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New and Established Patient E/M Definitions (CMS vs. CPT®)

I get lot of requests from readers of The Happy Hospitalist asking how to know if a patient is a new or established patient. Identifying the correct classification will prevent delays or denials of payment. Many evaluation and management (E/M) codes are by definition described as new or established. This lecture will attempt to explain various important clinical aspects related to this determination. Keep in mind while the Centers For Medicare & Medicaid Services (CMS) uses Current Procedural Terminology (CPT) codes, CMS definitions do not always agree with CPT® definitions. This discrepancy often leads to confusion for practitioners. I will attempt to provide some insight into these differences as well. I am a practicing clinical hospitalist with over ten years of experience and I understand how complicated these E/M rules can be. I have written an extensive collection of CPT® and E/M lectures to help physicians and other non-physician practitioners (NPP) navigate the complex rules of medical billing and coding. The Medicare Evaluation and Management Services Guide on page six defines a qualified NPP as nurse practitioners, clinical nurse specialists, certified nurse midwives and physician assistants.

CPT® DEFINITION OF NEW VS. ESTABLISHED PATIENTS

The CPT® definition of a new patient underwent subtle changes in 2012. Unfortunately, CMS did not change their definition to stay aligned with these changes. This difference in language has caused great confusion for many qualified healthcare practitioners trying to stay compliant with the complex rules and regulations of E&M. I encourage all readers to have a handy copy of the American Medical Association's CPT® manual for quick and easy reference. The 2015 standard edition manual is available for purchase from Amazon by clicking on the image to the right. How does the 2014 CPT® manual define a new patient?

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

Let's look at this definition a little closer. The 2014 CPT® manual defines professional services as those face-to-face services provided by physicians or other qualified health care professionals who may report an E/M service by a specific CPT® code. In other words, if you provided a service, such as interpretation of an EKG or you read an echo, or you called in a prescription but you did not provide a billable E/M face-to-face encounter, the patient is still considered a new patient by the definition of professional services. The 2012 updated definition of a new patient also added in the the words exact as well as and subspecialty. Unfortunately, CMS did not change their definition to recognize this change in specialty determination.

CPT® DEFINITION DECISION TREE

Decision trees may provide an easier way for qualified practitioners to understand these rules. A new vs. established patient decision tree analysis is provided here, as it is in the CPT® manual.

Decision tree new vs old patient CPT definition

CMS DEFINITION OF NEW VS. ESTABLISHED PATIENTS

CMS provides insight into their definition of new versus established patients in several important resources. These definitions are not the same as the updated 2012 CPT® definition. First, a CMS definition of a new patient is provided in section 30.6.7 of Chapter 12 of the Medicare Claims Processing Manual (pdf page 52). From section A:

Definition of New Patient for Selection of E/M Visit Code

Interpret the phrase “new patient” to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years. For example, if a professional component of a previous procedure is billed in a 3 year time period, e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit. An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.

Page 7 of the Evaluation and Management Services Guide also provides definitions of new and established patients.

For purposes of billing for E/M services, patients are identified as either new or established, depending on previous encounters with the provider.

A new patient is defined as an individual who has not received any professional services from the physician/non-physician practitioner (NPP) or another physician of the same specialty who belongs to the same group practice within the previous three years.

An established patient is an individual who has received professional services from the physician/NPP or another physician of the same specialty who belongs to the same group practice within the previous three years.

Both definitions lack the updated CPT® definition that includes the exact same specialty and subspecialty. This has lead to great confusion when trying to define when a patient is new vs. established within the same group practice but of different specialty or subspecialty. For patients not covered by Medicare, knowing how the insurance carrier reconciles this difference may prevent delays or denials of claims.

DEFINITION OF A GROUP PRACTICE (CMS)

One must also know how to define a group practice to interpret the new and established patient rules. Medicare has defined a group practice in Chapter 5 of Medicare General Information, Eligibility, and Entitlement. Section 90.4 (pdf page 38) says:

A group practice is a group of two or more physicians and non-physician practitioners legally organized in a partnership, professional corporation, foundation, not-for-profit corporation, faculty practice plan, or similar association:
In which each physician who is a member of the group provides substantially the full range of services which the physician routinely provides (including medical care, consultation, diagnosis, or treatment) through the joint use of shared office space, facilities, equipment, and personnel;
For which substantially all of the services of the physicians who are members of the group are provided through the group and are billed in the name of the group and amounts so received are treated as receipts of the group;
In which the overhead expenses of and the income from the practice are distributed in accordance with methods previously determined by members of the group; and
Which meets such other standards as the Secretary may impose by regulation to implement §1877(h)(4) of the Social Security Act. The group practice definition also applies to health care practitioners.

This Medicare carrier further clarifies the definition of a group practice by stating we determine whether physicians are members of the same group based on the Tax Identification Number. They also have an assortment of other clinically relevant scenarios in question and answer format. I encourage all readers to review them for their own educational value.

RECOGNIZED MEDICARE SPECIALTIES

What specialties does Medicare recognize? This list can be found in Chapter 26 of the Medicare Claims Processing Manual in Section 10.8.2 (starting on page 37).

Physicians are allowed to choose a primary and a secondary specialty code. If the carrier and DMERC provider file can accommodate only one specialty code, the carrier or DMERC assigns the code that corresponds to the greater amount of allowed charges. For example, if the practice is 50 percent ophthalmology and 50 percent otolaryngology, the carrier/DMERC compares the total allowed charges for the previous year for ophthalmology and otolaryngology services. They assign the code that corresponds to the greater amount of the allowed charges.

Effective April 1st, 2012, these are the 63 recognized physician specialty codes. Medicare provides a definition of each recognized specialty here.

01 General Practice
02 General Surgery
03 Allergy/Immunology
04 Otolaryngology
05 Anesthesiology
06 Cardiology
07 Dermatology
08 Family Practice
09 Interventional Pain Management
10 Gastroenterology
11 Internal Medicine
12 Osteopathic Manipulative Medicine
13 Neurology
14 Neurosurgery
16 Obstetrics/Gynecology
17 Hospice and Palliative Care
18 Ophthalmology
19 Oral Surgery (dentists only)
20 Orthopedic Surgery
21 Cardiac Electrophysiology
22 Pathology
23 Sports Medicine
24 Plastic and Reconstructive Surgery
25 Physical Medicine and Rehabilitation
26 Psychiatry
27 Geriatric Psychiatry
28 Colorectal Surgery (formerly proctology)
29 Pulmonary Disease
30 Diagnostic Radiology
33 Thoracic Surgery
34 Urology
35 Chiropractic
36 Nuclear Medicine
37 Pediatric Medicine
38 Geriatric Medicine
39 Nephrology
40 Hand Surgery
41 Optometry
44 Infectious Disease
46 Endocrinology
48 Podiatry
66 Rheumatology
70 Single or Multispecialty Clinic or Group Practice
72 Pain Management
73 Mass Immunization Roster Biller
76 Peripheral Vascular Disease
77 Vascular Surgery
78 Cardiac Surgery
79 Addiction Medicine
81 Critical Care (Intensivists)
82 Hematology
83 Hematology/Oncology
84 Preventative Medicine
85 Maxillofacial Surgery
86 Neuropsychiatry
90 Medical Oncology
91 Surgical Oncology
92 Radiation Oncology
93 Emergency Medicine
94 Interventional Radiology
98 Gynecological/Oncology
99 Unknown Physician Specialty
C0 Sleep Medicine

RECOGNIZED AMA SPECIALTIES AND SUBSPECIALTIES

What about other specialties or subspecialties not recognized by Medicare? Here are several nice resources reviewing AMA physician specialty codes

AMA physician specialty groups and codes
American Medical Association self designated practice specialty definitions
Side-by-side comparison AMA and Medicare recognized specialties.

DIFFERENCE BETWEEN CPT® AND CMS CAUSING CONFUSION

Clearly, these differences in how a new vs. established patient are defined has caused great confusion for providers. This April 15th, 2011 letter to CMS from the AMA provides further insight into the confusion.

NEW VS. ESTABLISHED PATIENT DETERMINATION DOES NOT APPLY

By CPT® definition, not all E/M codes require the qualified practitioner to determine if the patient is new or established. Which common E/M code groups are excluded from the new patient vs. old patient determination?

Initial observation care (99218-99220)
Subsequent observation care (99224-99226)
Observation care discharge services (99217)
Initial hospital care (99221-99223)
Subsequent hospital care (99231-99233)
Admission and Discharge Services same day (99234-99236)
Hospital discharge services (99238, 99239)
Critical care services (99291, 99292)
Emergency department services (99281-99285)
Initial nursing facility care (99304-99306)
Subsequent nursing facility care (99307-99310)
Inpatient consultations (99251-99255). This code group is no longer recognized by CMS.
Office or other outpatient consultations (99241-99245). This code group is no longer recognized by CMS.

NEW VS. ESTABLISHED PATIENT DETERMINATION DOES APPLY

By CPT® definition, some E/M codes require the practitioner to determine whether the face-to-face encounter involves a new patient or an established patient.

Office or other outpatient services new patient (99201-99205)
Office or other outpatient services established patient (99211-99215)
Domiciliary, rest home (eg, boarding home), or custodial care services new patient (99324-99328)
Domiciliary, rest home (eg, boarding home), or custodial care services established patient (99334-99337)
Home services new patient (99341-99345)
Home services established patient (99347-99350)
Preventative medicine services new patient (99381-99387)
Preventative medicine services established patient (99391-99397)

NEW VS. ESTABLISHED CLINICAL EXAMPLES IN THE HOSPITAL

Most E/M code groups used in the hospital do not require the practitioner to determine whether the patient is new or established in their group practice. However, one common hospital billing and coding scenario does require quite a bit of effort to determine the correct E/M code group. As a consultant caring for a Medicare patient in the hospital under ambulatory surgery center (ASC) or observation status, practitioners are directed to use the office or other outpatient service codes. This also applies to any other patient who's insurance does not accept consultation codes. Determining whether the patient is a new patient or an established patient is necessary to prevent delays or denials in payment.

A 42 year old morbidly obese man with chronic lymphedema and a diagnosis of bilateral cellulitis is admitted to observation status by a hospitalist in a different group as a direct admission from the primary care physician's office with a request to consult an infectious disease specialist.

In this scenario, the hospitalist would use the attending physician initial observation code group 99218-99220 for the admission, code group 99224-99226 for subsequent care visits and 99217 for the date of discharge. However, the infectious disease (ID) consultant would first have to know whether the patient's insurance carrier accepts consultation codes. If they do, the initial encounter should be coded as an outpatient consultation (99241-99245). All subsequent care visits should be coded as office or other outpatient services of an established patient (99211-99215).

However, if the patient's insurance does not accept consultation codes, then the ID consulting specialist must determine whether the patient is a new patient or an established patient in their group practice. If the ID specialist determines the patient is new, they should bill their initial encounter as an office or other outpatient service of a new patient using code group 99201-99205. If they determine the patient is an established patient of their group practice, they should choose the office or other outpatient service established patient code group 99211-99215 as their initial and all subsequent care visits. Here is another clinical example.

A healthy 37 year old with stable seasonal allergies is admitted under ASC status by an orthopedic surgeon for shoulder surgery. The hospitalist is consulted for medical management.

What should the hospitalist bill? The hospitalist must follow the same decision analysis as the ID specialist did in the clinical example above. Most hospitalists do not have their own office charts or EMR to reference when trying to determine if they have seen the patient in the last three years. The only way to know for sure whether any other hospitalist or other physician of the same specialty or non-physician practitioner (NPP) working with the same specialty in the same group practice has seen the patient in the last three years is to search their hospital's EHR for evidence of any prior H&P, consult note or other face-to-face E/M progress note visit that would qualify as a professional service. Most doctors don't have the time, energy, education or resources to figure all that out.

NEW VS. ESTABLISHED CLINICAL EXAMPLE IN THE OFFICE

Excluding consultation codes, choosing new vs. established codes in the office is straight forward. Either the patient is or isn't a new patient based on the prevailing rules of the patient's third party payer. If the patient is a new patient, choose code group 99201-99205 for the initial encounter and 99211-99215 for subsequent established care visits until it is determined the patient is no longer an established patient. If the patient is not a new patient, established care codes should be used.

If consultation codes are allowed by the patient's insurance company, then code group 99241-99245 should be used for the consult request. Depending on whether a transfer of care is made or not, subsequent visits should be coded using either this same consult code group or the office established patient code group (99211-99215).

A 78 year old Medicare patient is referred by the primary care physician to a cardiology group for chest pain. A stress test, ordered the day prior, was read as abnormal by a different cardiologist in the same group practice.

What should the cardiologist code for their initial E/M encounter? Based on the Medicare definition detailed above, reading of a stress test does not constitute professional services. It should be ignored when determining whether the patient is new or established. In addition, Medicare does not recognize consult codes. Cardiology is a Medicare recognized specialty. If the patient has received any professional services (E/M service or other face-to-face service) by any cardiologist or NPP working under the direction of the cardiologist or any other cardiologist in the same group practice in the last three years, only the established patient clinic code group 99211-99215 can be used. If no cardiologist or NPP working with a cardiologist in this group practice has seen the patient in the last three years, then the patient is a new patient. Code group 99201-99205 should be used for the initial visit.

NURSE PRACTITIONER AND PHYSICIAN ASSISTANT E/M VISIT SCENARIO

Qualified non-physician practitioners are considered part of the group practice and specialty for which they provide service along with physicians in the same specialty and group practice. In fact, Medicare's E/M Services Guide (on page 7 linked above) states quite clearly that non-physician practitioners are treated the same as physicians as providers of professional services over the three year time frame. Even the CPT® definition bundles the physician with qualified health care professional in their definition of new vs. established patients. In addition, the 2014 CPT® manual says

When advanced practice nurses and physician assistants are working with physicians they are considered as working in the exact same specialty and exact same subspecialties as the physician.

ON CALL AND CROSS-COVERING PROFESSIONAL SERVICES SCENARIO

If a physician or other qualified NPP is providing cross-cover care for another physician, how does this affect the new or established patient decision? The answer to this question has been answered by WPS, a Medicare contractor.

In the instance where a physician is on call for or covering for another physician, the patient's encounter will be classified as it would have been by the physician who is not available.

The 2014 CPT® manual says

In the instance where a physician/qualified health care professional is on call for or covering for another physician/qualified health care professional, the patient's encounter will be classified as it would have been by the physician/qualified health care professional who is not available.

I find this guidance interesting and conflicting with the definition of a new patient. If one solo practitioner is providing coverage for another solo practitioner in a different group practice, they have different tax identification numbers. By their own admission, Medicare states they audit the new vs. established patient decision based on the tax identification number. Their computer algorithms may not be able to establish an on call or cross-covering scenario in situations where two physicians, whether of like specialty or not, of different groups with different tax identification numbers, are providing coverage for each other.

When would this scenario occur? Consider the hospital observation scenario where one physician is providing on call services for another physician and they are asked to consult on a Medicare observation patient being admitted to the hospital by another group practice. It may be possible the on call physician has not seen the patient in the last three years but the patient's normal physician has. Should the cross-covering physician bill for a new patient encounter or an established patient encounter? According to CMS and CPT® guidance, the on call physician should bill as if they were the patient's normal physician. However, if they choose to bill the E/M visit as a new patient encounter, it may be difficult for computer algorithms to identify this coding error due to the different tax identification numbers used by both physicians. In fact, the covering physician wouldn't even know whether the patient had professional services provided by the patient's normal physician in the prior three years as they probably would not have access to their office records.

MULTIPLE PRACTICE SITES, SAME TAX ID SCENARIO

Consider the scenario where a family practice group has multiple sites of care all billing under the same tax identification number. Each site has their own patient records that are not available at other clinic sites. The patient is now being evaluated at a clinic site by a different physician or NPP who has never seen the patient and has no records available. Should this patient be coded as a new patient or an established patient? If a patient has been seen in the previous three years by any physician or NPP in the same group and specialty, regardless of which clinic site they went to and regardless of whether patient records are available, only established patient codes should be used. CMS and CPT® rules do not provide exceptions to practice sites that do not have access to records.

Site of service also does not apply if the patient received professional services in the hospital or in the emergency department. Consider the scenario where Physician A provides inpatient hospital care for a patient. The patient has never been seen previously by Physician A or any other physician or NPP in the same specialty and same group practice of Physician A. The patient is discharged and fails to follow up as requested. Two years later the patient calls the office of Physician A requesting to establish care in the clinic with Physician A. Because Physician A has provided professional services in the last three years, the patient is considered an established patient, regardless of which physician or NPP in the in the same specialty and group practice provides the care.

CHANGE IN GROUP PRACTICE SCENARIO

How should a physician or NPP code patients after they have left one group practice and joined another? Under a new group or solo practice, the physician would have a new tax identification number. However, the definition of a new patient says they cannot have received professional services in the last three years from the physician or qualified health care professional. Some payer algorithms may not be able to identify the new vs. established patient decision for physicians or NPP who change tax identifications. Some may. To bill and code correctly the correct interpretation of this scenario says to bill established patient care codes if the physician or NPP has seen the patient for professional services in the last three years.

What if a physician changes groups and one of their established patients is seen in the new group for the first time by a physician or non-physician practitioner in the new group who has never seen the patient and has no records on the patient? Since the patient is established to the physician new to the group, the patient is established to all physicians and qualified health care professionals in the group. Established care codes should be used.

RECOVERY AUDITORS AND NEW PATIENT CODES

Physicians and other non-physician practitioners should be aware that Recovery Auditors, under contract from CMS, are specifically targeting improper payments involving new patient claims when the beneficiary does not meet defined criteria to be a new patient. Medicare Learning Network document MM8165 says

As a result of overpayments for new patient E&M services that should have been paid as established patient E&M services, CMS will implement changes to the Common Working File (CWF) to prompt CMS contractors to validate that there are not two new patient CPTs being paid within a three year period of time.

Which codes will be checked? This document further clarifies which codes the Recovery Auditors will be checking.

The new patient CPT codes that will be checked in these edits include 99201- 99205, 99324 - 99328, 99341 - 99345, 99381 - 99387, 92002, and 92004. The edits will also check to ensure that a claim with one of these new patient CPT codes is not paid subsequent to payment of a claim with an established patient CPT code (99211 - 99215, 99334 - 99337, 99347 - 99350, 99391 - 99397, 92012, and 92014) .

Given the desire of CMS to recuperate overpayments and the complexity of the rules to follow, I encourage all physicians to be diligent in determining when their patient is a new patient or an established patient by CMS criteria.

RVU OF NEW AND ESTABLISHED CLINIC PATIENTS

What is the difference in relative value unit (RVU) for the new and established common outpatient clinic codes? In 2016, the work RVU (wRVU) values of these common codes are described here. I have provided a more detailed RVU and dollar analysis at each linked CPT® lecture below. As you can see, the difference in work RVU value (and total RVU value) is quite significant for similar levels of service when comparing new vs. established care codes.

MID-LEVEL OFFICE VISIT

99203 (new) wRVU = 1.42
99213 (established) wRVU = 0.97

MID-HIGH LEVEL OFFICE VISIT

99204 (new) wRVU = 2.43
99214 (established) wRVU = 1.50

HIGH LEVEL OFFICE VISIT

99205 (new) wRVU = 3.17
99215 (established) wRVU = 2.11

LINK TO E/M POCKET REFERENCE CARD POST

Click image for high definition view

Why We Built HealthPlanRatings.org – and What Makes it Different

Here at Consumers' CHECKBOOK, what we’ve always focused on is helping consumers make their best choices. And we felt that right now, choosing insurance plans on the Marketplace is difficult and confusing for most consumers, and that Healthcare.gov doesn't give consumers the key information they need to choose the best plan.

So what we did was build a model for how to get consumers to their best health plan choices – and get them there quickly. We launched this Health Plan Comparison tool at www.HealthPlanRatings.org.

This tool actually compares every plan available in the Illinois Marketplace based on total estimated cost (not just premiums or deductibles), plan quality, doctor availability, and other key factors. But it's designed to take consumers with little or no knowledge of insurance through a few simple steps – which take about five minutes – to help them choose the best plan for them.

Although it is intended to be a model for the country, right now the Health Plan Comparison tool only includes plans in one state: Illinois. Our hope is that the Feds and states that are running the Marketplaces will learn from what we have done and make their Marketplaces work better for consumers for the next open enrollment period, this Fall. Meanwhile, we want to have as many Illinois consumers as possible use the tool right now.

Here are some examples of what we've done:

COST. This is the primary consideration for most consumers when purchasing health insurance. Right now, Healthcare.gov lets you compare plans, but it just gives you the premium and the amounts of deductibles, co-payments, coinsurance, etc., for various health care services and products. Since it is all but impossible to calculate the likely total cost for each plan based on this confusing mass of benefit information, consumers often choose based on premium alone, or some other unreliable shortcut. Instead, our model uses actuarial analysis of data from large health-care-usage databases to calculate an Estimated Average Total Cost (premiums plus out-of-pocket costs) for a family of the same size, ages, health statuses, and other characteristics. That gives you a single dollar amount for each plan, making it easy to compare plans.

RISK. The Marketplace gives a consumer little or no help assessing risks of having a "bad year," or what the cost of an event such as heart attack could be. We calculate the cost in bad years and the probability that a family like yours will have such a year, giving you an easy-to-understand, easy-to-compare measure of "Risk" with each plan.

DOCTORS. For many people, whether they will be able to keep their physician – or be able to have one they like – is a key consideration in choosing a plan. But it can be challenging finding out which plans have the doctors you care about available in their networks by going to each of the insurers' doctor directories one at a time. So we combined them into an "All-Plan Doctor Directory" and when you see the list of available plans, you see which of your preferred doctors are in each plan.

QUALITY. All plans are not alike in the quality of care or service their members get, and the Marketplace gives little or no information on the quality of each plan. But we actually provide quality ratings. For all the plans, we initially display a simple overall quality score, and you can personalize the score based on the aspects of plan quality that are most important to you.

We believe that the Health Plan Comparison tool will save many consumers thousands of dollars and connect them to good care and service. It was a lot of work creating this website. We launched it two weeks ago, and did a demo for about 200 Navigators at a meeting set up by Get Covered Illinois. We want to reach out and help as many consumers as possible before March 31. Please take a look at www.HealthPlanRatings.org. Here is a sample plan-comparison page:

One more thing. We have been asked why we, based in Washington, DC, chose Illinois for our model plan comparison tool. There are various reasons, including the fact that it is a large, diverse state, with major urban and rural populations; has a lot of creative, consumer-oriented leaders; and has a substantial number of plans in the Marketplace. And okay, I admit it: we have some personal connections: My mom and dad were both born and raised in Illinois (Lexington and Lincoln); I graduated from the University of Chicago Law School; the director of our health plan ratings work got a Masters in opera (very different from what he has done for many years for us) from University of Illinois and sang sometimes in Chicago before spending eight years singing opera in Europe; and we publish one of our regional versions of Consumers' CHECKBOOK magazine in Chicago, with ratings or service firms, from auto repair shops to plumbers to doctors and veterinarians, and thus have reason for frequent trips to do Chicago TV appearances talking about our findings.

We really hope that you will tell everyone who might still be looking for insurance, or helping others look for insurance, in the Illinois Marketplace about this tool. And of course, we welcome any feedback. You can email me at rkrughoff@checkbook.org

– By Robert Krughoff, President, Consumers' CHECKBOOK

Funny ICD-10.2 Codes Never Before Discovered!

UPDATE: ICD-10 has been delayed until October 1st, 2015.

If you have never had a chance to cruise through the 68,000 ICD-10 codes set to go live on October 1st, 2014, you're missing out on some great humor. What does ICD stand for? ICD stands for International Statistical Classification of Diseases and Related Health Problems. Medicaid.gov provides a nice brief review of the transition from ICD-9 to ICD-10. If you do a Google search for funny ICD-10 codes, you'll find some healthcare related websites claiming to describe the best, funniest, strangest, most outrageous and colorful codes in the book. Heck, some sites even claim to have discovered the zaniest ICD-10 codes around.

Hogwash. Struck by a turtle (W5922XA)? Not outrageous. Problems with the in-laws (Z63.1)? Not zany. Not even close. That's just stupid. Struck by orca, initial encounter (W56.22xA). Not the least bit colorful. Quit wasting our time people. We only have a few more months to master ICD-10 before the most popular phrase in healthcare becomes a reality: Your claim has been denied. Even though ICD-10 is almost here and ICD-11 has a 2017 date with destiny, The Happy Hospitalist has learned the government is set to announce a January 1st, 2015 start date for ICD 10.2.

That's right folks, you heard it here first on The Happy Hospitalist. You'd better enjoy ICD-10 as much as you can for those last three months of 2014, because ICD-10.2 is just around the corner. For the last five years, The Happy Hospitalist Government Consulting Group has been asked to participate in developing thousands of new codes that more accurately reflect the healthcare experience. Starting January 1st, 2015, ICD-10.2 will expand to 482,697 codes. In addition to the numerous letters and numbers extending several decimal points, ICD 10.2 will add a mandatory hieroglyphic symbol to the last code definition.

This promises to add several trillion dollars to the cost of healthcare as doctors and hospitals scramble to buy computers, keyboards and software that can handle this ancient Egyptian language. In addition, new government regulations are set to require bedside physician-to-patient communication explaining to patients, in detail, which ICD 10.2 codes are being submitted for payment. If the physician is not fluent in Ancient Egyptian hieroglyphics, they will be required to purchase MARTI language interpretation systems that offer this service as part of the Super Expensive Languages of Ancient Worlds add-on option.

The exact codes of these real life medical diagnoses have not yet been established but are open to public comment until 12:00 PM EDT on December 31st, 2014 at the Medicare.gov website. This gives all stakeholders 12 hours to comply with any final determinations. Without further delay, here is the Top Ten List of Best ICD-10.2 Diagnoses that made the final cut!

One-In-A-Million-Doc; Implanted Household Device In Rectum; First Time
Positive Meth Test; Patient Claims He Didn't Take No F***in' Meth
Abdominal Pain In The ER, Not Exacerbated By Big Mac Brought In By Baby Daddy
Completely Satisfied Patient With No Complaints About Stupid Stuff
Any Injury Due To Less Than 1/10 Of An Inch Of Snow; Atlanta, Georgia
Facial Trauma Secondary to Getting Beat Up By Sum Dude
Hospital Acquired COPD Exacerbation After Going Outside For "Some Fresh Air"
Family Upset Nobody Explains Anything; 4 or More One Hour Family Conferences Documented
Patient Upset Hospital Discharge Paperwork Not Complete 10 Minutes Or Less After Doctor Visit
Leaving Against Medical Advice Because Patient Believes Dr Oz Would Recommend It

"Abdominal pain in the ER not exacerbated by Big Mac brought in my baby daddy? There's a code for that!"

Abdominal pain in the ER not exacerbated by Big Mac brought in by baby daddy? There's a code for that nurse ecard humor photo

For more ground breaking insight, make sure to also checkout the complete list of fake medical diagnoses, medical slang, and medical mispronunciations.

This post contains humor that may only be understood by some healthcare professionals. Read at your own risk.

Are You Really That Gullible? Take The Test Now!

Really? REALLY? Are you REALLY that gullible? I spent hundreds of hours searching the internet trying to find the perfect link for people wondering whether that shocking story they read on Facebook or Twitter was really true. You know those people. They believe anything. They are the ones who respond with emotional lability when everyone else understands the humor and satire. Yes stranger, if you're reading this, I'm probably talking about you. You probably landed here because of some link suggesting an incredible story that nobody believes is true, except you and your gullible soul.

I don't blame you for your lack of ability to tweak out comedy from reality. I suspect you grew up in a broken home with no electricity and no running water. I suspect you had no fun in your life. Your daddy made you eat peas. You're mommy made you do your own laundry. You grew up in misery and despair and now you're taking out your anger on social media platforms for all the world to see just how emotionally frail you really are.

Us normal folk? We don't blame you for being really super gullible. We think it's funny. Sometimes we think it's sad. But mostly just funny. And, we're probably laughing AT you and your Downer Debby life. For you healthcare workers, now that we know you're gullible, it's going to be really easy to mess with your mind. Remember that nurse who said they put Lasix in your coffee? Remember that doctor who you curb-sided and he said you probably got gonorrhea from sitting on the toilet seat at the State Fair? They were kidding. Really, they were. Or maybe they weren't. Maybe you really are just a gullible little puppy searching for a hug.

I'm not saying you're stupid. Out loud. I'm not saying you're dumb. Out loud. I'm just saying you're really gullible. If all the comments say LOL! or FUNNY STUFF! or THAT'S HILARIOUS! and you find yourself upset, you're probably extremely gullible. But there's only one way to know for sure. The Happy Hospitalist has put together a top 10 list of life situations you may encounter on your daily travels through WiFi. Grab a sheet of paper and label it from 1-10. Then, read each scenario out loud slowly and carefully. Absorb every word. Use your God given upper motor neuron complex to form rational thoughts about each issue. Take your time. There's no hurry. This test is important. For each issue, mark a zero if you agree or if it makes you think of someone in YOUR life or if it makes you laugh out loud. Mark a one if you disagree or if it makes you want to get into a really long Facebook comment debate or if it makes you angry, even if it's just a little angry.

Vaccinations are harmful. I prefer cute homeschooled, unvaccinated children ravished with measles over vaccinated children cared for by responsible adults.
Listen up women. Breastfeeding is not a choice. Just like pooping is not a choice. What the f*** is wrong with you. You are a bad mother if you don't breastfeed your baby.
Circumcision is not a decision that should be left to the boy once he's older. Have YOU ever heard of a 13 year old is asking his mama to get circumcised like the other boys in gym class?
Capital punishment saves lives, except maybe a couple dozen a year.
Abortion should not be a choice, except for parents who don't believe in vaccinating children.
Healthcare is not a right just like not paying your doctor bill is not a right.
Bleeding heart liberals think everything is a right, except free speech for people on the right.
Instead of taxing the rich, we should be taxing the poor and uneducated as punishment for being poor and uneducated. Why the heck should we punish people for being successful. It's all backwards. Tax something. Anything. And you get less of it. Bam. Problem solved.
Fibromyalgia is not a real disease. The other name for it is Depressed Women With Borderline Personality Disorder.
Minimum wage is minimum because it requires minimum skills. If you don't want to make minimum wage, don't have minimum skills.

If you're still reading this, you're probably gullible. And, you probably need to find some other way to spend your time. You just wasted three minutes of your life. Consider going to the ER immediately and ask for Bob. Tell them Happy sent you. They'll be expecting you. Before you go, make sure to review the giant collection of medical humor ecards on Pinterest. You've already wasted 3 minutes of your life. What's another hour in the grand scheme of things.

"The doctor said this new medication called Placebo works better than Dilaudid."

This post is for entertainment purposes and likely contains humor that is only understood by some healthcare professionals and people who are emotionally stable. Read at your own risk.

CBO on ACA: Devil is in the Details

On Tuesday, while driving between meetings, my favorite talk radio host shared shocking details from a new report – Obamacare, or the Affordable Care Act, is going to result in a loss of 2 million jobs in the United States over the next 10 years. Well, I thought, it's going to be a long day.

Later I learned that this reporter was sharing details from the latest Budget and Economic Outlook Report from the Congressional Budget Office. The CBO is an independent agency tasked with providing fiscal analysis for Congress with the intent of informing the budget-making process. Periodically, they release these reports which provide a 10 year forecast demonstrating the economic impact of many policies. Since 2010, they have included analysis on the impact of the ACA.

Needless to say, I was anxious to dig into this nearly 200 page behemoth and figure out what was going on. What I read in this report turned out to be great news. The report does not say that the economy will lose 2 million jobs. It says that, by making it easier to access affordable, high quality health insurance, more than 2 million people can make the choice to leave their job and pursue their passions, spend time with their families, start businesses, or find better jobs.

For those of us that have been following and championing the ACA, this isn't actually new information. Last year, the Robert Wood Johnson Foundation released a report, entitled The Affordable Care Act: Improving Incentives for Entrepreneurship and Self-Employment, which estimated that we could see as many as 1.5 million entrepreneurial spirits leave their jobs to become their own boss in 2014 alone!

Both reports highlight the same important fact: Because of the promise made by the ACA, that we can all access good health care, people will have the freedom to do what they want without fear of medical emergency and financial ruin.

My father, sister, and brother-in-law are all self-employed. Even my grandmother owned a small craft shop for the better part of my 26 years. While they were all brave (and maybe a little stubborn) enough to pursue these passions before the ACA, it has not been without sacrifice. After my self-employed and uninsured father had emergency eye surgery in 1992, my family filed bankruptcy as a result of unpaid medical bills. If the ACA had been around then, things would have been much easier for us and my dad certainly would have avoided a lot of sleepless nights worrying about keeping his business or providing for my sister and I.

I was shocked when I heard that radio report, but – as always – the devil was in the details. Except the devil isn't really a devil at all. The bottom line is that the ACA presents a new opportunity: an opportunity for people like my dad, to become their own boss; for someone who has put in their years and saved their pennies to retire early; or for a new parent to work part time so they can spend more time watching their child learn and grow. The CBO report means that what happened in my family, and millions like us, doesn't have to happen anymore – and that is why I will continue to be a proud champion of the ACA.

– By Kathy Waligora

Kathy Waligora is the Manager of Health Reform Initiatives at EverThrive Illinois (formerly the Illinois Maternal and Child Health Coalition).

See the 2013 ACA Self-Employment Infographic in PDF.

99226 CPT® Code Description, Progress Notes, RVU, Distribution.

This 99226 CPT® lecture reviews the procedure code definition, progress note examples, distribution and RVU values for this new since 2011 subsequent observation care evaluation and management (E/M) code. CPT stands for Current Procedural Terminology. CPT® 99226 is the highest (level 3) subsequent observation care code in this family of codes that also includes CPT® codes 99224 and 99225. All three codes are part of the Healthcare Common Procedure Coding System (HCPCS). Observation care is considered outpatient care. A patient is considered outpatient until inpatient admission to a healthcare facility occurs. This procedure code lecture for subsequent observation care is part of a complete series of CPT® lectures written by myself, a board certified internal medicine physician with over ten years of clinical hospitalist experience in a large community hospitalist program. I have written my collection of evaluation and management (E/M) lectures over the years to help physicians and non-physician practitioners (nurse practitioners, clinical nurse specialists, certified nurse midwives and physician assistants) understand the complex criteria needed to stay compliant with the Centers for Medicare & Medicaid Services (CMS) and other third party insurance companies.

You can find my entire collection of constantly updated medical billing and coding CPT® lectures together in one place on my Pinterest site (CPT® lectures here and other associated E/M lectures here). You don't need to be a Pinterest member to get access to any of my CPT® procedure lectures. As you start to understand these E/M procedure codes, remember you have an obligation to make sure your documentation supports the level of service you are submitting for payment. The volume of your documentation should not be used to determine your level of service. The details of your documentation are what matter most. In addition, the E/M services guide says the care you provide must be "reasonable and necessary" and all entries should be dated and contain a CMS defined legible signature or signature attestation, if necessary.

99226 MEDICAL CODE DESCRIPTION

The Centers for Medicare & Medicaid Services (CMS) has recognized subsequent observation care codes (99224-99226) since calendar year 2011's Physician Fee Schedule (PFS) with comment period (CMS-1503-FC). CPT® codes 99224-99226 should be used by the admitting physician for day(s) other than the initial or discharge date. Consulting physicians should continue to use established outpatient care codes 99211-99215 instead for all days other than the initial encounter, in most circumstances.

My interpretations discussed below are based on my review of the 1995 and 1997 E&M guidelines, the CMS E&M guide and the Marshfield Clinic audit point system for medical decision making. These resources can be found in my hospitalist resources section. The Marshfield Clinic point system is voluntary for Medicare carriers but has become the standard audit compliance tool in many parts of the country. You should check with your own Medicare carrier in your state to verify whether or not they use a different criteria standard than that for which I have presented here in my free educational discussion. I recommend all readers obtain their own updated CPT® reference book as the definitive authority on CPT® coding. I have provided access through Amazon to the 2015 CPT® standard edition pictured below and to the right. The American Medical Association (AMA) describes the 99226 CPT® procedure code as follows:

Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a detailed interval history; a detailed examination; medical decision making of high complexity. Counseling and/or coordination of care with other clinicians or agencies is provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit.

This medical billing code can be used to bill based on time when certain requirements are met. However, documentation of time is not required to remain compliant with CMS regulations. If billed without time as a consideration, CPT® 99226 documentation should comply with the rules established by the 1995 or 1997 guidelines referenced above. The three important coding components for a subsequent observation care evaluation are:

History
Physical Exam
Medical Decision Making Complexity (MDM)

Of note, the E/M coding requirements for CPT® 99226 are exactly the same as subsequent hospital care CPT® 99233. For all subsequent observation care codes (99224-99226), the highest documented two out of three above components determines the correct level of service code. This is different from initial observation care encounter (99218-99220) rules, which require the highest documented three out of three above components. In addition to a face-to-face encounter, what are the absolute minimum requirements for this level three 99226 visit?

Detailed interval history: Requires four elements of the history of present illness (HPI) or documentation of the status of three chronic medical conditions. Two review of systems (ROS) are also required. No past medical history or family history or social history is required (PMFSH).
Detailed physical exam:

1995 E/M guidelines require an extended exam of the affected body area(s) and other symptomatic or related organ systems. These terms are poorly defined and I feel they are open to great variation of interpretation. Note the wordage difference with body area vs organ systems. They are not the same. A review of the acceptable body areas and organ systems can be found in the CMS E&M reference guide on pages 31 and 32. I recommend instead to consider using the 1997 guidelines that provide better clarity.
1997 E/M guidelines more clearly define the need for a physical exam that includes at least six areas with two bullets each, or two plus areas with 12 total bullets.

High complexity medical decision making (MDM): This is split into three components. The two out of the three highest levels in MDM are used to determine the overall level of MDM. The level is determined by a complex system of points and risk. What are the three components of MDM and the minimum required level of points and risk as defined by the Marshfield Clinic audit tool for high complexity MDM?

Diagnosis (four points)
Data (four points)
Risk (high) The table of risk can be found on page 37 of the CMS E&M reference guide.

The medical decision making point system is highly complex. I have referenced it in detail on my E/M pocket cards described below. These cards help me understand what level of service my documentation supports. I carry these cheat sheet cards with me at all times and reference them all day long. As a hospitalist who performs E/M services almost exclusively, these cards have prevented me from under and over billing thousands of times over the last decade.

CLINICAL EXAMPLES OF CPT® 99226

Here are my general thoughts on billing a 99226 followup note: They almost always have some sort of new issue going on. That's a general rule I use when trying to decide whether or not to code this level, but that's by no means always the case. When billing this level three note, I usually try and include medical decision making in my coding decision. As I said above, MDM is not required because only two out of three for history, physical and MDM must qualify for a level three 99226. However, I feel, if I am doing a physical exam that warrants 12 bullet points, it's because they have an issue or are sick enough to qualify for the highest MDM category. With that said, this may not always be the case. For example, a patient with acute or chronic multiple organ failure may require extensive daily physical exam that requires at least 12 bullet points for medically necessary care. Evaluation and management "check list" rules allow history and physical documentation to determine the overall level of care for observation follow-up care notes.

When I come upon the chart of a patient, I want to know if there are any new issues that have presented since my last evaluation. If the answer is yes, my documentation can usually support a level three progress note. Remember, the rules are not based on how much is written, but rather what is written. If the answer is no, I review the chart and medical conditions to decide whether the patient would qualify anyway in an effort to submit accurate coding decisions everytime. I think physicians universally underestimate risk as it applies to E/M coding. Many of our patients should be categorized as high risk and billed as such if other documentation supports the highest level of medically reasonable and necessary service. Listed below are some examples of 99226 subsequent observation care notes in subjective, objective, assessment, plan (SOAP) format. A CPT® 99226 note could look like this:

S) RLQ abdominal pain, sharp, started yesterday, constant (4 HPI)
no CP, no SOB (2 ROS)
O) 120/80 80 Tm 98.6n (3 vitals is 1 organ)
Alert, anxious, regular rhythm, normal femoral pulses, lungs clear, normal respiratory effort, bowel tones present, no tenderness, no palpable abdominal masses, no peritonitis signs, no clubbing, no synovitis, no rash (6 areas, 12 bullets)
A) nothing needed
P) nothing needed

In this example history (subjective) and physical (objective) meet the requirements to get paid for a 99226. Remember, the highest two out of three components determine the highest level of service for subsequent observation care visits. Do note that linking an ICD code to a CPT® code is required for all visits submitted for reimbursement to CMS. Most progress notes should provide at least one ICD code to clearly indicate a purpose for the visit. I suspect this is necessary to meet the reasonable and necessary threshold, unless that can be inferred from other chart documentation. Medicare doesn't want to pay for doctors just to talk about the Super Bowl with their patients.

Some folks may argue that MDM must be included as one of the three components for this high level E/M visit. The rules and guidelines we are asked to follow do not state that. They clearly say that two out of three from history, physical and medical decision making determine the overall level of care. They do no state medical decision making must be one of the components. Some may argue that 12 bullet points are not medically necessary without high complex medical decision making. As a practicing hospitalist of over ten years, I would consider that assumption to be inaccurate. Every patient presents with their own special circumstances and a blanket statement about the extent of a physical exam needing to correlate with medical decision making has never been defined for us. Again, I encourage using MDM as one of the two elements in determining the overall level of care, but the rules do not state this to be necessary.

There are many patients that require intensive physical exam that may not have criteria for high complexity MDM. Documentation is vitally important to avoid any questions in an audit situation. If you feel an extensive physical exam is warranted everyday, document your reasoning why. That's what determines medically reasonable and necessary care. And always remember, when submitting payment to CMS, documentation must support at least one ICD (the problem) code from which to link the CPT® code to. I usually recommend documenting at least one problem in the note, unless the problem can be inferred elsewhere in the chart (such as in the orders as an indication for a test). Here's another example of a level three subsequent observation progress note below:

S)   no CP, no SOB (2 ROS)
O) 120/80 80 Tm 98.6 (3 vitals as 1 organ system)
   Alert, anxious, regular rhythm, normal femoral pulses, lungs clear, normal respiratory effort, bowel tones present, no abdominal bruit, no tenderness, no clubbing, no synovitis, no rash (6 areas, 12 bullets)
A) HTN-stable, no changes planned (status of 3 chronic medical conditions)
   COPD-stable, no changes planned
   CAD-stable, no changes planned
P) Nothing needed

Again, this progress note meets criteria for a high level (level 3) based on history and physical exam. However, in this case, the status of three chronic medical conditions (which have relevance to the patient's condition) substitute for four elements of HPI. Documenting stable HTN, CAD and COPD with no changes planned is considered an appropriate substitute for four HPI elements. I would only consider using chronic conditions that have relevance to the patient's condition. Again, if there is any question about their relevance, document your thought process. The reason many physicians fail audits is not because they are committing fraud but rather because they commit omissions of documentation. They fail to explain their reasoning behind their decisions. Here is another high level progress note below:

S) Nothing needed
O) 120/80 80 Tm 98.6 (3 vitals is 1 organ)
Alert, anxious, regular rhythm, normal femoral pulses, lungs clear, normal respiratory effort, bowel tones present, no tenderness, no clubbing, no synovitis, no rash (6 areas, 12 bullets)
Labs INR 1.7 on Coumadin (high risk for drug management requiring intensive monitoring for toxicity). CXR film personally reviewed-normal (2 points-Data for personal review of CXR). Discussed antibiotic options with Dr Smith. (2 points-Data for discussion of case with another healthcare provider).
A) Nothing needed
P) Nothing needed.

In this progress note example a level three is achieved based on documentation bullets from the physical exam and medical decision making. Nothing is needed from the history component. Remember, two out of three for subsequent observation care documentation. I documented a 99226 in the medical decision making because I achieved four points in the data section with two points for discussing with Dr Smith and two points for personally reviewing the CXR. I also got high risk for drug therapy requiring intensive monitoring for toxicity. Coumadin is a drug that I follow for toxicity by drawing INR levels. I think Coumadin use in the hospital is high risk, under most circumstances, and I make sure my documentation supports my thought processes on why I consider it so.

Remember, medical decision making guidelines also require a determination of the highest two out of three for data, diagnosis and risk. I received high complexity medical decision making based on data and risk. I had documentation of at least 12 bullets in six organ systems on physical exam. Therefore, this note meets criteria for a CPT® 99226. One does not need to write volumes of information to meet criteria for high complexity care. While I wrote no ICD code in this note, documentation should support somewhere what the visit was for. These progress note examples are based on strict interpretation of the E/M Marshfield Clinic audit tool rules. Remember to always include medically reasonable and necessary in your evaluation decisions. Here is another example:

S) nothing needed
O) 120/80 80 Tm 98.6 (3 vitals is one organ)
   Alert, anxious, regular rhythm, normal femoral pulses, lungs clear, normal respiratory effort, bowel tones present, no tenderness, no clubbing, no synovitis, no rash (at least 6 areas, 12 bullets)
A) 1) Afib, rate controlled, improved, on Coumadin, INR 1.7 (High risk for drug therapy requiring intensive monitoring for toxicity)
   2) Acute HTN, improved (4 points for Diagnosis for 4 stable conditions)
   3) Uncontrolled DM, improved
   4) Acute systolic HF, improved
P) Nothing needed

This note meets a high level 99226 progress note based on physical exam and MDM again. History does not matter here. The physical exam achieves level three based on 12 bullets in at least six areas. The MDM is high complexity based on the diagnosis and risk components. Documentation supports four points for documenting four stable chronic medical conditions with AF, HTN, DM and CHF. You get high risk for documenting high risk drug management with warfarin. This is a level three progress note. The care and documentation is medically reasonable and necessary. These are hospitalist patients that I feel we under code every day because we fail to appreciate how complex they are and we fail to document work we are already doing to indicate complexity.

Is the patient worse or unstable? Not necessarily. But their complexity and risk overcome that aspect based on the Marshfield Clinic audit tool rules we have been expected to comply with. The E/M rules do not say the patient must be unstable or worse and the CPT definition does not say they must be unstable or worse. These rules were created to provide clarity for physicians and coders and auditors alike. Here is another 99226 example:

S) nothing needed
O) 120/80 80 Tm 98.6 O2 86% RA (at least 3 vitals is one organ)
Alert, anxious, regular rhythm, normal femoral pulses, lungs clear, no crackles, no wheezes, normal chest wall motion, no JVD, normal respiratory effort, bowel tones present, no tenderness, no clubbing, no synovitis, no rash (at least 6 areas, 12 bullets)
INR 1.7 on Coumadin (High risk for drug management requiring intensive monitoring for toxicity)
A) hypoxemia-new issue (Diagnosis-4 points for new problem with further workup planned)
P) get CXR, ABG

This is a high level subsequent observation care progress note based on physical exam and MDM. The physical exam has at least 12 bullet points in six areas. The MDM is high complexity based on diagnosis and risk. Four points is given for addressing a new issue with further workup planned. In addition, this note provides high risk for drug therapy requiring intensive monitoring for toxicity. This is a level three progress note. Do you see how compact the note is? What is written is what matters. How much is written does not determine the level of care because documentation guidelines do note state how long your note is determines the level of care. Here is another example of a 99226 progress note:

S)   RLQ abdominal pain, sharp, started yesterday, constant (4 HPI)
   no CP, no SOB (2 ROS)
O) nothing needed
   INR 1.7 on Coumadin (high risk drug management)
A) hypoxemia-new (Diagnosis-4 points for new problem with further workup)
P) Check ABG, CXR

Level three is achieved using history and MDM. The history qualifies for a 99226 based on four HPI and two ROS elements. The MDM qualifies based on diagnosis and risk. Four diagnosis points is given for a new problem with further workup planned. High risk for Coumadin management. Did you ever think you could write so little and still bill an appropriate 99226 based on the audit tool E/M guidelines physicians are expected to follow? Here is another example using history and MDM:

S) no CP, no SOB (2 ROS)
O) Nothing needed
A) 1) DM-stable, no changes planned (status of 3 chronic medical conditions in place of 4 HPI)
   2) HTN-stable, no changes planned
   3) chronic afib-stable, no changes planned
   4) hypoxemia-new (Diagnosis-4 points for new problem, more workup planned)
P) Discussed code status today. Patient wishes to be a DNR due to poor prognosis.(high risk for DNR discussion, order for DNR) Check CXR ( Data-1 point for radiology)

In this example, the status of three chronic medical conditions substitutes for the four HPI elements. The MDM is high complexity for risk and diagnosis. Discussing DNR and writing an order for such can qualify for high risk under the risk table guidelines. In addition, four points under diagnosis of a new medical condition with further workup planned meets high complexity care criteria. This is a high level 99226 progress note. The following progress note is one last example of a CPT 99226 based on history and MDM:

S) RLQ abdominal pain, sharp, started yesterday, constant (4 HPI)
no CP, no SOB (2 ROS)
O) Nothing needed
Hgb 13.6 (Data-1 point)
EKG tracing personally reviewed- sinus rhythm without ST or TW changes (Data-2 points for personally reviewing tracing or image)
Discussed CXR findings with the radiologist (Data-1 point for discussing test with performing physician)
A) Patient on a PCA for back pain, no changes today (High risk for IV opiate management)
P) Nothing else needed

The history of 99226 compliant with four HPI and two ROS elements. The MDM is high complexity based on data and risk. The data has the required four points with one point for reviewing lab, two points for personally interpreting an EKG tracing and one point for discussing the CXR with the radiologist. In addition, the case is high risk based on IV opiate therapy, a high risk therapy based on the risk table guidelines.

I hope these common clinical examples offer further proof that documentation is key to staying compliant. Writing a novel is not required. As physicians, I think we tend to underestimate the level of complexity we encounter because we are used to it. We need to do a better job of documenting what we do and understand the rules we have been given to follow. Notice these notes are not long essays. They are strategically written to capture value in work we are doing but not currently describing in the correct manner. Don't be afraid to bill 99226 if the face-to-face encounter you provide is medically reasonable and necessary and your documentation supports CPT® 99226. In fact, if you think about it, patients in observation may not be "sick enough" to be admitted, but CMS has instructed us to use CPT® code 99226 for high complexity observation evaluations whose criteria is exactly the same as high complexity patients who are admitted as inpatients. Being observation does not mean they are too healthy for high complexity care. Always keep in mind documentation is key to getting paid, based on the rules we have been given, for the work we are providing.

DISTRIBUTION OF OBSERVATION SUBSEQUENT CARE CODES (99224-99226).

What is the distribution of CPT® code 99226 relative to other levels of service in this family of medical codes? The CPT® group 99224-99226 is pretty new. CMS has only recognized these codes since 2011. However, CMS has data explaining how often 99224, 99225 and 99226 have been used. The graphic below was obtained from the 2011 CMS Part B National Procedure Summary Files data (2011 zip file) showing how many CPT® 99226 encounters were billed and the dollar value of their services for Part B Medicare. As you can see in the image below, E/M code 99226 was billed 88,982 times in 2011 with allowed charges of $6,534,122.22 and payments of $5,153,258.29.

National Summary Data File 2011 (99224-99226)

RVU VALUE

How much money does a CPT® 99226 pay in 2016? That depends on what part of the country you live in and what insurance company you are billing. E/M procedure codes, like all CPT® billing codes, are paid in relative value units (RVUs). This complex RVU discussion has been had elsewhere on The Happy Hospitalist. For raw RVU values, a CPT® 99226 is worth 2.96 total RVUs. The work RVU for 99226 is valued at 2.0. Make sure to review the complete list of RVU values on common hospitalist E/M codes. What is the Medicare reimbursement for CPT® code 99226? In my state, a CPT® 99226 pays just over under $100 in 2016. The dollar conversion factor for one RVU in 2014 is 35.8043.

My E/M reference card below has taught me that I should be billing for the work I'm providing and it has taught me how to document appropriately. You can see many more of my E/M lectures by clicking through on the provided link. If you need bedside help determining what level of care you have provided, I recommend reviewing the pocket card described below.