- Medical Decision Making (MDM) Section (shows the 3 parts of MDM coding and how to use it).
- Coding for procedures and skin surgery.
- Modifier 25 (Billing for both Preventive and other Diagnosis and other Services during the same visit).
- Prescription Drug Management – Meaning.
- MDM Documentation Tips (What to include in your note).
- Coding Benchmarks, 2017.
- Table of Risk from the CMS.
- When to bill 99214, from the AAFP.
- Coding Level IV without fear, AAFP.
- When to bill 99215, from AAFP (2014).
- New vs. Established Problem.
- New Vs. Established Patient in the Outpatient Setting.
- New Patient vs Established Patient Codes, from AAFP
- Documentation by medical students.
- FPM Toolbox.
- Outpatient Coding Guide. Card for coding outpatient visits and hospital consults, PDF
- Hospital Coding Guide. Card for coding hospital visits.
- Audit Sheet used by medical billing (used by my employer)
- Medical Billing Audit Sheet (from ACP website, same thing as from my employer)
- HPI Table – defines and explains each of the expected OPQRST-A elements of HPI.
- Emuniversity.com.
Medical record quality and accurate EM code selection are the physician’s responsibility. Coding tools, including EMR EM calculators, cannot assess the appropriate level nor the quality of documentation. All EM services should include: Reason for Encounter, Assessment, Care Plan, Signature/Date
Note: New office visit codes are 99201 to 99205. Outpatient consultation codes 99241–99245. Inpatient consultation codes are 99251–99255.
| NEW PATIENT OFFICE VISITS, OUTPATIENT & INPATIENT CONSULTS* – 3 OF 3 KEY COMPONENTS ** | |||||
| CODE | 99201 –10 min | 99202 – 20 min | 99203 – 30 min | 99204 – 45 min | 99205 – 60 min |
| 99241 – 15 min | 99242 – 30 min | 99243 – 40 min | 99244 – 60 min | 99245 – 80 min | |
| 99251 – 20 min | 99252 – 40 min | 99253 – 55 min | 99254 – 80 min | 99255 – 110 min | |
| HISTORY (3 of 3) | Focused | Expanded | Detailed | Comprehensive | Comprehensive |
| HPI | 1 – 3 | 1 – 3 | 4+ or 3 chronic | 4+ or 3 chronic | 4+ or 3 chronic |
| ROS | None | 1 | 2-9 | 10+ | 10+ |
| PFSH | None | None | 1 | All 3 | All 3 |
| EXAM | Focused (1) | Expanded (2 – 7) | Detailed (2 – 7) | Comp (8+) | Comp (8+) |
| MDM (2 of 3) | Straightforward | Straightforward | Low | Moderate | High |
| Dxs/options | 0 – 1 | 0 – 1 | 2 | 3 | 4+ |
| Data | 0 – 1 | 0 – 1 | 2 | 3 | 4+ |
| Risk | Minimal | Minimal | Low | Moderate | High |
*Consults – Document requesting physician & send a report to the requestor. Do not report consult codes to Medicare.
| ESTABLISHED PATIENT OFFICE VISITS – 2 OF 3 KEY COMPONENTS** | |||||
| CODE | 99211 – 5 min | 99212 – 10 min | 99213 – 15 min | 99214 – 25 min | 99215 – 40 min |
| HISTORY (3 of 3) | None | Focused | Expanded | Detailed | Comprehensive |
| HPI | None | 1 – 3 | 1 – 3 | 4+ or 3 chronic | 4+ or 3 chronic |
| ROS | None | None | 1 | 2 – 9 | 10+ |
| PFSH | None | None | None | 1 | 2 of 3 |
| EXAM | None | Focused (1) | Expanded (2 – 7) | Detailed (2 – 7) | Comp (8+) |
| MDM (2 of 3) | Straightforward | Straightforward | Low | Moderate | High |
| Dxs/options | 1 | 0 – 1 | 2 | 3 | 4+ |
| Data | None | 0 – 1 | 2 | 3 | 4+ |
| Risk | None | Minimal | Low | Moderate | High |
Use time ONLY if over 50% of encounter is counseling and/or coordination care.
**Key components = History (HX), Exam, and Medical Decision-making (MDM)