CPC Exam Review

Evaluation and Management

Medical Decision Making (MDM)

Number of diagnoses or management options, Amount and/or complexity of data to be reviewed, Risks of complications and/or morbidity and morality.

Office or other Outpatient Services

Physicans’s office, urgent care, hospital outpatient clinic, dialysis clinic

New Patient Level's

99203-Forward

99204-Moderate

99205-High

99202-Straigthforward

Established Patient Levels

99212-Straigthforward

99213-Low

99214-Moderate

99215-High

History

Exam and MDM

*Providers can use total time or MDM at their discretion

Number and Complexity of problems addressed

• Minimal: a problem that may not require the presence of the physician, but the service is provided under the supervision of the physician.

• Self-Limited or Minor Problem

Consultations must have:

-A request by another provider

-Consulting provider needs to render an evaluation and option.

-Consulting provider needs to respond to the requesting provider by a written report of the evaluation.

Hospital Inpatient or Observation Care Services

When the time is less than 8 hours on the same date of service you report the initial hospital inpatient or observation care codes 99221-99223.

Preventative

(determined by):

1. Age

2. Type: New and Established

Critical Care Services

*Can only be reported by time

• When the critical care is less than 30 mins, critical care codes are not reported, report code 99291. Each additional and part thereof, is reported with 99292.

• 99291 (30 mins-74 mins)

• 99292-additional time

Critical Care Coding (younger patients)

• Neonates(28 days or younger):Inpatient Critical Care Services are 99468-99469

• Infants(29 days through 24 months); Codes are 99471-99472

• 2 years- 5 years: Codes are 99475-99476

• Critical care for 6 years for age and older: Codes are 99291 and 99292

Nursing Facilities Services

When selecting level of MDM, the number and complexity of problems addressed at the encounter is considered.

This includes services provided in skilled nursing facilities, such as rehabilitation and long-term care, which impact the medical decision-making process.

Prolonged Services

Prolonged services are elected based on:

• The date of the prolonged service

• Who provided the prolonged service

• The patient status(outpatient, inpatient, or observation)

*Read guidelines for prolonged services for information regarding coding from this scetion.

Non Face to Face Services

If the provider calls the patient within seven days of an E/M for something related to that E/M visit, the call is not reported separate.

Code selection is based on the amount of time for medical consultative discussion and review.

Care Management Services

The patients condition must be expected to last 12 months or until death of the patient to report codes 99487-99490.

Transitional Care Management Services

-Codes 99495-99496 are selected based on level of MDM (moderate or high) and when the first face to face encounter occurs after discharge.

The codes in this subsection can only be reported once in a 30 days period.

Choosing the E/M Service Level

May include place and/or type of service; Content of the service provided; Nature of the presenting problem; and the time generally required to provide the service.

Most visits, the providers performs three main components:

1. History

2. Exam

3. MDM (Medical Decision Making)

Determining the Medical Decision Making