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CHAPTER FIVE EVALUATION AND MANAGEMENT SERVICES Medicare Physician Guide: A Resource for Residents, Practicing Physicians and Other Health Care Professionals 53
This chapter discusses common sets of codes and evaluation and management (E/M) documentation. COMMON SETS OF CODES When billing for a patient’s visit, codes are selected that best represent the services furnished during the visit. The two common sets of codes that are currently used are: Diagnostic or International Classification of Diseases, 9 th Edition, Clinical Modification (ICD-9-CM) codes; and Procedural or American Medical Association Current Procedural Terminology (CPT) codes. These codes are organized into various categories and levels. It is the physician’s responsibility to ensure that documentation reflects the services furnished and that the codes selected reflect those services. The more work performed by the physician, the higher the level of code he or she may bill within the appropriate category. The billing specialist or alternate source reviews the physician’s documented services and assists with selecting codes that best reflect the extent of the physician’s personal work necessary to furnish the services. Evaluation and Management Services E/M services refer to visits and consultations furnished by physicians. Billing Medicare for a patient visit requires the selection of a CPT code that best represents the level of E/M service performed. For example, there are five CPT codes that may be selected to bill for office or other outpatient visits for a new patient: 99201 – Usually the presenting problem(s) are self limited or minor and the physician typically spends 10 minutes face-to-face with the patient and/or family. E/M requires the following three key components: o Problem focused history. o Problem focused examination. o Straightforward medical decision making. 99202 – Usually the presenting problem(s) are of low to moderate severity and the physician typically spends 20 minutes face-to-face with the patient and/or family. E/M requires the following three key components: o Expanded problem focused history. o Expanded problem focused examination. o Straightforward medical decision making. CPT only copyright 2008 American Medical Association. All rights reserved. Medicare Physician Guide: A Resource for Residents, Practicing Physicians and Other Health Care Professionals 54
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Medicare Physician Guide A Resource
Page 3 and 4: ICD-9-CM Notice The International C
Page 5 and 6: MEDICARE PHYSICIAN FEE SCHEDULE ...
Page 7 and 8: CHAPTER ONE INTRODUCTION TO THE MED
Page 9 and 10: THE MEDICARE PROGRAM The Medicare P
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Page 13 and 14: Part B - Medical Insurance Some of
Page 15 and 16: Where to Find Additional Informatio
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Page 43 and 44: OTHER HEALTH INSURANCE PLANS Medica
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For purposes of ROS, the following
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C. DOCUMENTATION OF THE COMPLEXITY
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occasion the physician who ordered
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Table of Risk Level of Risk Present
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1997 DOCUMENTATION GUIDELINES FOR E
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I. INTRODUCTION WHAT IS DOCUMENTATI
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III. DOCUMENTATION OF E/M SERVICES
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REVIEW OF SYSTEMS (ROS) A ROS is an
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Problem Focused Examination - shoul
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System/Body Area Respiratory Elemen
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Cardiovascular Examination System/B
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Ear, Nose and Throat Examination Sy
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Content and Documentation Requireme
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System/Body Area Elements of Examin
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System/Body Area Gastrointestinal (
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System/Body Area Skin Elements of E
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NUMBER OF DIAGNOSES OR MANAGEMENT O
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RISK OF SIGNIFICANT COMPLICATIONS,
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D. DOCUMENTATION OF AN ENCOUNTER DO
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