Pediatric Evaluation and Management Coding Revisions: Facility and Office Services

223 Pages·2023·12.888 MB·English

by  American Academy of Pediatrics

New
2023 Changes
2021
Revisions
Pediatric
Evaluation and
Management
Coding
Revisions
Facility and
Offi ce Services
Pediatric
Evaluation and
Management
Coding
Revisions
Facility and
Office Services
American Academy of Pediatrics
Linda D. Parsi, MD, MBA, CPEDC, FAAP, Editor
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American Academy of Pediatrics Publishing Staff
Mary Lou White, Chief Product and Services Officer/SVP, Membership, Marketing, and Publishing
Mark Grimes, Vice President, Publishing
Mary Kelly, Senior Editor, Professional/Clinical Publishing
Laura Underhile, Editor, Professional/Clinical Publishing
Jason Crase, Senior Manager, Production and Editorial Services
Leesa Levin-Doroba, Production Manager, Practice Management
Peg Mulcahy, Manager, Art Direction and Production
Mary Jo Reynolds, Marketing Manager, Practice Publications
Published by the American Academy of Pediatrics
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The American Academy of Pediatrics is an organization of 67,000 primary care pediatricians, pediatric medical subspecialists, and
pediatric surgical specialists dedicated to the health, safety, and well-being of all infants, children, adolescents, and young adults.
While every effort has been made to ensure the accuracy of this publication, the American Academy of Pediatrics does not
guarantee that it is accurate, complete, or without error.
The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care.
V ariations, taking into account individual circumstances, may be appropriate.
Vignettes are provided to illustrate correct coding applications and are not intended to offer advice on the practice of medicine.
Any websites, brand names, products, or manufacturers are mentioned for informational and identification purposes only and
do not imply an endorsement by the American Academy of Pediatrics (AAP). The AAP is not responsible for the content of
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This publication has been developed by the American Academy of Pediatrics. The contributors are expert authorities in the
field of pediatrics. No commercial involvement of any kind has been solicited or accepted in the development of the content of
this publication. Disclosures: Dr Lago disclosed an employee relationship with Cotiviti, Inc. Dr Parsi disclosed an ownership
and consulting relationship with The PEDS MD Company and is part of the Mead Johnson Speaker Bureau.
Please visit www.aap.org/errata for an up-to-date list of any applicable errata for this publication.
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CPT copyright 2022 American Medical Association (AMA). All rights reserved.
Fee schedules, relative value units, conversion factors, and/or related components are not assigned by the AMA, are not part
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CPT is a registered trademark of the AMA.
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MA1095
ISBN: 978-1-61002-670-3
eBook: 978-1-61002-671-0
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III
2022–2023 Committee on Coding and Nomenclature
Eileen D. Brewer, MD, FAAP, Chairperson
Margie C. Andreae, MD, FAAP
Joel F. Bradley, MD, FAAP
Mark Joseph, MD, FAAP
David M. Kanter, MD, MBA, CPC, FAAP, Immediate Past Chairperson
Steven E. Krug, MD, FAAP
Edward A. Liechty, MD, FAAP
Jeffrey F. Linzer Sr, MD, FAAP
Linda D. Parsi, MD, MBA, CPEDC, FAAP
Renee F. Slade, MD, FAAP
Liaisons
Kathleen K. Cain, MD, FAAP
AAP Section on Administration and Practice Management
Kathryn B. Lalor, MD, FAAP
AAP Section on Early Career Physicians
Benjamin Shain, MD, PhD
American Academy of Child and Adolescent Psychiatry
Samuel D. Smith, MD, FAAP
American Pediatric Surgical Association
2022–2023 AAP Coding Publications Editorial Advisory Board
Linda D. Parsi, MD, MBA, CPEDC, FAAP, Editor in Chief
Cheryl Arnold, MHSA, FACMPE
Greg Barabell, MD, CPC, FAAP
Vita Boyar, MD, FAAP
Joel F. Bradley, MD, FAAP
Timothy Ryan Hensley, MD, CPC, CPEDC, FAAP
David M. Kanter, MD, MBA, CPC, FAAP
Steven E. Krug, MD, FAAP
Jamie C. Lago, MD, CPC, FAAP
Edward A. Liechty, MD, FAAP
Jeffrey F. Linzer Sr, MD, FAAP
Richard A. Molteni, MD, FAAP
Karen Nauman, MD, FAAP
Piedade Oliveira-Silva, MD, FAAP
Julia M. Pillsbury, DO, FAAP
Renee F. Slade, MD, FAAP
Karla Nickolas Swatski, MD, FAAP
Sanjeev Y. Tuli, MD, FAAP
AAP Staff
Teri Salus, MPA, CPC, CPEDC
Cindy Hughes, CPC, CFPC, Consulting Editor
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IV
Disclaimer
Every effort has been made to include the new and revised 2023 Current Procedural
Terminology (CPT®) codes, their respective guidelines, and other revisions that might
have been made. Because of our publishing deadlines and the publication date of the
American Medical Association CPT, additional revisions and/or additional codes
may have been published subsequent to the date of this printing. It is the responsibil-
ity of the reader to use this manual as a companion to the CPT publication. Vignettes
are provided throughout this publication to illustrate correct coding applications.
They are not intended to offer medical advice on the practice of medicine. Further, it
is the reader’s responsibility to routinely access the American Academy of Pediatrics
website (www.aap.org/errata) for any errata in the published version. At the time of
this publication, final changes for 2023 codes and Medicare payment policies were
s pending. See www.aap.org/coding for updates.
e
n
deli Copyright Acknowledgment
Gui Current Procedural Terminology (CPT) is a listing of descriptive terms and 5-digit
n numeric identifying codes and modifiers for reporting medical services and proce-
o
ati dures performed by physicians. This presentation includes only the CPT descriptive
t
n terms, numeric identifying codes, and modifiers for reporting medical services and
e
m procedures that were selected by the American Academy of Pediatrics (AAP) for
u
c inclusion in this publication. The inclusion of a CPT service or procedure descrip-
o
t D tion and its code number in this publication does not restrict its use to a particular
n
e specialty group. Any procedure or service in this publication may be used to report
m
the services provided by any qualified physician or, when appropriate, other qualified
e
g
a health care professional.
n
Ma The American Medical Association (AMA) and the AAP assume no responsibility
d for the consequences attributable to or related to any use or interpretation of any
n
a information or views contained in or not contained in this publication.
n
o
ti Any 5-digit numeric CPT code, service descriptions, instructions, and/or guidelines
a
u are copyright 2022 (or such other date of publication of CPT as defined in the federal
al
v copyright laws) AMA. All rights reserved.
E
1. The most current CPT is available from the AMA.
r
e
pt No fee schedules, basic unit values, relative value guides, conversion factors or scales,
a
h or components thereof are included in CPT.
C
Equity, Diversity, and Inclusion Statement
The American Academy of Pediatrics is committed to principles of equity, diversity,
and inclusion in its publishing program. Editorial boards, author selections, and
author transitions (publication succession plans) are designed to include diverse
voices that reflect society as a whole. Editor and author teams are encouraged to
actively seek out diverse authors and reviewers at all stages of the editorial process.
Publishing staff are committed to promoting equity, diversity, and inclusion in all
aspects of publication writing, review, and production.
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V
Contents
Introduction .....................................................................................................................IX
Chapter 1. Evaluation and Management Documentation Guidelines
Chapter Highlights.............................................................................................................3
General Guidelines ............................................................................................................4
New Versus Established Patients ................................................................................5
Initial and Subsequent Services ..................................................................................6
Separately Reported Services ............................................................................................7
E/M Guidelines for Use of Total Time or MDM ..............................................................8
Applicability of E/M Guidelines for Use of Total Time or MDM .............................8
Code Selection Options ...............................................................................................9
C
Time Guidelines and Application .............................................................................11 h
a
Total Time of Teaching Physicians ..........................................................................14 p
t
MDM: Guidelines for Selecting a Level ....................................................................14 er
1
Number and Complexity of Problems Addressed .............................................15 . E
Amount and/or Complexity of Data to Be Reviewed and Analyzed ................20 va
Risk of Complications and/or Morbidity or Mortality of lua
t
Patient Management .......................................................................................26 io
n
Selection of Codes Based on MDM ................................................................................29 a
n
Chapter Takeaways ..........................................................................................................33 d
M
Resource ...........................................................................................................................33
a
n
a
g
Chapter 2. Non-preventive Evaluation and Management Services in e
m
Outpatient Settings e
n
t
Chapter Highlights...........................................................................................................37 D
o
c
Outpatient Evaluation and Management (E/M) Codes .................................................37 u
m
Sites of Service and Codes for Outpatient Services .......................................................37 e
n
Office E/M Guidelines .....................................................................................................38 t
a
New Versus Established Patients ..............................................................................38 tio
Visits Not Requiring a Physician’s or Qualified Health Care Professional’s n G
Presence .................................................................................................................39 u
id
Incident-to Requirements: Services Provided Under Physician Supervision .......41 e
Billing for Services Performed Under Supervision ...........................................41 lin
e
s
Documentation Requirements and Tips When Reporting Incident-to
Services ............................................................................................................43
Code Selection Guidelines for Outpatient E/M Services...............................................44
Application of Time Guidelines ................................................................................44
Guidelines for Medical Decision-making ......................................................................47
Number and Complexity of Problems Addressed ...................................................48
Amount and/or Complexity of Data to Be Reviewed and Analyzed ......................48
Risk of Complications and/or Morbidity or Mortality of Patient Management ....49
Selection of Office and Outpatient E/M Codes ..............................................................49
Examples of Code Selection for Office and Other Outpatient E/M Services .........53
Office E/M (99202, 99212) ..................................................................................53
Office E/M (99203, 99213)...................................................................................54
Office E/M (99204, 99214) ..................................................................................55
Office E/M (99205, 99215) ..................................................................................57
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VI CONTENTS
Outpatient Consultations (99242–99245) ......................................................................59
When a Payer Does Not Accept Consultation Codes ..............................................59
Selecting Codes for Outpatient Consultation Services............................................60
Home or Residence Services (99341–99350) .................................................................64
Home or Residence E/M Service Examples .............................................................64
Prolonged Office E/M Service .........................................................................................68
Prolonged Outpatient E/M Service, Physician or Other Qualified Health
Care Professional ...................................................................................................68
Prolonged Service Without Direct Patient Contact (99358, 99359) .......................71
Prolonged Clinical Staff Service (99415, 99416) ......................................................72
Codes for Reporting Special Circumstances ..................................................................74
Asthma, Attention-Deficit/Hyperactivity Disorder, and Otitis Media:
Coding Continuums ....................................................................................................75
Chapter Takeaways ..........................................................................................................80
Resources ..........................................................................................................................80
Chapter 3. Emergency Department Services
Chapter Highlights...........................................................................................................83
Emergency Department (ED) Code Updates in 2023 ...................................................83
Using Diagnosis Codes to Support the Level of ED Visits.............................................83
ED Evaluation and Management (E/M) Codes..............................................................85
Modifiers Used With ED E/M Codes ..............................................................................94
Time-Based Critical Care in the ED ...............................................................................95
Critical Care and ED E/M Services on the Same Date ..................................................97
Special Service Codes ......................................................................................................99
Continuum Model for Fever ...........................................................................................99
Chapter Takeaways ........................................................................................................103
Resources ........................................................................................................................103
Chapter 4. Noncritical Hospital Evaluation and Management Services
Chapter Highlights.........................................................................................................107
Coding for Noncritical Hospital Evaluation and Management (E/M) Services ........107
Guidelines for Inpatient and Observation Services .....................................................109
General E/M Code Selection Guidelines ......................................................................111
Medical Decision-making .......................................................................................111
Problems Addressed ..........................................................................................112
Data ....................................................................................................................113
Risk .....................................................................................................................114
Time-Based Code Selection ....................................................................................114
Hospital or Observation Services by Multiple Physicians and QHPs .........................115
Concurrent Care ......................................................................................................115
Reporting Services Split or Shared by a Physician and a QHP .............................116
CPT ® Guidelines for Split/Shared Services ............................................................116
Medicare Guidelines for Split/Shared Services ......................................................117
Selecting Hospital Inpatient or Observation Care Codes ............................................118
Same Date Admission and Discharge Services ......................................................122
Initial Inpatient Hospital Care ................................................................................125
Subsequent Hospital Care .......................................................................................128
Hospital Inpatient or Observation Discharge Management .................................131
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CONTENTS VII
Inpatient or Observation Consultations .......................................................................133
Consultation Guidelines ..........................................................................................133
Consultation Following a Related E/M Service ...............................................134
Medicare Consultation Guidelines ...................................................................135
Inpatient and Observation Consultations ..............................................................135
Interprofessional Telephone/Internet/Electronic Health Record Consultation ........137
Prolonged Hospital E/M Services .................................................................................137
Prolonged Service on the Date of an E/M Service .................................................137
Prolonged Service on Date Other Than the Face-to-face E/M Service
Without Direct Patient Contact..........................................................................139
Hospital-Mandated On-Call Services ...........................................................................141
Chapter Takeaways ........................................................................................................141
Resource .........................................................................................................................142
Appendix
Evaluation and Management Code and Guideline Changes .......................................145
Using Evaluation and Management Documentation Guidelines to Define
Problems Addressed .................................................................................................150
Data to Be Reviewed and Analyzed ..............................................................................155
Selecting the Level of Risk Associated With Patient Management ............................161
Selecting the Level of Service Based on Medical Decision-making ..............................167
Guidelines for Hospital Inpatient and Observation Services ......................................173
Inpatient and Observation Consultation Guideline Changes .....................................179
Same-Date Admission and Discharge Services ...........................................................183
Emergency Department Visits ......................................................................................186
Outpatient Consultations ..............................................................................................192
Home and Residence Services ......................................................................................198
Evaluation and Management Total Time and Prolonged Service ..............................203
New Time Requirements for Prolonged Service by Clinical Staff ..............................208
Certificate of Completion
An online quiz is available for you to further enhance your coding knowledge and demon-
strate your understanding of the concepts in this book. Upon successful completion of the
quiz, you will receive a Certificate of Completion from the American Academy of Pediatrics.
To complete the quiz and obtain the certificate, please go to www.aap.org/EMcertificate.
Note: This quiz is not for official credit from any credentialing society.
Updates
Evaluation and management coding continues to evolve. As they become available,
updates will be posted at www.aap.org/errata.
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||||||||||| IX
Introduction
Pediatric Evaluation and Management Coding Revisions: Facility and Office
Services takes an in-depth look at the Current Procedural Terminology® office
and facility-based evaluation and management code changes. It was devel-
oped to help you understand these changes and what their implications are
for your practice documentation and code selection.
This publication contains contents curated from American Academy
of Pediatrics (AAP) coding publications. The first half of the book contains
excerpts from 4 chapters of Coding for Pediatrics 2023. These chapters, listed
below, c ontain a detailed overview of the changes, key definitions, coding
examples, and much more.
● Evaluation and Management Documentation Guidelines
● Non-preventive Evaluation and Management Services in Outpatient
Settings
● Emergency Department Services
● Noncritical Hospital Evaluation and Management Services
The Appendix in the second half of the book contains articles from
the AAP Pediatric Coding Newsletter™. In April 2022, the newsletter began
publishing articles related to these coding revisions. Within these articles,
you will find detailed information on the codes and examples to help guide
implementation. We recommend reading them in the order in which they
appear, as some articles build on the contents of previous articles.
An online quiz is available for you to further enhance your coding
knowledge and demonstrate your understanding of the concepts in this
book. On successful completion of the quiz, you will receive a Certificate
of Completion from the AAP. To complete the quiz and obtain the certificate,
please go to www.aap.org/EMcertificate.
The AAP coding experts are ready to assist you with any coding-related
questions or concerns.
Linda D. Parsi, MD, MBA, CPEDC, FAAP
Editor in Chief, AAP Coding Publications Editorial Advisory Board
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