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Seeing the Forest Through the Fees: Earning Your Green Using the New, Confusing CPT Codes

Seeing the Forest Through the Fees: Earning Your Green Using the New, Confusing CPT Codes

Elements of the examination and scoring guideTABLE 1 - Elements of the examination and scoring guide
History component guideTABLE 2 - History component guide
Process to determine the appropriate outpatient follow-up E&M codeFigure. Process to determine the appropriate outpatient follow-up E&M code
Medical decision makingTABLE 3 - Medical decision making, part 1
Medical decision making - amount and complexity of data and corresponding pointsTable 4 - Medical decision making, part 2
Medical decision making: risks of complications, morbidity, and mortalityTABLE 5 - Medical decision making, part 3
Choosing the overall medical decision complexityTABLE 6 - Choosing the overall medical decision complexity
CPT code guideTABLE 7 - Final code guide

Gone are the simpler days before 2013, when psychiatrists could bill third-party payers for their services using just a few codes based largely on the type of service provided, such as an initial evaluation (90801, 90802), psychotherapy with medication management (90805, 90807), or medication management alone (90862). Now, to more accurately capture the complexity of what many psychiatrists are actually doing, the new Evaluation and Management (E&M) codes in use since January 2013 are based on the components of the patient encounter, namely the history, the examination, and the assessment and plan, or medical decision making, to use the language of the code. Although the codes are more complicated to learn initially, psychiatrists can now deservedly (in our opinion!) get paid more for treating their more complicated patients or for engaging in time-consuming activities, such as coordinating care when necessary or providing psychotherapy.

The new, 5-digit E&M codes start with 99 and are usually used by physicians and other prescribers, such as nurse practitioners, for either an initial evaluation or for a psychiatric follow-up visit. But there are also add-on codes, such as psychotherapy codes and interactive codes, that can be combined with an E&M code or billed separately, as in the case of psychotherapy, to capture the additional complexity of the work.

In this article, we focus on the codes for outpatient follow-up visits, namely 99212 to 99215, because clinicians are likely to bill those codes most often. The Figure illustrates the process needed to determine the appropriate code.

The examination component

Let us review first the examination component of the encounter, which is the easiest to code. The elements of the examination are derived from Medicare’s 1997 documentation guidelines for evaluation and management services.1 Simply put, each element of the examination (eg, orientation, thought process) is counted, and the more you do and document, the more comprehensive the examination is. Documentation of 1 to 5 elements is scored as a problem-focused examination and 6 to 8 elements as expanded problem–focused. Nine or more documented elements count as detailed, and any 3 vitals plus 12 psychiatric elements and 1 or 2 neurological elements (either muscle strength and tone and/or gait and station) constitute a comprehensive examination. The elements and the scoring system are shown in Table 1.

In general, factors such as the chief complaint, interval history, medical status, and prescribed medications should guide how comprehensive you need to be regarding the examination as described above and the history component, which we describe next.

Coding the history component

The history component is a little more involved because it has 3 sections:

• History of present illness (HPI)

• Review of systems

• Past psychiatric/family/social history (PFSH)

Brief and extended HPIs are distinguished from each other by the amount of detail needed to accurately characterize the clinical problem(s). A brief HPI consists of 1 to 3 of the following elements: quality, duration, location, frequency, severity, timing, context, modifying factors, and associated signs and symptoms. An extended HPI consists of at least 4 elements of the HPI or the status of at least 3 chronic or inac-tive conditions. See Table 2 to compare the scoring of conditions versus elements.

For the review of systems (ie, constitutional, eyes, ears/nose/mouth/throat, skin, cardiovascular, respiratory, GI, genitourinary, integumentary, neurological, musculoskeletal, allergy/immunological, hematological/lymphatic, and endocrine), Table 2 shows that documenting just 1 system makes this section of the history component expanded problem–focused, and 2 to 9 systems documented confers a score of detailed. One or 2 systems are probably reasonable to inquire about if the clinician is prescribing a medication and assessing adverse effects (eg, sleep and energy level [constitutional], appetite [GI], palpitations [cardiovascular], muscle stiffness [musculoskeletal]). Physicians often forget to take credit for this review, but it is easy enough to do and document.


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