tests”?
A: If a test for which there is a CPT code and an interpretation or report is customary that is reviewed and interpreted by a provider and that interpretation is documented in the medical record and that interpretation is not separately reported and billed, then this would qualify as “independent interpretation of tests”.
Q: What is considered discussion of management or test interpretation with external physician/other qualified health care professional?
A: This is a direct interactive exchange, not through intermediaries such as clinical staff or trainees, and the discussion is used in medical decision making on the day of encounter. The discussion may be asynchronous and may occur on a date other than the date of encounter, but it is only considered once for MDM in an individual encounter. Simply routing a chart note through the electronic health record would not meet the necessary criteria for “discussion.”
Q: What is an external physician or other QHCP?
A: An external physician or other QHCP is not in the same group practice or in the same specialty or subspecialty.
Q: What is a unique source?
A: A unique source is a physician or other QHCP who is in a distinct group or different specialty or subspecialty or a unique entity. All medical record notes from a unique source count as one element toward MDM.
Q: What is risk of complications of patient management?
A: Risk is the probability and/or consequence of an event to occur when the addressed problem is treated appropriately. The level of risk is determined by the nature of the considered event, such that a low probability of death to occur with treatment may be a high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be a low risk. Risk is based on the problems addressed at the encounter and includes diagnostics and disposition considered during the encounter. Diagnostics, therapeutics and decisions regarding hospitalization, escalation of care or surgery considered during the encounter contribute to the risk and include those considered, but not done.
Q: How do I determine if a drug therapy requires intensive drug monitoring?
A: Intensive monitoring may be long-term or short-term. Long-term intensive monitoring is not performed less than quarterly. You should consider drug therapy to require intensive drug monitoring if the monitoring includes either laboratory tests, physiologic tests or imaging as history and physical examination is not included and the monitoring is required due to the potential of the dug to cause serious morbidity or death and requires intensive monitoring for potential adverse effects and not primarily for assessment of therapeutic efficacy.
Q: What activities would count toward total time on the date of encounter?
A: Time for all activities, including face-to-face and non-face-to-face activities, that are spent on the date of encounter that are not separately billed can be summed to get total time on date of encounter. These activities include: preparing to see patient, reviewing medical records, obtaining history, performing physical examination, counseling/ educating patient/ family/ caregiver, ordering medications/ tests/ procedures, communication with other medical providers, documentation, independent interpretation of tests, care coordination.
Q: Can I count the time it takes to walk to the microbiology lab to review Gram stains and cultures for a patient?
Time spent for travel should not be used to count for total time on date of encounter.
Q: Do I have to say which way, MDM or time, that I am using to select my level of service?
A: No. You do not need to document that you are billing using MDM or time as criteria to select your level of service, but your documentation should reflect that information that was used to select your level of service. If billing by MDM, then you should have documented in the medical record those parts of the MDM that were used to select the level of service. If billing by total time on date of encounter, then you should document total time spent on that date of encounter and those activities performed for that visit.
Q: Can I guess at the time I spent with an encounter?
A: You should be as specific as possible with time spent during an encounter if that is the criterion used for level of service selection. You should not guess at that time nor round up or round down your time.
Q: Sometimes I increase my level of billing because the work I did seemed to me more than what the actual level of service came out to be. Can I do this?
A: You should only bill for the services provided and documented in the chart. If you are deciding on a level of service and you “feel” that you did more work than what that level of service entails, then you should review your documentation to assure that all that work that was performed was done. You can also review the total time on date of encounter spent with that visit as this may allow for a higher level of service rather than billing by medical decision making (MDM).
Q: I am the physician performing a split or shared visit with my QHCP and my QHCP discussed the patient with the physician who performed and interpreted the echocardiogram which was used for MDM. Can I use that for me to consider in MDM?
A: No.
ICD-10 Coding
Q: I am unsure of the diagnosis. How should I choose an ICD-10 code?
A: In the inpatient (hospital) setting, it is acceptable to code diagnoses as if they were established when they are documented as "probable," "suspected," "likely," "questionable," "possible," or "still to be ruled out" by the provider. For instance, possible pneumonia due to unknown bacteria in a patient with clinical findings suggestive of, but not definite for, pneumonia can be coded with ICD-10 code J18.9 “Pneumonia, unspecified organism.” In the outpatient setting, if a diagnosis is not definitive, then coding for signs and symptoms is acceptable. For example, a patient with an acute cough with probable pneumonia should be coded with ICD-10 code R05.1 “Acute cough.”
Q: Why is it important to be specific when documenting diagnoses in the chart?
A: Coding and billing professionals rely on medical record documentation to support code selection; they cannot make assumptions or extrapolate information to assign diagnoses. Your documentation should be as specific as possible to facilitate accurate coding. As an example, a diagnosis such as “cellulitis” would be coded as L03.90 “Cellulitis, unspecified”, but if it is actually cellulitis of the right leg, your documentation should specify that so the correct ICD-10 code can be chosen, in this case L03.115 “Cellulitis of right lower limb.”
Q: Why can’t I write “urosepsis” in the chart?
A: “Urosepsis” does not have an ICD-10 code, but maps to urinary tract infection ICD-10 codes. If a patient has “urosepsis,” document “sepsis due to urinary tract infection” so that the appropriate code(s) can be selected.
Modifiers
Q: What is a modifier?
A: A modifier identifies that a service or procedure performed was altered or modified or that more than one service or procedure was performed.
Q: What is modifier 25?
A: Modifier 25, Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service, indicates that more than one service or procedure were required on same day and that both services/ procedures were separate and significant. Both of the services/ procedures can be done for the same diagnosis.
Q: Do I need a modifier for a telemedicine service?
A: Modifier 95, Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System, indicates that a service was performed through synchronous interactive audio and video telecommunications system.
Q: What is modifier FS?
A: Modifier FS is a modifier used for Medicare claims indicating that an evaluation and management service was performed as a split or shared visit.