The following physician reporting scenario portrays a patient encounter that would lead to a visit that would be reported with CPT code 99214 (office or other outpatient visit for the E/M of an established patient, which requires a medically appropriate history and/or examination and moderate level of MDM. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter) under the current E/M office visit guidelines.
This sample was provided by Laurie Baker, MSN, RN, CCDS, clinical documentation specialist at Memorial Hospital and Health Care Center in Jasper, Indiana. It was originally posted on ACDIS.org.
This sample was reviewed and approved by the ACDIS Resource Library Committee in 2023. The committee recommends that, should you choose to use this sample, you adapt it to your particular programmatic needs, policies, and procedures. Additionally, the committee notes that the ACDIS Pocket Guide is used as a reference in this sample and should be cited as such. Individuals adapting this sample should also customize the list depending on individual facility data and provide links to the full 4th Universal Definition of MI and the KDIGO guidelines.
This sample was provided by Laurie Baker, MSN, RN, CCDS, clinical documentation specialist at Memorial Hospital and Health Care Center in Jasper, Indiana. It was originally posted on ACDIS.org.
This sample was reviewed and approved by the ACDIS Resource Library Committee in 2023. The committee recommends that, should you choose to use this sample, you adapt it to your particular programmatic needs, policies, and procedures. Additionally, the committee suggests adding options for morbid obesity, cachexia/underweight (BMI <19.9), hepatic failure, viral pneumonia, and acute on chronic respiratory failure. Those looking to shore up their documentation for denial prevention may also want to add a section about treatment plans.
This sample was provided by Laurie Baker, MSN, RN, CCDS, clinical documentation specialist at Memorial Hospital and Health Care Center in Jasper, Indiana. It was originally posted on ACDIS.org.
This sample was reviewed and approved by the ACDIS Resource Library Committee in 2023. The committee recommends that, should you choose to use this sample, you adapt it to your particular programmatic needs, policies, and procedures.
Anatomy and terminology, Hospital outpatient, Questions and answers
There can be a lot of misunderstanding and confusion surrounding the CPT guidelines pertaining to how coders should report a diagnostic angiogram in conjunction with a therapeutic intervention. In this expanded Q&A, Stacie L. Buck, RHIA, CCS-P, RCC, RCCIR, CIRCC, president and senior consultant for RadRx of Stuart, Florida, addresses the topic. This question was answered during the webinar, “Branching Out with CPT Diagnostic Angiography FAQs.”
Use this decision tree to illustrate Medicare’s rules for coding prolonged E/M services. Medicare created codes and rules for prolonged services performed by a physician or qualified healthcare professional (QHP) because it disagrees with portions of the CPT guidelines.
DecisionHealth, the publisher of Part B News, has revised its tool for office/other outpatient E/M visits (99202-99215) to include encounters performed in the inpatient or observation (99221-99223 and 99231-99236), emergency department (99281-99285), nursing facility (99304-99310) and home or residence (99341-99350) settings and consults (99242-99245 and 99252-99255).
