ebook img

Pediatric Evaluation and Management Coding Revisions: Facility and Office Services PDF

223 Pages·2023·12.888 MB·English
Save to my drive
Quick download
Download
Most books are stored in the elastic cloud where traffic is expensive. For this reason, we have a limit on daily download.

Preview Pediatric Evaluation and Management Coding Revisions: Facility and Office Services

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 PPeedd EEMM CCooddiinngg RReevviissiioonnss iinntteerriioorr 22002233--1100--2200..iinndddd 11 1100//2211//2222 99::4433 AAMM 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 345 Park Blvd Itasca, IL 60143 Telephone: 630/626-6000 Facsimile: 847/434-8000 www.aap.org 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 external resources. Information was current at the time of publication. 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. Special discounts are available for bulk purchases of this publication. Email Special Sales at [email protected] for more information. © 2023 American Academy of Pediatrics All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means—electronic, mechanical, photocopying, recording, or otherwise—without prior written permission from the publisher (locate title at https://publications.aap.org/aapbooks and click on © Get Permissions; you may also fax the permissions editor at 847/434-8780 or email [email protected]). 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 of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the AMA. Printed in the United States of America 11-135 1 2 3 4 5 6 7 8 9 10 MA1095 ISBN: 978-1-61002-670-3 eBook: 978-1-61002-671-0 PPeedd EEMM CCooddiinngg RReevviissiioonnss iinntteerriioorr 22002233--1100--2200..iinndddd 22 1100//2211//2222 99::4433 AAMM 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 PPeedd EEMM CCooddiinngg RReevviissiioonnss iinntteerriioorr 22002233--1100--2200..iinndddd 33 1100//2211//2222 99::4433 AAMM 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. PPeedd EEMM CCooddiinngg RReevviissiioonnss iinntteerriioorr 22002233--1100--2200..iinndddd 44 1100//2211//2222 99::4433 AAMM 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 PPeedd EEMM CCooddiinngg RReevviissiioonnss iinntteerriioorr 22002233--1100--2200..iinndddd 55 1100//2211//2222 99::4433 AAMM 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 PPeedd EEMM CCooddiinngg RReevviissiioonnss iinntteerriioorr 22002233--1100--2200..iinndddd 66 1100//2211//2222 99::4433 AAMM 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. PPeedd EEMM CCooddiinngg RReevviissiioonnss iinntteerriioorr 22002233--1100--2200..iinndddd 77 1100//2211//2222 99::4433 AAMM PPeedd EEMM CCooddiinngg RReevviissiioonnss iinntteerriioorr 22002233--1100--2200..iinndddd 88 1100//2211//2222 99::4433 AAMM ||||||||||| 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 PPeedd EEMM CCooddiinngg RReevviissiioonnss iinntteerriioorr 22002233--1100--2200..iinndddd 99 1100//2211//2222 99::4433 AAMM

See more

The list of books you might like

Most books are stored in the elastic cloud where traffic is expensive. For this reason, we have a limit on daily download.