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Sickness billing format for Product Management

e m is a tough concept to understand there's so many different components and sometimes it can make more sense when you isolate one specific code and just go over the components that way when i was a coding supervisor i supervised the coding specialist who did a lot of audits and education on our providers and one of the concepts that we focused on was our level fives because those were our biggest risks so we used to look at a lot of documentation altogether and say hey the provider thinks this is a level five what does everyone else think or we would say hey the provider codes it this way but i think this is a level five does everyone else agree because sometimes there's just these little tiny details that you can see it maybe hits a level five or it doesn't hit a level five if you're not super familiar with the different levels of office outpatient visits so for office outpatient we have five different levels one two three four and five the higher the level the bigger payment that's attached to it in our fee for service world so most providers want to build a level 5 when it's warranted because they know they're going to get reimbursed more money but what are the components of a level 5 visit well let's take a look so this is the grid for billing office and outpatient visits code through nine nine 99201-992 one five starting january first of twenty twenty one now you can watch some of my older videos if you want on how to build them based off of history exam medical decision making for dates of service prior to that but effective january 1 2021 this is what we utilize and what the guidelines basically tell us is for a level 5 service so we're going to isolate we're going to talk just about this section down here our level 99205 or 99215 we need a medically appropriate history and examination so what does that mean medically appropriate so for example if a patient's coming in and they have knee pain i would expect to see that the provider examined their knees so i would want to see a musculoskeletal examination and a review of their knee like are you having knee pain i would think that would be medically appropriate for something that was coming in for a patient complaint for knee pain prior to that there were all these little boxes and we had to calculate all the different boxes and even if they weren't related oftentimes providers could score higher levels of service but now they're saying you know because we've automated this and made it so much more efficient with emrs to just do a complete review of systems or do a complete exam it's just saying hey providers do what's medically appropriate that doesn't mean that they don't have to document a history an exam they should it just should be pertinent to what their thought process is what they're performing what they're asking what they're examining with that patient that day so if we zoom in actually here on our level five service let's actually look at these columns first so here we have the code the level of medical decision making and it says we need two out of the three elements of medical decision making so these are our three elements first one is number and complexity of problems addressed next is our amount of data or complexity of data to be reviewed and analyzed and then our risk of complications and or morbidity or mortality of patient management again i'm going to link this below so you can follow along if you want to look at your own copy but we need to meet at least two out of the three in the row that we're trying to code for so we would need to meet either the number and complexity of problems and amount of data or number of complexity of problems and risk or complexity of data and risk so two out of these three here one two three elements we need to meet at least three of these so if we look at our level five that means we would need to hit either the level to get our high level decision making we would need to hit either the elements here and here or here [Music] and here or here and here so two out of these three of these components one two three so in order to meet a high complexity we have to get one of these two things either this or this one is one or more chronic illnesses with severe exacerbation progression or side effects of treatment or one acute or chronic illness or injury that poses a threat to life or bodily function so for example a patient has copd if they have a severe exacerbation of their copd that would qualify as high so you know just the status of saying copd exacerbation alone doesn't qualify that because it says it has to be severe and that's a very key term there we have to prove that this is a severe exacerbation of a copd or an asthma or of kidney failure something that is a severe or side effects treatment so severe side effects of their treatment or we could meet one acute or chronic illness or injury that poses a threat to life or bodily function so remember bodily function is part of that so if maybe the patient is going to lose function of their kidney or their liver or even their ambulation because maybe they have gangrene and they're at risk of losing a limb bodily function that would qualify they're posing a threat to life that you're either going to die or they are going to lose a bodily function something like losing their sight losing their limb losing their liver and if you're ever concerned about these definitions and if something you're looking at meets the definition or not reference this guide and i'll link this below you can easily access it for free online the ama does provide this for free it's the cpt e m office or other outpatient and prolonged service code and guideline changes so these are the ones that were effective january 1st 2021 they also made technical corrections on this on march 9th of 2021 and they retro affected them to january 1st of 2021 and here you can see it gives some examples of this and it says examples may include acute myocardial infarction pulmonary embolus severe respiratory distress not just respiratory distress severe respiratory stress progressive severe rheumatoid arthritis etc etc etc now back to our grid so if we're looking at this element and we want to see if we mean this element this is what we would need to meet this extensive level of data reviewed so we have to meet at least two out of these three categories meaning that this is category one this is category two this is category three we have to get at least two of those so we could meet this or this or this or this or this or this so so two of these three so category one we would need any combination of three of the following a review of prior external notes from each unique source a review of the results of each unique test ordering of each unique test assessment requiring an independent historian and you can find those definitions again on that guideline page here it even tells you what we consider analyzed what we consider a test it says here this is one of the technical corrections that they put in here because there was some confusion about this a pulse oximetry is not a test i've had these in a lot of primary care urgent care settings even that's a little clip that they put on your finger and the reason they don't consider it a test is because it's more of a vital sign versus having a test and each unique test is defined by that cpt code so for it to be a test it has to have a cpt code and you can't be billing out for it separately because if you're billing out for it separately as that separate cpt code you're getting paid for reviewing and analyzing it on that cpt code you can't also get reimbursed for that in the consideration for your e m level as well category two is independent interpretation of tests so independent interpretation of a test performed by another physician or qualified healthcare professional again not separately reported now if you do something like a point-of-care test where you're doing a like you're in pregnancy where you're just looking and analyzing the results it's either positive or negative you either get credit for ordering or you get credit for reviewing that test you can't get credit for both so then our category two would be independent interpretation of a test performed by another physician or another qualified health care professional that's again not separately reported so if you're not billing out for interpreting that test you can count it for part of your e m service and then category three in here is discussion of management or test interpretation so discussion of management or test interpretation with an external physician so someone not in your physician group or other qualified healthcare professional appropriate source not separately reported again you can't be billing it out separately as an e m um an external physician they do define and there has been some questions about this because i've worked for example with a lot of pediatrician offices where they have peds and then they have peds specialties come in so they might have a peds gastro and a ped's cardiology because those are different subspecialties they would not be considered the same group so if peds is consulting with peds cardio that would be an external source because if you look here at the definition it says an external physician or other qualified healthcare professional who is not in the same group practice or as a different specialty or sub specialty so for high risk they do give some examples only but so it has to be something that is along this level of severity of risk if you're looking for more examples i would actually recommend the evaluation and management compendium i will link that below i have the digital version but they also make a print version you can buy it on amazon and that gives a lot more clarification it is published by the ama and i find it helpful because they don't give the clinical vignettes they took those out in 2021 because people were using those to code off of they would say hey this example here in the book is what my e m case is that i'm looking at for the documentation and that's the same level and now that we're kind of tweaking things they kind of temporarily at least took those small sample of like this is the type of scenario it would look like if you look at the back of your e m book for 2021 you can still find them for other types of evaluation and management services but not office outpace if they took those out temporarily but some examples would be drug therapy requiring intensive monitoring for toxicity again and that is defined here in the guidelines that the ama gave us so it says a drug that requires intensive monitoring is a therapeutic agent that has the potential to cause serious morbidity or death the monitoring is performed for assessment of these adverse effects and not primarily for the assessment of therapeutic efficacy so not just checking to make sure that the medication is working but to make sure that they're not having any toxic or adverse side effects and then it does give us some nice examples here so it says examples may include monitoring for cytopenia and the use of an anti-neoplastic agent between dose cycles or the short-term intensive monitoring of electrolytes and renal function in a patient who is undergoing diuresis examples of monitoring that do not qualify include monitoring glucose levels which i've heard some hospitals try to say in the past but yeah monitoring glucose levels during insulin therapy does not unless severe hypoglycemia is a current significant concern it also doesn't qualify if it's annual electrolytes than renal function for a patient on a diuretic it has to be intensive monitoring another example here is decision regarding elective major surgery with identified patient or procedural risk factor so not just the normal you know these are the risks of just surgery in general but specific to that patient also the ama does not go by the global surgical package definition of major surgery um you can elect as a healthcare organization to say well we're just going to go with as far as major or minor surgeries our definition is going to go with global periods and have that in writing it does kind of help more to streamline your processes within the healthcare organization that way but technically speaking per the ama they do not go just by the medicare definition of what is a major surgery versus what is a minor surgery and what i mean by that is medicare has certain surgeries that they've said it has a 90-day global like we expect that the recovery period everything that's going to be included in that should be about 90 days so those are your big surgeries so things like delivering a baby or having part of your liver removed or a kidney removed would be a major surgery something that would be more like a minor 10 day would be you know having a laceration repair or a mole removal or maybe a foreign body removed so that's going to have a short duration of recovery they're only going to include your post-op care for 10 days for those minor services an example of something that could be high risk as well decision regarding emergency major surgery a decision regarding hospitalization which i find interesting because in regards to the hospitalization they do kind of make this remark here so for example decision about hospitalization includes consideration of alternative levels of care but ultimately it doesn't say they have to be hospitalized as an inpatient it says that they are deciding that that's part of their medical decision making they're looking at this patient and going gosh you know we might have to hospitalize them and then finally in our level five one of the examples is decision to not resuscitate or to de-escalate care because of poor prognosis and that doesn't mean they're just looking at their end-of-life care decision or just stating that the patient's a dnr it means for that date of service for that level consideration for that medical decision making they had that conversation made that discussion to not resuscitate or they're de-escalating care they're moving them into hospice one of the things i've run into in the past is i've worked with hospitals that had hospitalists and then they had palliative care services which were separate and the palliative care providers would have those decisions regarding either end-of-life care wishes or you know hospice care and they would bill out the appropriate codes for that and then the hospitalist would come in the same day and go oh we're de-escalating care they're going on hospice and they would want to get credit for that as well well all that decision was really made by palliative care not hospitalists they were just notating the fact that those decisions were already made so the hospitalist services would not get credit for those end-of-life care planning or wishes that would all go to palliative care so let's say we have a patient here and they've got a severe exacerbation of their condition and they have and we have a decision regarding elective major surgery that would count for our level five because we've met two of these three elements they would be around that high risk they're doing major surgery and they are having a severe exacerbation now the difference between the 205 and the one five is the new versus established and that goes back to our definitions in our cpt book so in your cpt book they do provide a decision tree for new versus established patients which is helpful but basically um [Music] a new patient is one who has not received any professional services from the physician or qualified health care physician in the exact same specialty and subspecialty so kind of going back to our peds versus peds cardiology and they've not had services within that past three years so if they are established they have seen a provider in that group in that same specialty subspecialty within the past three years so that's our difference between our new versus our established patients sometimes with large organizations it can get difficult because they will group certain specialties together for the insurance companies so you might get denial saying hey this isn't a new patient it's really established and from what i've experienced in the past oftentimes you try to appeal and send notes and the insurance company just kind of stands by what they say that it's an established patient and they're going to pay you that lower established patient rate now we could also just build the services based off of times it would be 60 to 75 minutes the provider has to document an actual exact time not say it was approximately 60 to 75 minutes or it was approximately 62 minutes because they want the exact time for medicare now for our 99215 services it can be 40 to 454 minutes of total time and the total time definition is on here as well so if you look here when we're talking about total time that includes basically everything except for rooming the patient and taking their vitals so we have preparing to see the patient reviewing their tests obtaining or reviewing separately obtain history performing a medically appropriate examination or evaluation counseling and educating the patient family or caregiver ordering medications tests or procedures referring and communicating with other health care professionals when we're not separately reporting it out billing it with another cpt code documenting clinical information in the emr independently interpreting test results and communicating results to the patient or family caregiver and care coordination things that are not included are performance of services that are are billed separately so if we're doing a cerumen removal that doesn't go into our time because that's a service we're billing out with a separate cpt code travel is not included and teaching that is general and not limited to discussion that is required for the management of a specific patient is not included in that total time so that's it for our level five services if you want to see me go through all the other levels just kind of go backwards from five four three two one definitely let me know in the comments below i will see you guys in the next video and until then just keep on coding on