Review CPT E/M changes for correct code assignment

Coders still don’t have national evaluation and management (E/M) guidelines to follow to ensure correct code selection. However, the AMA did make significant revisions to the E/M CPT® codes for 2011.

The changes include new codes for subsequent hospital observation, changes to the guidelines for critical care coding, and a new coding tip on transfer of care. The AMA does plan to reverse one change in the 2011 CPT Manual. The 2011 CPT Manual does not include the E/M decision tree. However, the omission was accidental and the AMA has stated that the decision tree will be back in the 2012 CPT Manual, says Jennifer Avery, CCS, CPC-H, CPC, CPC-I, senior regulatory specialist for HCPro, Inc., in Danvers, MA.

Subsequent hospital observation
The AMA added new codes for subsequent hospital observation (99224–99226). These codes match the subsequent hospital care codes already in use. The new codes are “per day” to report additional days of observation services; do not report them on the same calendar date as the initial observation care or discharge services. Do not report these codes on the same day as an office or ED visit.

“Either it’s the initial, a subsequent day, or the discharge, so you have to know the services,” says Avery.
The new subsequent observation codes are very similar to the subsequent hospital care codes for inpatients, says Avery. They include similar time designations, but the AMA developed new typical patient and service descriptions.

These patients do not meet the criteria for inpatient status, but remain in the hospital for several days. Patients do not need to be located in a designated observation area for coders to select the new codes.

All levels of subsequent observation care include review of:

  • Medical record
  • Results of diagnostic studies
  • Changes in patient status (e.g., changes in history, physical condition, and response to management)

Multiple physicians (e.g., attending physician, surgeon) may report these codes for their E/M services provided to an observation patient. “Remember we can have more than one physician providing services in observation,” Avery says. You can also assign these codes when a physician is called in for a consultation. CMS no longer recognizes the CPT consultation codes, so you can use the subsequent observation codes to report consult services, Avery says.

For example, a patient is admitted to observation at 7 a.m. Tuesday. The patient remains in the hospital on Wednesday and is responding to treatment. On Thursday, the physician discharges the patient. Using the new subsequent observation codes, you would report:

  • Initial hospital observation (99218–99220) for Tuesday
  • Subsequent hospital observation (codes 99224–99225) on Wednesday
  • Observation care discharge (code 99217) on Thursday

Choose the level of E/M for initial and subsequent hospital care based on the physician’s documentation of the three key components of an E/M visit—history, exam, and medical decision-making.

Note that these subsequent observation care codes are resequenced codes, meaning they are integrated into the existing code families even when sequential code numbers are not available. The AMA uses the “#” to denote resequenced codes and parenthetical notes to identify that the code is in a different section.

While the initial observation codes (99218–99220) remain the same, the AMA revised the guidelines for those codes to include references to the new subsequent observation care codes.

Critical care coding guidelines
The CPT panel revised its guidance for critical care codes 99291 and 99292 to specifically state that, for hospital reporting purposes, critical care codes do not include the specified ancillary services, and facilities may report these services separately. The guidelines before the codes now identify services that are bundled when reporting professional services.

The AMA wanted to make sure it differentiated between bundled services for facilities and professional services because they are different. If you work in a facility, make sure you review these revisions, Avery says.

The CPT guidelines will allow facilities to separately report ancillary services and associated charges when provided in conjunction with critical care. For professional reporting, the services are still included in the critical care when the physician performs the service during the critical care period. Those services include:

  • Interpretation of cardiac output measurements (93561, 93562)
  • Chest x-rays (71010, 71015, 71020)
  • Blood draw for specimen (36415)
  • Blood gases and information data stored in computers (e.g., ECGs, blood pressures, hematologic data) (99090)
  • Gastric intubations (43752, 43753)
  • Pulse oximetry (94760, 94761, 94762)
  • Temporary transcutaneous pacing (92953)
  • Ventilator management (94002–94004, 94660, 94662)
  • Vascular access procedures (36000, 36410, 36415, 36591, 36600)

Report separately any services not part of this list for both facility and professional services.

Critical care transport changes

Be sure to read the revised guidelines for pediatric critical care transport codes 99466–99467. The AMA changed the list of bundled services back to what was bundled in 2007, says Avery. The AMA made significant changes in 2009 and 2010, but after reviewing the changes, decided to go back and clarify the guidelines, she adds.

These codes report direct face-to-face care by a physician when a critically ill or injured pediatric patient 24 months of age or younger is transferred from one facility to another. Only report the face-to-face time, and do not assign codes 99466 and 99467 if the physician spent fewer than 30 minutes of face-to-face time with the patient during transport.

The AMA revised the list of bundled services for codes 99466 and 99467 to reflect the same services that were bundled in 2007. The guidelines also differentiate this list of services from those bundled into codes 99468–99472, 99475, 99476, and 99477–99480.

Transfer of care tip
Also review the new coding tip on transfer of care under the Office and Other Outpatient Consultations section (codes 99241–99255). The tip defines what transfer of care is and when it takes place.

Report services that constitute transfer of care with the appropriate code for a new or established patient office or other outpatient service, or a domiciliary, rest home, or home visit.

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