Documentation- Best practices for E&M Codes

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Hello, there all my friends and colleagues. This is Sam Collins, your coding and billing expert for chiropractic specifically the HJ Ross Company. And for all of you for the profession, it’s something that we all love. Something we want to make sure we’re always being at our best. What are the areas?

I commonly get questions. Cause I get them all the time and teaching seminars and doing our network service. Of course, I get a lot of offices to say, Hey Sam, how do I properly? Evaluation management. And considering the changes that have occurred with the update that happened in 2021, there’s still some confusion.

I think one of the things that always frustrated doctors at chiropractic was you often could have. That the exam takes a lot of time. The history is very involved. The patient has multiple complaints, but yet, because the medical decision-making, if you will, or the severity of the problem, wasn’t high enough, you will be limited to a 2 0 2 or 2 0 3, even though you spent an hour.

Of course, that has updated. And of course, now time can be used for an E&M code, but what about medical? Decision-making what about. Much like a medical doctor. They may see someone for a few minutes, but yet bill high value code because of what they’re seeing for, is there some sort of protocol for us or a doctor of chiropractic to do that?

And I will say yes, there is. So what we’re going to focus on a little bit in this conversation is how to make sure we’re understanding what the medical decision making portion of the evaluation management codes are. So let’s head over and go to the slides now. And what I want to focus in on here is the idea of.

Medical decision-making when it comes to E and M services. Let me make sure I’ve got this moving away. I want looks like this is coming up. Okay. There we go. It’s just taking a little bit of time to pause. So you’ll see here. Here are the codes we have. Of course, the E&M codes we’re all familiar with.

Of course it did change a little bit. We no longer have 9 9 2 0 1. We have 2 0, 2 to 2, 0 5. And then 2, 1, 1 to 2, 1 5. And of course, when you look at the codes, of course they have the same protocols. A new patient is brand new or three years and established patient would be someone you’ve seen within three years.

So that didn’t change. But what did change? In fact, let’s focus here is that they took away all those old components that you have to have for an E&M code. The complexity. The site of service and so forth, no longer do you have a minimum of a history and exam or a certain physical exam? Remember, in the old system you had to have kind of the number of bullets and the number of organ systems they’ve taken that away.

It doesn’t mean you still wouldn’t do some of that. It’s just no longer part of it. That is a mandatory level. The new system of course uses time. Or medical decision-making now time of course is pretty straightforward. It’s the time you spend with the patient examining. So I’m going to make sure everyone gets to that.

It is the time, but not the time, just face-to-face, but the time spent on the part of the visit in total. So if you are spending 30 minutes, but 10 of it is pre seeing the patient, maybe you’re reviewing notes of the patient, or maybe you have an electronic health record system that the patient fills out a lot of details.

History and so forth family, and then you review it, make some notes and then get in the room with the patient that all counts. So it is face-to-face time, but it’s also the time you spend before this. And after the visit so long as it’s related to the exam, the things you might do at the end would be completing the notes as many of you might do.

So you’ll look here and you’ll notice this is exactly what it says, and we’ll just pick the 9, 9 2 0 3 and you’ll notice it says office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and or examination. So I want to highlight now it just says the medically appropriate.

It’s no longer a minimum per se. However it does. Of low level medical decision-making and actually each of the codes do that. They will say whether it’s straightforward, low, moderate, or high. What we’re going to focus on today is that understanding. But I do want to make clear that everyone sees what is written in the last sentence of every code.

And it says when using time for code select. For 900, 203 specifically notice it says 30 to 44 minutes of total time is spent on the date of the encounter. So what’s important to note here. It’s the things you do on the date. So if before the patient comes at 11 o’clock nine in the morning, you’re reviewing their file of the history notes they sent in that will count.

Let’s say you had a staff person helped take information from the patient the time the staff does it doesn’t count, but the time that you spend reviewing the information from the staff, In addition, it would include the time after if you’re completing the notes. So that part is pretty straightforward.

I think that’s pretty easy to see, however it’s dealing with the medical decision-making and of course, I think just like the old code set, it has the levels which say straightforward, low, moderate, and high. So when you see that you still go what does that mean? So what a high level require that you spend 60 to 74 minute.

It might, but think of it. Have you ever been to a medical doctor when you’ve been with him or her for a relatively short period of time, but yet they build a high value code because the codes are not only based on time, but also on the medical decision making. So if you spend less time, but yet it’s of a high level of medical decision making, you could build a higher code.

Hence why an oncologist or a cardiologist often bill high level codes. Because even though they may not take an hour for the exam. The medical decision-making be that life or death because of those conditions with certainly lend to it. Now, does chiropractic fit into that realm? I think to some extent we do so long as we understand what these levels mean.

So straightforward, low, moderate, and high. You still hear that and go what is that? So what we have here is a chart and this is the chart it’s put out through the AMA. And it outlines each code with the level of, decision-making the number of complexity of areas, the types of medical decision making in the sense of the things you have to do, weather testing and the type of treatment.

Now I know I’m giving you this, your thing, wild Sam, this is overwhelming, but I want to break it down just a little bit simple. We can go a little bit more in depth, but I’m going to suggest that. A seminar with me and, or our network service will be that place to do it. But let’s take a look at kind of the simplistic nature of it.

You’ll notice here. It says 9, 9, 2 0 2 says straightforward. So what does straightforward mean in the sense of what am I evaluating? I think the easiest way to see it as notice that it says number and complexity of problems, it’s just one self-limited minor problem. So in the simplest sense, a straightforward.

As one complaint to one area, my shoulder, my neck, my back. Even if you don’t spend the 10 or excuse me, the 15 to 29 minutes with the service, could you still build a car? What if a patient came in and you were able to evaluate them? Would it be sufficient to build a two D 2 0 2, even though you didn’t hit the 15 minute threshold?

Absolutely. Because all it needs is one self-limited or minor problem, pretty easy to see. And you can see the medical decision making is pretty minimal. It’s not anything that you consider there’s any life depth morbidity, mortality, of course. So that was pretty easy. It is straightforward. Let’s talk about what does low mean, and this is where things, I think sometimes people get a little bit confused, but low simply means.

Patient with notice two or more self-limited problems. So when a patient has two complaints, would that automatically make the complaints? Probably a 2 0 3, even if you don’t spend a half an hour, because some of you are going to say Sam, I’m very efficient. I don’t need to take 30 minutes to evaluate a neon.

Or a neck and a low back together. And you’re probably right, but you shouldn’t be limited to just the 2 0 2 because you’re efficient, but it’s the level of problem. So think of it simply one complaint, one area, two. Two complaints, two areas 2 0 3, but what’s also the 2 0 3. Look at the last one. It says an acute uncomplicated illness or injury.

Now we don’t really qualify under the illness, but what a chiropractor qualify under injury. So you look at this, you’re going to say what trauma automatically make it a 2 0 3 in essence, that would, and it’s because the medical decision making of trauma brings it up to where now you’re going to do some additional things like order next.

So therefore that medical decision making becomes higher because you have to rule out other things. Could there be a fracture of something more severe? So simply put two complaints or trauma, 2 0, 3. Now where things get a little bit trickier. And I will say that chiropractors may not often qualify here, but you certainly know.

Is with the 2 0 4 2 1 4. Now probably qualifying it for time. Won’t be that difficult. Think of a personal injury patient that the exam and history does take 45 minutes to an hour. But what about that one that doesn’t take that long? How does this fit? So here it says moderate and you’ll notice it says stable, chronic illnesses, stable, chronic illnesses.

We don’t really fit there, but notice the last one, it says an acute complicated. So that’s not your simple trauma, but what about a person involved in a car accident with a whiplash disorder, but they also have numbness tingling in the hand or some radicular signs. I would certainly say that fits into a complicated problem.

So again, regardless of the time, It’s also can be based on the severity or complexity of what the patient’s presenting with. So moderate means probably for our purposes, not three areas. Of course, that would still be a 2 0, 2 or 2 0 3, excuse me. But the injury with complications now you’re gonna have to look at complications to be, you’re going to start ruling out certain things like notice here, and it’s hard to see it talks about prescription drugs.

Think of if a medical doctor is likely to script a drug for it, that automatically puts it up to a two zero. And so I would say in that same case for us, the medical decision-making is one that fits, but we’re also going to do some additional things. Like when you have a complicated injury, are you going to do additional testing?

Oh, you bet. We are. You’re going to probably send out for x-rays at minimum or take x-rays maybe even an MRI or CT scans. Lots of other testing, NCVs and so forth. So again, that severity is not one necessarily that it takes more time, but the complexity of what you’re reviewing. So again, time is one.

But medical decision-making the other. And I would say pretty severe trauma in my opinion, will likely fit a 2 0 4. Regardless if you don’t spend 45 minutes or not. Now what about the 2 0 5 2 1 5. This is where things do get a little bit harder. I don’t think we’re going to qualify on the medical decision making because it says hi, and it just make it simple.

You don’t want high medical decision making. Things that are going to create life death or long-term, or potentially serious disability. And if you think of it, do we see, or do chiropractors see patients of that nature? Yes, but not typically. So I’m not saying this will never happen, but it would be a bit unusual.

I think a scenario might fit this way. What if you have a patient that’s had an injury or have symptoms in their back where they complain of, my low back is hurting, but right. Where I see. It feels very numb or at times feels numb. That could be the signs of cauda equina syndrome. That of course could be very serious.

That’s when you’re going to say, Hey, let’s get you to the emergency room because that could lead to paralysis. That certainly would fit because that complexity is one that there’s a high risk. And that’s really the difference here is the risk. So medical decision making for a 2 0 5, I’m going to say is pretty well.

2 0 4. I won’t say is rare, but maybe not typical or 200 twos. I’m not going to really focus on the time. Tell me what you’re seeing. I bet many of you are very efficient and evaluating a patient with a trauma that could be fairly significant and do it in a half hour or less. And when you do it still would mean potentially a 2 0 4 or for certain 2 0 3.

So don’t be afraid to start choosing. Based on the complexity of what you’re seeing. Not necessarily time though. I think time does play a role. One thing I do want to be clear with though, what if you like to say, Hey Sam, the next day, I would like to do a report of findings for my patient. I’m all in.

Please understand though, that style doesn’t give you an extra way to bill anything in that day. You’ve unbuttoned. Counseling or report of findings is part of the overall E&M code. And if you choose to do it the next day, that’s certainly fine. You don’t bill extra for it. If it’s included in the same day, then you certainly can.

So be careful. However, I want to highlight something about coding and I want you to see here. This is a denial. I had an office that I was helping that got a denial that said, Hey Sam, I got an insurance company. This is an auto case, as you can. That denied them because it says here we cannot agree to pay you or that you qualify for a 2, 1 4, because you said in your own notes that you spent 20 to 25 minutes, therefore that doesn’t qualify a 2, 1, 4 requires 30 minutes.

So a couple of problems I have with this is why would you ever write? I spent 20 or 25. It can’t, it’s gotta be 20, 21, 22. So to me, it tells me they were looking at the old code set probably, but have they indicated they spent 30 minutes? Would they have qualified? They would have. Now that doesn’t mean just write 30 minutes because, but tell me how much time you really did spend.

And remember it’s prior, during and after so long as it’s the same day, but here’s the issue I have with this particular case. You’ll notice the date of loss. July of 2019, the date of the exam was February of 21. So we all would agree. This was a patient being examined for an auto case, basically a year and a half later, they were still having problems.

I don’t think the argument should have been, or what the provider should have done is made a dispute based on time. The dispute should have been in my opinion, being based on complexity, would we all agree a patient who’s getting care. Or an exam from an injury that happened a year and a half ago would be one of a fairly high complexity or severity.

So I don’t think time is there because clearly that’s a chronic condition. Chronic condition of that nature I think, is going to fit here. So be careful when you’re choosing your. Choose the code that fits best weather time becomes the driver or medical decision-making. And I want to be careful because just because you’re refrigerant doesn’t mean you can’t bill a higher code should the medical decision-making be there.

So now I’ve given you a short little primmer, but I know that’s a lot to try to absorb, but I wanted to give you a bit of it. Don’t be afraid to reach out to me. Obviously we’re have the network service that you can do. And remember HJ. Ross is always here for you. If you haven’t taken a look, go to our website, HJ Ross, click on our Facebook page.

Take a look because what we do is update news. Here’s the Medicare fee for service. I bet some of you said, Hey, Sam, what’s going on? I’ve noticed Medicare has reduced my fees. A little bit like 50 cents. Sequestrations back. Remember it. Got, they got rid of it during the pandemic. It’s now come back beginning, April 1st.

It’s back to 100. Beginning of July. It will be back to 2% now that’s not new. They just re implemented it. So when you see that 60 to 90 cents taken off, that’s just something that happens. Remember, we’re here for you. Check our new section, become part of the network. Make me part of your office. I could be your staff.

I could be on your team. We’re here to help chiropractor. HJ Ross company are your partners. What I want to say to all of you. Thank you. And I wish you well, next week, pay attention. Sherry. McAllister will be here. I’ll see you all at another time. Thank you. And wishing you the best.