Medycoding

1.What is Evaluation and Management ?

Evaluation and Management (E/M) services are physician services that involve assessing a patient’s condition and deciding how to treat or manage it.

 

So,Evaluation includes:

1. Taking patient history

2. Performing physical examination

3. Reviewing tests and reports

4. Assessing the patient’s condition

 

Management includes:

1. Making a diagnosis

2. Ordering tests

3. Prescribing medications

4. Planning treatment

5. Counseling the patient

 

2.In what Scenario we can code 99211 ?

99211 is the lowest-level office/outpatient E/M service for an established patient.

It is used for minimal problems and typically does not require the physician’s direct involvement, but must be performed under physician supervision. For this not Key component of MDM is required.

Example: Simple suture removal after procedure,Patient receives a previously ordered injection, Routine wound check and dressing change.

 

CPT Code 99211: Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional

 

3.What are the code range for New Patient and Established Patient ?

99211-99215 Established Patient

99202-99205 New Patient

 

4.What are the E&M Updates ?

1. History and Physical exam no longer be the key component.MDM is the only key component.

2. 99241 Consult code deleted.

3. We can determine the level of care only based on time.

4. If time based E&M suggest high level than MDM based E&M then go with time based because of high severity.

 

5.What are the time range of E&M Level for both New and Established Patient ?

For New Patient

99202 : 15 to 29 Min

99203 : 30 to 44 Min

99204 : 45 to 59 Min

99205 : 60 to 74 Min

 

For Establish Patient

99212 : 10 to 19 Min

99213 : 20 to 29 Min

99204 : 30 to 39 Min

99205 : 40 to 54 Min

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6.What is new patient and established patient ?

A new patient is one who has not received any professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

 

An established patient is one who has received professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

 

7.What is Outpatient  status? 

Outpatients are the people who visit a hospital for treatment but are not admitted. These patients may stay at the hospital for few hours or even overnight. Since outpatient visits are short-term, outpatient coding is relatively less complex than inpatient coding.

 

8.What are initial and subsequent services ?

An initial service is when the patient has not received any professional services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, during the inpatient, observation, or nursing facility admission and stay.

 

A subsequent service is when the patient has received professional service(s) from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, during the admission and stay.​

 

9.What is the place of service ?

The place of service and service type are defined by the location where the face-to-face

encounter with the patient and/or family/caregiver occurs. For example, service provided to a

nursing facility resident brought to the office is reported with an office or other outpatient

Code.

 

10.What are the place of service used for Inpatient, Outpatient, Office Setting?

Place of Service for Outpatient is 22, Inpatient- 21 and for Office-11.

 

11.What is E&M Modifier?

These are the modifier used with E&M service only :

Modifier 24 : Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period.

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.

Modifier 57: Decision for Surgery:

Modifier 27: Multiple Outpatient Hospital E/M Encounters on the same date.

 

12.Who are qualified healthcare professional ?

A “physician or other qualified health care professional” 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.​

 

13.Who are Clinical staff ?

A clinical staff member is a person who works under the supervision of a physician or other qualified health care professional, and who is allowed by law, regulation and facility policy to perform or assist in the performance of a specific professional service but does not individually report that professional service.​

 

9.What is Principal diagnosis ?

Principal diagnosis is the primary condition or disease identified by a healthcare provider as the main reason for a patient's encounter or hospitalization.

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10.How to bill Telemedicine Service ?

1. Telemedicine service should be billed with E&M code (99202-99215) with 95 modifier.

2. Both audio and Video should be documented.

3. For Medicare GT modifier should be used.

 

11.How to bill audio only visits ?

1. For Audio only visit, need time to code.

2. Code from CPT range 99441-99443

3. 93 Modifier should be used.

 

12.What is Prolonged Service Code  and when to use ?

A Prolonged Service Code is used when a provider spends significantly more time than the typical time for an Evaluation & Management (E/M) service on the same date.

It is reported in addition to the primary E/M code when the total time exceeds the maximum time of the highest-level code.

You may report prolonged service code 99417 (each 15-minute increment beyond threshold).

For Medicare G2212 for each additional 15 min.

 

13.What is Consultation ? 

A consultation is a type of evaluation and management service provided at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient.

 

14.Is consultation initiated by patient is considered under consultation ? 

A “consultation” initiated by a patient and/or family, and not requested by a physician or other appropriate source (eg, physician assistant, nurse practitioner, doctor of chiropractic, physical therapist, occupational therapist, speech-language pathologist, psychologist, social worker, lawyer, or insurance company), is not reported using the consultation codes but may be reported using the office visit, home service, or domiciliary/rest home care codes as appropriate.

 

16.Is new or established patient exist in ED department like as E&M ?

No distinction is made between new and established patients in the emergency department. E/M services in the emergency department category may be reported for any new or established patient who presents for treatment in the emergency department.

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19.What is Medicare Preventive Visit ?

A Medicare Preventive Visit is a wellness-focused visit covered by Medicare to help prevent disease and promote early detection.

G0402 : Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment . Life time once code.

G0438 : Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit. Life time once code.

G0439 : Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit

​

20.How to report separte service performed along with E&M ?

Any specifically identifiable procedure or service (ie, identified with a specific CPT code) performed on the date of E/M services may be reported separately. The E&M service should report with Modifier 25.​

 

21.In how many different ways you can report E&M service ?

Select the appropriate level of E/M services based on the following:

1. The level of the MDM as defined for each service, or

2. The total time for E/M services performed on the date of the encounter​

 

Number of Complexity Grid

22.What is the meaning of "Problem" in MDM table ?

A problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other matter addressed at the encounter, with or without a diagnosis being established at the time of the encounter.​

 

23.What  is  the meaning of "Minimal problem" in MDM table ?

A problem that may not require the presence of the physician or other qualified health care professional, but the service is provided under the physician’s or other qualified health care professional’s supervision (see 99211, 99281).​

 

24.What does "Self limited or Minor problem" indicate in MDM table ?

A self-limited or minor problem is a health condition that usually gets better on its own or with simple treatment. It follows a short and predictable course, meaning it does not last long and is temporary. This type of problem is not serious and is unlikely to cause long-term damage or permanently affect the patient’s overall health. 

Examples include a common cold, mild sore throat, minor rash, or simple sprain. These conditions typically resolve without major medical intervention and have a low risk of complications.

 

25.What does "stable,chronic illness" indicate in MDM table ?

Stable, chronic illness: A problem with an expected duration of at least one year or until the death of the patient. For the purpose of defining chronicity, conditions are treated as chronic whether or not stage or severity changes (eg, uncontrolled diabetes and controlled diabetes are a single chronic condition).

 

"Stable" for the purposes of categorizing MDM is defined by the specific treatment goals for an individual patient. A patient who is not at his or her treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function. 

For example, a patient with persistently poorly controlled blood pressure for whom better control is a goal is not stable, even if the pressures are not changing and the patient is asymptomatic. The risk of morbidity without treatment is significant.​

 

26.What does "acute, uncomplcated illness or injury" indicate in MDM table ?

Acute, uncomplicated illness or injury: 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 selflimited or minor but is not resolving consistent with a definite and prescribed course is an acute, uncomplicated illness.​

 

27.What is meaning of "stable , acute illness"  in MDM table?

Stable, acute illness: A problem that is new or recent for which treatment has been initiated. The patient is improved and, while resolution may not be complete, is stable with respect to this condition.​

So in your sentence:

“The patient is improved and, while resolution may not be complete, is stable…”

It means:

The illness has started recently (acute)

Treatment has been started

The patient is improving

But the disease has not completely gone away yet

However, the condition is stable (not worsening)

 

28.What is chronic illness with severe exacerbation ?

Chronic illness with severe exacerbation, progression, or side effects of treatment: The severe exacerbation or progression of a chronic illness or severe side effects of treatment that have significant risk of morbidity and may require escalation in level of care.​

 

29.What is unique test and unique source indicated in MDM table ?

A unique test is defined by the CPT code set. When multiple results of the same unique test (eg, serial blood glucose values) are compared during an E/M service, count it as one unique test. Tests that have overlapping elements are not unique, even if they are identified with distinct CPT codes. For example, a CBC with differential would incorporate the set of hemoglobin, CBC without differential, and platelet count.

 

A unique source is defined as a physician or other qualified health care professional in a distinct group or different specialty or subspecialty, or a unique entity. Review of all materials from any unique source counts as one element toward MDM.

 

30.What is independent historian ?

An independent historian is someone who gives medical history about the patient when the patient cannot give complete or reliable information.

The patient cannot provide full information, such as:

• Young child

• Dementia patient

• Psychosis

• Confused or unconscious patient

• Developoment Stage

The provider does not have to speak to the independent historian face-to-face.The provider must get the information directly from that person, not through someone else.

 

31.What are the difference between Review of systems and the physical examination sections of the H&P mentioned by the physician ?

 

The ROS is a systematic inquiry of the patient's symptoms and signs, organized by body systems. The physician asks the patient a series of questions to obtain information about any current or past symptoms or medical conditions. The ROS includes questions about the patient's general health, such as fatigue, fever, or weight loss, as well as specific symptoms related to each body system, such as chest pain, shortness of breath, or abdominal pain.

 

The ROS is a comprehensive assessment of the patient's health status and helps the physician to identify any potential health problems that may require further evaluation.​

 

The PE is a physical examination of the patient's body, performed by the physician. The PE includes a thorough inspection, palpation, percussion, and auscultation of each body system. The physician examines the patient's vital signs, such as blood pressure, heart rate, and respiratory rate, and evaluates the patient's overall appearance, skin, and musculoskeletal system. The PE is a hands-on assessment of the patient's physical health and helps the physician to identify any abnormalities or physical findings that may require further evaluation.

 

32.What is Morbidity ?

Morbidity: A state of illness or functional impairment that is expected to be of substantial duration during which function is limited, quality of life is impaired, or there is organ damage that may not be transient despite treatment.

 

33.What is social determinantes of health ?

Social determinants of health are social or economic conditions that affect a patient’s ability to receive care, follow treatment, or maintain health.Examples may include food or housing insecurity.

Homelessness (Financial factor)

Lack of family support (Social Factor)

Unsafe environment (Social Factor)

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33.1.How the social determinantes of health (SDOH) affect MDM?

SDOH can increase risk of complications and/or Morbidity or Mortality of Patient Management.

If the provider documents that SDOH:

1. Significantly limits diagnosis or treatment

2. Affects compliance

3. Impacts management decisions

It may support Moderate MDM.

 

33.2.What is major or minor surgery term used in MDM ?

When we say minor surgery or major surgery in the MDM grid, it is based on how doctors commonly understand those terms — not based on CPT global period rules.

Major or minor surgery term used by trained clinicians based on :

• Complexity of procedure

• Risk involved

• Type of anesthesia

• Body area involved

• Expected recovery

 

34.What is Elective and Emergency procedure mentioned in MDM table ?

Elective and emergent/urgent procedures describe when a surgery is done based on how serious the patient’s condition is.

An elective procedure is typically planned in advance (eg, scheduled for weeks later), while an emergent procedure is typically performed immediately or with minimal delay to allow for patient stabilization. 

Both elective and emergent procedures may be minor or major procedures.
 

36.What is undiagnosed new problem with uncertaing prognosis ?

Undiagnosed new problem with uncertain prognosis: A problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment.
 

35.What is major and minor surgery ?

According to medicare, a major surgery has a global period of 90 days and minor surgery has a global period of either 10 or 0 days.

 

38.What are the Key component of Evaluation and Managment ?

E/M services are based on three key components:

History: It Includes:

1. Chief Complaint (CC) – Why the patient is here

2. History of Present Illness (HPI)

3. Review of Systems (ROS)

4. Past, Family, Social History (PFSH)

 

Examination

Physical examination performed by the provider.

May be:  Problem-focused, Expanded, Detailed or Comprehensive Exam.

 

MDM is based on 

1. Number & complexity of problems addressed

2. Amount/complexity of data reviewed

3. Risk of complications or morbidity/mortality

 

39.What are the Steps to assign a consultation code in E&M?

Step 1: Confirm There Is a Request for Consultation

There must be:

• A request from another physician or qualified healthcare professional

• The request must be documented in the medical record.

• Verify the Reason for Consultation

 

Step 2 : The consultant must:

Evaluate a specific problem

Provide an opinion and/or recommendations

 

Step 3 : Ensure the 3 R’s Are Met

For a true consultation, documentation must support:

• Request – From another provider

• Render – Consultant provides evaluation/opinion

• Report – Consultant sends written report back to requesting provider

All 3 must be present.

 

Step 4 : Confirm It Is Not a Transfer of Care

If the requesting physician transfers care completely to the consultant,

Then it is not a consultation — it becomes a regular E/M visit.

 

Step 5 :Choose Correct Setting

Consult codes differ by location:

Office / Outpatient Consult: 99242–99245

Inpatient Consult: 99252–99255

 

40.Is Consultation Applicable for Same Specialty or Different Specialty?

Consultation is generally applicable when requested by a different specialty provider, but it can be same specialty in limited situations.

 

41.How to report Consult code for Medicare ?

Medicare does not recognize consultation codes, regardless of specialty.

You must report appropriate E/M codes instead.

 

42.What is Office Visit and Outpatient Visit ?

An Office Visit is an Evaluation & Management (E/M) service provided in a physician’s office or clinic setting.

An Outpatient Visit is an E/M service provided in a hospital outpatient department or other facility where the patient is not admitted.

 

43.What is Split or Share Visit ?

A Split/Shared Visit is an Evaluation & Management (E/M) service performed jointly by a physician and a Non-Physician Practitioner (NPP) (such as a Nurse Practitioner or Physician Assistant) on the same patient, same day, in a facility setting.

It means:

Both the physician and NPP provide portions of the E/M service

The combined work determines the level of service

 

44.Who will bill the service for Split or Share Visit ?

Under current CMS rules:

The provider who performs the substantive portion of the visit must bill the service.

 

45.What is Susbstantive portion of the visit?

It is defined as:

Whoever has given more than 50% of total time or

The provider who performs the Medical Decision Making (MDM)

Whichever applies based on payer rules.

 

46.What Are Incident-To Services?

Incident-to services are services provided by a non-physician practitioner (NPP) (such as a Nurse Practitioner or Physician Assistant) that are billed under the supervising physician’s NPI in the office setting.

 

47.How to report incident to service?

1. Billed only in Physician office or clinic

2. The patient should be established.

3. The service must be part of the physician’s existing care plan.

4. The physician must:Be physically present in the office suite or Immediately available

 

48.What is concurrent care?

Concurrent care occurs when two or more physicians of different speciality provide medical services to the same patient on the same day for the same condition.

It usually happens in hospital settings.

 

49.Give an Example of concurrent care ?

Example: A patient is admitted for heart failure.

Cardiologist manages cardiac condition

Nephrologist manages kidney complications related to heart failure

Both physicians are treating related aspects of the same overall condition.

 

50.What is Transfer of care and how to report this services ?

Transfer of care occurs when one physician formally hands over the complete management of a patient’s condition to another physician.

After the transfer:

• The receiving provider becomes responsible for treatment.

• The original provider no longer manages that condition

It is reported using regular E/M codes, not consultation codes.

 

51.Can you bill E&M Service during Global days ?

Generally, E/M services are not separately billable during the global period, because routine follow-up visits are included in the global surgical package.

However, you can bill an E/M service during the global period if certain conditions are met.

 

1. Unrelated Visit-If the patient is seen for a condition completely unrelated to the surgery during the global period. Report E/M with Modifier 24

2. Significant & Separately Identifiable E/M – If on the same day as a minor procedure, the provider performs a separate and significant E/M service, you can report.Report E/M with Modifier 25

3. Decision for Surgery :If an E/M service results in the initial decision to perform a major surgery (90-day global period).Report E/M with Modifier 57

 

52.Can we use modifier 25 with preventive services ?

Yes — Modifier 25 can be used with preventive services, but only in specific situations.

Patient comes for Annual Preventive Exam (99396).

During the visit:

• Patient also complains of severe knee pain.

• Physician performs additional evaluation.

• Orders imaging and prescribes medication.

 

The knee pain evaluation is separate from the preventive exam.

 

How to Bill: 99396 – Preventive service

99213-25 – Problem-oriented E/M with Modifier 25

 

53.What Is the Welcome to Medicare Visit?

The Welcome to Medicare Visit is officially called the Initial Preventive Physical Examination (IPPE).It is a one-time preventive visit covered by Medicare Part B and must be performed within the first 12 months of a patient’s enrollment in Medicare Part B.

It is not a routine physical exam.

 

54.How to report Welcome to Medicare Visit?

Report with CPTG0402 – Initial preventive physical examination (IPPE)

Additional Codes (If Performed) :

(G0403–G0405) Screening EKG (if ordered/performed)

(EKG is optional and separately reportable.)

 

55.What is global period ? 

Global period is the period in which the the service that is related to the surgery performed are bundled  like preop visit and follow up service.

The three types of procedures that carry a global surgical package include simple, minor and major procedures.

 

Simple Procedures  (Zero Global Period): There is no preoperative/postoperative period so the global period is only the day of the procedure.

Services are generally simple minor procedures and some endoscopic procedures.

Minor surgical procedures  (10-day global period)

There is no preoperative period so the global period starts the day of the procedure.

There are 11 days in the global surgical package beginning the day of the procedure and then the 10-days following it.

Major surgical procedures  (90-day global period)

There is one day of preoperative care so the global period starts the day prior to the surgery.

Care on the day of the surgery is included in the global period unless the decision to perform the surgery was made during the visit on this day. (See modifier -57).

There are 92 days in the global surgical period beginning the day before the procedure, the day of the procedure, and the 90 days following it.

 

56.What is differential diagnosis?

Differential diagnosis is the process of listing and evaluating all possible medical conditions that could be causing a patient’s symptoms before making a final diagnosis.

In E/M coding, considering multiple differential diagnoses may increase:

• Complexity of problems

• Data reviewed

• Risk level

This can affect the MDM level.

​

57.Abbreviation of HCPCS?

Health Care Common Procedure Coding System

 

58.What is NCCI Edit ?

NCCI stand for National correct coding initiative. It is a system that helps ensure correct coding and prevent improper payment for medicare Part B claims. The NCCI has two type of edits

1. Procedure to procedure (PTP) edits

2. Medically Unlikely Edits (MUEs)

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When to use modifier 57 ?

Modifier 57 is appended to the E/M service when the physician makes the initial decision to perform a major surgery (90-day global period) on the same day or the day before the procedure.

When to Use Modifier 57

• An E/M service resulted in the decision for a major surgery.

• Surgery has a 90-day global period.

• The E/M service occurred on the same day or the day before the surgery. ( 24 to 48 hours before surgery )

Before 48 hours, Modifier 57 generally does not apply, because the decision was not made on the day before or the day of surgery.

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When to use modifier QW ?

Modifier QW is appended to certain laboratory CPT codes to indicate that the test is CLIA-waived, meaning it is a simple laboratory test approved for use under the Clinical Laboratory Improvement Amendments (CLIA).

When to Use Modifier QW

• The test is CLIA-waived.

• The laboratory or physician office has a CLIA Certificate of Waiver.

• The payer requires Modifier QW for that CPT code.

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Common Examples

CPT CodeTestModifier

81002-QWUrine dipstick (non-automated)- QW

87880-QWRapid Strep A test- QW

​​

Modifier JW is used to report the unused (discarded) amount of a drug or biologic from a single-dose vial or single-use package that is not administered to any patient but is eligible for Medicare payment. It is reported on a separate claim line from the administered dose.

​

When to Use JW

• Drug comes from a single-dose vial/single-use package.

• A portion of the drug is administered to the patient.

• The remaining amount must be discarded and cannot be used for another patient.

• The discarded amount is separately billable under the payer's policy.

Example

Drug: J1745 (Infliximab)

• Vial contains 100 mg

• Patient receives 70 mg

• 30 mg is discarded

Billing:

• J1745 × 70 mg (No modifier)

• J1745 × 30 mg–JW (Discarded amount)

​

When to use modifier JZ ?

Modifier JZ is used to indicate that no amount of a drug or biologic from a single-dose vial or single-dose package was discarded. It is reported on the claim to attest there was zero wastage. Medicare requires JZ for applicable single-dose container drugs when no drug is discarded.

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When to use modifier KX ?

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