It's Me Hi, I'm the Problem
How is a " self limited or minor problem " defined?
AMA: A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status.
What constitutes "moderate" in Category 1? Is it three out of the four possible bullets or three from any combination in this category?
The requirements in the category can be met any way (as long as there are 3).
What are "social determinants of health?"
AMA answer: Economic and social conditions that influence the health of people and communities. Examples may include food or housing insecurity.
Only staff that is licensed to practice medicine counts when coding is based solely on time.
What are the 3 categories in E&M Coding?
Problems Addressed, Data Reviewed, Risk of Complications
Does this scenario qualify for an acute illness with systemic symptoms?
"Pt presents with pneumonitis with SOB, cough, loss of appetite, unintended weight loss, fatigue"
Yes because the patient has symptoms in other body areas/ organ systems than condition
Who qualifies as an independent historian?
AMA answer: An individual (e.g., parent, guardian, surrogate, spouse, witness) who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history
What level of risk is the decision regarding elective minor surgery with identified patient and/ or procedure risk?
Moderate Risk
If the provider documents that they spent 30 minutes performing chart review the day prior to the appointment, is this time billable?
No. non face to face time is billable, however it must be done on the date of service the patient was physically seen.
Which Modifier cannot be used on an E&M Code? 24, 57, 59, 25
59- This can only be applied to a Procedural CPT code.
How is "an acute, uncomplicated illness or injury" defined?
AMA answer: A recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected.
A problem that is normally self limited or minor, but is not resolving consistent with a definite and prescribed course is an acute uncomplicated illness.
Does a translator count as an independent historian?
No utilizing an independent historian does not include translation services.
The provider prescribes Metformin for a diabetic patient and the patient refuses the medication. Does this still count under prescription drug management?
Yes because although the patient declined, the Provider still utilized the prescription as their treatment plan in medical decision making
What is the Prolonged Service Code for Medicare?
G2212
How do you determine if the patient is New or Established?
A new patient is one who has not received any professional service from the physician or another physician of the same specialty who belongs to the same group practice, within the past 3 years, if the patient has been seen, they would be established.
If provider A documents that provider B is managing a problem, without their own assessment or coordination of care of the problem, does this qualify as a problem being addressed by physician A?
No, notation in the patient’s medical record that another professional is managing the problem without additional assessment or care coordination documented does not qualify as being addressed or managed by the physician or other qualified health care professional reporting the service.
No, discussion requires an interactive exchange, and the exchange must be direct and not through intermediaries (eg, clinical staff or trainees).
How many categories must you meet or exceed in order to level an E&M visit?
You must meet or exceed 2 out of the 3 categories in order to level an E&M visit.
How would you code an established pt with commercial insurance, when the provider spent 97 minutes with the patient?
99215 x1 , 99417 x 3
What does M.E.A.T stand for?
M- Monitoring
E- Evaluating
A- Assessing/Addressing
T- Treatment
Is it expected that the patient has a Low Risk of morbidity, when the problem addressed is an acute, uncomplicated injury requiring hospital inpatient, or observation level of care?
Yes: the definition is as follows
Acute, uncomplicated illness or injury requiring hospital inpatient or observation level care: A recent or new short-term problem with low risk of morbidity for which treatment is required. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. The treatment required is delivered in a hospital inpatient or observation level setting.
Is pulse oximetry considered a test when reviewing and analyzing data?
No it is not.
What is drug therapy requiring intensive monitoring for toxicity?
A drug that requires intensive monitoring is a therapeutic agent that has the potential to cause serious morbidity or death.
If documentation for an established patient supports- a moderate Problems addressed, Moderate Data Reviewed, and a low risk. But the provider states they spent 43 minutes with the patient. What is the correct CPT code for this date of service?
99215 based on time spent with the patient
The patient comes in for a routine Preventative visit. During the appointment the pt mentions a wart on their hand that is bothersome and sometimes irritated. The provider decides to prescribe medication for the patient to apply at home for removal. Is an additional E&M appropriate to bill along with the preventative visit?
Yes because the Provider assessed and addressed a separately identifiable problem- apart from the standard preventative visit.