Published 7/1/2010
James Davidson, MD

Updating office E/M coding

Updated guidelines and tables for 2010

In May 2007, AAOS Now published “A simple system for coding E/M services,” a series of guidelines and tables for correct coding of evaluation and management (E/M) services. But the rules have changed since then, so this article updates that information. Orthopaedists and practices may use these guidelines to assist in internal compliance. New rules such as “no consults for Medicare” and emphasis of current red flags for audits are included.

The guidelines and tables summarize and organize information from the AAOS, the American Medical Association, the Centers for Medicare and Medicaid Services (CMS), and the Arthroscopy Association of North America; they have been reviewed by coding consultants from KarenZupko & Associates. Physicians are encouraged to download the tables for reference when dictating and coding. (All tables are available here; instructions for use can be found at the end of this article)

New patients and established patients
Determining whether the patient is new or established is the first step in the E/M coding process. New patient visits are reimbursed at a higher rate than established patient visits by most payors and “the 3-year rule” applies in defining a new patient visit.

New patients have not been seen by the treating orthopaedist or another orthopaedist (or nonphysician provider [NPP]) in the same practice within the past 3 years. Established patients have been seen by the treating orthopaedist or another orthopaedist (or NPP) in the same practice within the last 3 years.

Likewise, in a multispecialty group, new patients have not been seen by the treating orthopaedist or another orthopaedist (or NPP) in the same practice within the past 3 years. This is true even if the patient had been seen previously by a physician in a different CMS-defined specialty in the practice within the 3 years.

CMS has established specific taxonomy codes to define areas of specialization for healthcare providers. Orthopaedic surgery, internal medicine, physical medicine and rehabilitation, and family practice are all distinct specialties.

A hand specialist credentialed with CMS and insurance carriers first or only as a hand specialist is also considered to be in a different specialty than the orthopaedist. At this time, hand surgery is the only orthopaedic specialty that has specialty recognition from CMS.

Interpretation of the 3-year rule is nuanced when orthopaedic surgeons practice in a group with hand surgeons who at times function as general orthopaedic surgeons. For example, if a patient is seen by an orthopaedist, and no other orthopaedist in the group has seen that patient in the past 3 years, the encounter qualifies as a new patient visit. This is true even if the patient had been seen by a credentialed hand specialist in the group for hand problems within 3 years.

Similarly, if a patient sees a credentialed hand specialist for a hand problem and that patient has not seen another hand specialist in the practice within 3 years, the encounter qualifies as a new patient visit—even if that patient was seen by an orthopedist in the group within 3 years.

However, if a patient sees a hand specialist on call for the group for a hip problem and then sees an orthopaedist in the same group within 3 years for a knee problem, the patient is typically treated as an established patient. In this case, although the hand surgeon is a different specialty, he or she functioned as a general orthopaedist for treatment of the hip problem.

As of January 2010, CMS carriers no longer accept consultation codes, but other insurance carriers still allow consultation codes with specific requirements. For a visit to be considered a consultation, there must be documentation of a request from another physician (or appropriate source) to either recommend care for a specific condition or problem or determine whether transfer of care will be accepted for the patient’s entire care or for the care of a specific condition or problem. If there is no request, there is no consultation.

The request for consultation may be verbal or written and must be documented in the patient’s record. For example, the requesting physician can send a letter to the orthopaedist asking for the consultation. The orthopaedist may give requesting physicians a pad of consultation request slips to use. Or at a minimum, the orthopaedist must include a statement in the documentation such as “I was asked to see this patient in consultation by Dr. X for an opinion regarding problem Y.”

Transfer of care is the process whereby a physician who is providing management for some or all of a patient’s problems relinquishes this responsibility to another physician who explicitly agrees to accept this responsibility and who, from the initial encounter, is not providing consultative services. The physician transferring care is then no longer providing care for these problems, although he or she may continue providing care for other conditions when appropriate. The orthopaedist may order tests and/or institute treatment at the time of the consultation; however, the visit is not a consultation if the orthopaedist already has accepted transfer of care before seeing the patient for the first time.

The patient’s record must reflect that the orthopaedist communicated the findings in writing via a separate written report to the requesting physician. This is usually in the form of a cover letter that summarizes the orthopaedist’s opinions and accompanies the standard office note.

For consultations, as with all categories of E/M, the documentation criteria for the level of service reported must be met.

The 3-year rule for new patients does not apply to consultations. For example, a primary care physician may ask the orthopaedist for a consultation for a patient’s foot problem this year and next year ask for a consultation for the same patient’s shoulder problem. Both visits may be reported as consultations if all other requirements are met. The 2010 Current Procedural Terminology (CPT) guidelines state, “If an additional request for an opinion or advice regarding the same or a new problem is received from another physician or other appropriate source and documented in the medical record, the office consultation codes may be used again.”

Under very special circumstances, an orthopaedist in a practice may consult an associate within the same practice. For example, a joint surgeon treating a patient for hip pain may request a consultation with a spine colleague to obtain an opinion on whether spinal arthritis may be the primary cause of the hip pain. The joint surgeon would then continue treating the patient. This qualifies as a consultation.

In contrast, if a hand specialist refers a patient to a joint specialist to treat a degenerative hip, a transfer of care occurs. Similarly, a referral by a physician’s assistant or an “office-only” orthopaedist to another orthopaedist for additional treatment would not qualify as a consultation.

Intra-group consults present the highest level of risk in reporting consultation services; a practice with a large number of consultations or high-level codes may raise a red flag to payors and auditors.

The orthopaedic evaluation
The orthopaedic evaluation is made up of three key components: the history, the physical examination, and medical decision-making.

The history component
The history component consists of the chief complaint (CC); history of present illness (HPI); review of systems (ROS); and past, family, and social history (PFSH) sections.

Document a CC for every visit, using the patient’s own words. If the patient states, “my back is killing me” for the first visit CC, “follow-up for low back pain” might be the CC for a follow-up visit.

The HPI uses descriptive elements to document the current problem. This section of the history must be obtained and described by the billing physician or the nonphysician provider (NPP) who is billing for the service.

The ROS and PFSH can be recorded on an office health history questionnaire completed by the patient or ancillary staff and reviewed by the physician or NPP of record. The data may then be documented or dictated into the orthopaedic evaluation, or the health history questionnaire may be referred to by date in the note. The provider of record must sign and date the form indicating his or her review and agreement with the information on the questionnaire. Credit may not be granted if the form is only referenced in the documentation.

The ROS is an inventory of 14 body systems focusing on a description of symptoms (chest pain or shortness of breath) rather than diseases (myocardial infarction or chronic obstructive cardiopulmonary disease). To receive credit for a system review documented on a questionnaire, an individual entry of positive or negative response for each system is required. If a system is left blank, it is assumed that the patient or staff did not complete the form in its entirety.

The PFSH is a review of three areas: past history, family history, and social history.

Because every note must be a stand-alone note, a physician or NPP who chooses to refer to the ROS or the PFSH on a health history form must initially sign the form and then reference the form by date in future notes (“ROS, PFSH reviewed from March 1, 2010, no changes” or “…changes as follows…”).

Physical exam component
Most orthopaedic surgeons use the Musculoskeletal Single Specialty Examination (MSSE), which includes both a general examination and six musculoskeletal areas: neck, back, right and left upper extremities, and right and left lower extremities. Each examined area should be described in the report. The description should include inspection/palpation, range of motion, stability, and strength.

Orthopaedists who prefer to use the multisystem examination instead of the MSSE should check the AAOS Musculoskeletal Coding Guide or CMS guidelines for information.

Medical decision-making component
The medical decision-making component (MDM) has three parts: data, diagnosis, and risk. It is a measure of the complexity of the case and the recorded evaluation. Medical decision-making is more complex for patients who undergo multiple tests or have multiple diagnoses, or who have increased risk factors. Any invasive procedure has a risk of morbidity and mortality. The physician should document all the data reviewed, the comorbidities considered, and the risk factors reviewed.

In some cases, time may be a factor in determining the level of service. Although time is not one of the three key components in selecting a level of service, time can become the determinant for CPT code selection when the visit consists predominantly of counseling or coordination of care. The total time must be spent face-to-face between the physician (or NPP) and the patient; more than half of that time must be spent counseling or coordinating care, and the content of those activities should be summarized. Time spent reviewing records while the provider is not with the patient does not qualify. Time should be rounded down, not up.

Modifiers are 2-digit codes that can be appended to evaluation and management (E/M) services to indicate the physician or NPP has provided a service that is variant to the normal definition or surgical package.

E/M codes should not be billed for services related to the surgical procedure during the global period. E/M services for conditions at other anatomic locations than the global surgical procedure may be reported during the global period if the medical necessity of performing an E/M service is supported and the documentation supports the level of service. For example, if during the postoperative global period for a total knee arthroplasty, the orthopaedist treats the patient for a newly sprained wrist, the orthopaedist may bill for treatment of the wrist using a modifier that indicates the visit is unrelated to the global surgical procedure.

E/M codes should not be billed the day of or the day before a surgical procedure unless the decision for surgery was made at that time and the appropriate modifier is appended.

E/M codes should not be billed with planned injections. If the decision to perform the injection is made on the same day the injection is given, an E/M code with a modifier and an injection procedure code may be billed if the medical necessity of performing an E/M service is supported and the documentation supports the level of service. If the patient returns for a planned injection, however, only the procedure code should be submitted.

E/M modifiers enable E/M services to be billed with additional services that might otherwise be considered bundled in a global fee. CPT modifiers that can be used with E/M coding are listed in Table 4.

The use of office forms and templates can greatly simplify documentation of orthopaedic evaluations, but the physician should customize the template for each specific patient condition. Fixed templates that produce identical notes for every patient are red flags and present significant risk to the practice.

James Davidson, MD, practices with Canyon Orthopaedic Surgeons, OSNA, in Phoenix, Arizona. The author acknowledges the assistance of Blair Filler, MD, and Brad Henley, MD, MBA, of the AAOS Coding, Coverage, and Reimbursement Committee and Mary LeGrand, RN, MA, CCS-P, CPC, of KarenZupko & Associates, Inc., in preparing this article. This information is for reference use only and does not constitute the rendering of professional consulting or legal advice by the AAOS or the author. Refer to the practice management center on the AAOS Web site, and submit specific questions to KarenZupko & Associates, Inc.

Five steps for using the tables

  1. Determine whether a visit should be coded as a New Patient, Consultation, or an Established Patient.
    Table 1 and 2 are divided into columns corresponding to the level of E/M service and E/M code. The level of service of the visit and level of code is determined by the number of bullets/elements recorded in the note for each of the Key Components. As of Jan. 1, 2010, Medicare stopped recognizing CPT codes for consultation services.
  2. Review the History key component. Every note needs a CC.
    For the HPI section, score one bullet for each descriptive element recorded in Table 3.
    For the ROS, score one bullet for each system described. To receive credit for a system review documented on a questionnaire, there must be an individual entry of positive or negative response for each system.
    For the PFSH, score one bullet for each history area described: past, family, and social. The number of bullets scored determines which coding level or column of the table is met for the History key component (Tables 1 and 2).
    The criteria for each section—CC, HPI, ROS, and PFSH—must be met or exceeded for the history component to qualify for a given code level or column in the table. For example, the minimum requirement for a detailed new patient history requires that the chief complaint, four elements describing the HPI, two systems from ROS, and one area from PFSH be documented.
  3. Review the Physical Exam component, using the Musculoskeletal Exam bullet counter (Table 3).
    The minimum requirement for a comprehensive exam is documentation for all 4 bullets (Inspect/palpate, ROM, Stability, and Strength) in four body areas and Skin in four body areas in addition to all other exam elements noted in the table.
    If both the involved and the contralateral extremity are examined, document this appropriately. Documentation of multiple joints in the same body area are scored as one bullet for each descriptor. For example, range of motion of the right shoulder, right elbow, and right wrist is one bullet. But range of motion from right shoulder, left shoulder, right knee, left knee, neck, and back is six bullets.
    The number of bullets scored determines which coding level or column of the table is met for the Physical Exam key component (Tables 1 and 2).
  4. Review the Medical Decision Making (MDM) key component.
    In the Data section, points (listed in parentheses in Tables 1 and 2) are given for several data-gathering tasks. Add up the points to determine the level of complexity. For example, ordering an X-ray and then providing an independent interpretation totals three points of complexity—one for ordering the study and two for the interpretation. This has been referred to as the “orthopaedic three-point play.” But ordering multiple X-rays—knee, hip, and ankle—still only scores one point for ordering imaging. Likewise, reviewing and summarizing one page of old records or 100 pages scores the same two points.
    The Diagnosis section is similarly scored (Tables 1 and 2). For example, evaluating a new problem without a planned work up and reassessing another improved established problem at the same visit totals four points of complexity—three for the new problem, and one for the established stable problem.
    Finally, the Risk section of the MDM is a measure of the risk of complication, morbidity, or mortality of the management options selected, diagnostic procedures ordered, or presenting problems. Examples of these from some CMS carriers and AAOS are listed in Tables 1 and 2. The highest level of risk from any one category (management options selected, diagnostic procedures ordered, or presenting problem) determines the overall risk. Two of the three MDM elements—Data, Diagnosis, and Risk—must be met or exceeded for the MDM component to qualify for a given code level or column in the table (Tables 1 and 2).
  5. Choose a code.
    For a New Patient visit or Consultation, documentation for all three of the key components must meet or exceed the level for the code to qualify. The left-most column of the table determines the code. For example, a new patient visit note that documents a detailed history, a detailed exam, and a low complexity MDM qualifies for a 99203 level of service. A new patient visit note that documents detailed history, an expanded exam, and a low complexity MDM qualifies for a 99202 level of service.
    For an Established Patient visit, documentation of only two of three key components must meet or exceed the level for the code to qualify. The left-most column of those two key components chosen determines the code. For example, an established visit note that documents an expanded history, a focused exam, and a low complexity MDM qualifies for a 99213 level of service.
    Alternatively, and less frequently, time can be used as a stand-alone factor in determining the level of service and code with minimum time and documentation requirements specified in Tables 1 and 2. If time is used as the determining factor, the appropriate time column demonstrates the level of service and code.
    Finally, the level of service that is reported must reflect the medical necessity of the problem. For example, the treatment of a simple bug bite would not qualify for a comprehensive level of service regardless of the history and physical exam documented.