Goals

Medical Billing and Coding

⚫ Become familiar with current
medical coding
⚫ Identify resources to help build
Allan Platt PA-C medical coding skills
⚫ Code several notes
⚫ Learn how good charting can
help coding
⚫ Think!

1 2

Getting Paid Who Pays for your work

⚫ Medicare (US Govt for over 65yo)

You evaluate patients, do
⚫ Medicaid (State plan for low income)
procedures, and assist in surgery
⚫ Childrens Health Insurance Plans (Govt)
You document what you did in the
medical record ⚫ Private Insurance – Employer sponsored
You bill for what you do based on ⚫ Champus (Govt – Military)
your documentation and code ⚫ Out of Patient’s Pocket – self pay
You get paid so you can vacation ⚫ For all Govt, and Insurance you need a NPI #
and will need to use Codes

3 4

Coding Systems Coding Systems

⚫ What – ICD 10 = International Classification of Diseases

– Provides a common documentation language (A number for every disease or condition) = What
⚫ What did you do? = CPT codes
you Diagnosis effective 10/1/2015 (5 Xs the
⚫ What diseases and conditions treated? ICD-10
codes as ICD 9)
⚫ What equipment and supplies were used? HCPCs part 2 – CPT = Current Procedural Terminology- Exam,
Procedures, Surgery, Tests = What you did
⚫ Why
- HCPCS - Healthcare Common Procedure Coding
– Used by medical insurers to process claims
System -2 parts,
⚫ To get paid disease must correlate with what was done
- part 1 is the CPT list What you did
⚫ Documents workload
- part 2– Procedures, equipment, products, supplies not in
the CPT list = What you use

5 6

1
 CPT –EM
codes

ICD-10 codes

HCPCS
codes
CPT
codes ICD-10
codes

Super Bill

7 8

HCFA Billing
Form ICD 10 CM Codes

⚫ Has CPT and ⚫ International Classification of Disease, 10th Revision,

Clinical Modification
ICD-10 codes
⚫ A system of diagnoses descriptions/disease
⚫ Charges classification
⚫ Developed and maintained by WHO – changes
annually ICD-10 final on 10/1/2015
⚫ Each code consists of a 3-5 digit number
⚫ Each CPT service provided needs justification by a
code from the ICD 10 CM code manual
⚫ Available in Dynamed, Online (several sites)

9 10

Ordering Tests Dynamed -

⚫ A 40 year old teacher has fatigue and

dizziness (non-vertigo). On PE he has pallor Dynamed
Main Index
you suspect anemia. Search for the
⚫ To order a Hemoglobin, what ICD-10 would disease

you put on the lab slip? (Dynamed look up

anemia)
⚫ A. D64.9
⚫ B. F72.34
⚫ C. D51.4

11 12

2
 Dynamed - Dynamed -

Dynamed ICD 10 list

Main Index
Search for the
disease

13 14

Dr. Google Time saver

⚫ When doing your patient’s problem list look-

up the ICD-10 code and write it down on the
problem list (date it) so every time the patient
comes for follow-up, the code is there. Saves
look-up time
⚫ EMR – Electronic Medical Records do this!!

15 16

CPT codes E/M Services

⚫ Per CPT manual ⚫ Evaluation and Management Services

“…a set of codes, descriptions, and ⚫ Copyrighted and maintained by AMA
guidelines intended to describe procedures ⚫ Each service is assigned a CPT code for
and services performed by physicians or billing purposes to represent the providers
other health care providers. Each procedure personal work necessary to perform the visit
or service is identified with a five-digit code. service
The use of CPT codes simplifies the ⚫ CPT is a subset of HCPC (“HixPix”)
reporting of services.” Healthcare Common Procedure Coding
System

17 18

3
 RVU or RBVUs Definitions

⚫ Resource Based Value Unit Scale ⚫ New Patient

⚫ The value of work assigned each CPT code – One who has not received professional services
from the physician or another physician of the
⚫ The dollar amount of 1 RBVU is set by same specialty in the same group practice within
Medicare each year. www.CMS.gov the past 3 years.
⚫ Also in payment equation is a regional factor, – First thing to determine: NEW or ESTABLISHED
Office overhead and professional liability – New 9920x where x = 1 through 5, Pays more
factor. These depend on where you see the ⚫ (zero is not in the practice vs you are 1 with the practice)
patient. – Established 9921x where x = 1 through 5

19 20

Evaluation and Management Categories of E&M codes -

Principles Where you are providing service

⚫ EM codes represent the service performed in Each area has a different set of codes
a particular setting – Hx/PE/Assessment/Plan ⚫ Outpatient – 992yx y=0 New, y = 1 Est, x= 1-5 level

⚫ The exact code is defined by medical record ⚫ Inpatient - 9922x or 9923x

documentation ⚫ Consultation – 9924x, 9925x, 9926x, 9927x

⚫ Emergency department - 9928x
⚫ Categories
⚫ Nursing home – 9930x
– Delivery site of service: Clinic, ED, Nursing Home
⚫ Rest home – 9932x
⚫ Levels
⚫ Home visits – 9934x
– Type of patient problem/ complexity

21 22

Evaluation and Management The exact code is defined by

Principles medical record documentation

⚫ Documentation of patient encounters is KEY ⚫ History (Hx)

⚫ The code must represent what was ⚫ Physical Examination (PE)
documented in the chart. ⚫ Medical Decision Making (MDM)
⚫ If it is not documented – it was not done
⚫ Billing above or below what was documented ⚫ Time - use only if greater than 50% of the
is FRAUD and can lead to fines and jail. visit includes counseling - face to face time
(must document this)

23 24

4
 Evaluation and Management Evaluation and Management
Principles Principles

Documentation of patient encounters (SOAP note)

⚫
Documentation evaluated for key components
⚫ Title the sections of your note, LABEL body systems
⚫ Chiefly History in the Past tells your Family Social Review – History (Hx - Subjective)
– CC ⚫ HPI – the cc and LOCATES
– HPI (LOCATES) label ⚫ ROS – by Body system
– Past Medical History, Family History, Social History (PFSH) ⚫ PFSH – Past/Family/Social History
– ROS (By System- Gen, Endo, HEENT, Lung, CV….
– Physical Exam (By System or Body location) – Physical Exam (PE- Objective)
– Assessment /Clinical Impression (Medical Decision Making) ⚫ by body system, body part, bullet points
– Plan of care (Risk Level)
– Medical Decision Making
⚫ Diagnoses - Assessment,
⚫ Data -Objective,
⚫ Risk- Plan

25 26

Evaluation and Management

Principles

⚫ Each key component is assigned a level

– Problem focused (PF)
– Expanded problem focused (EPF)
– Detailed (D)
– Comprehensive (C) Complete Database –Full
HxPE)
⚫ Once the level for each component is
assigned, all key component levels are
looked at and the CPT- E/M code is selected

27 28

Documentation of History

⚫ Components of History
– CC “patients words” x duration Needed for all levels
– HPI – LOCATES + Duration
⚫ 8 elements possible Always do 4 or more for Detailed
– PFSH = Past/Family/Social History
⚫ 1 element = Detailed, 3 elements =Comprehensive, May be
recorded by pt or staff with provider confirmation
⚫ New info or no change, noting date/location of previous
information
– ROS= Review of Systems
⚫ 2 systems General and whatever = Detailed
⚫ 10 or more = Comprehensive

29 30

5
 Example Example
⚫ S: New Patient states her chest pain a couple of nights ago was ⚫ S: New Patient states her chest pain a couple of nights ago was
relieved by ginger ale, she now says the pain lasted a few minutes and relieved by ginger ale, she now says the pain lasted a few minutes and
she’s had no chest pain since. She says she is feeling fine and wants she’s had no chest pain since. She says she is feeling fine and wants
to continue living with her husband. In discussion with her husband, to continue living with her husband. In discussion with her husband,
the family is very concerned about the patient’s increasing levels of the family is very concerned about the patient’s increasing levels of
dementia and confusion. Husband questions whether he will be able to dementia and confusion. Husband questions whether he will be able to
handle her, and the ABC Retirement Home first wanted to put her in handle her, and the ABC Retirement Home first wanted to put her in
XYZ Care, which is the nursing home, but then decided she would do XYZ Care, which is the nursing home, but then decided she would do
fine in assisted living. Notes from ABC’s infirmary show that she does fine in assisted living. Notes from ABC’s infirmary show that she does
wander a lot and has disturbed other patients. Current medications: wander a lot and has disturbed other patients. Current medications:
Multivitamin, Dulcolax, Calcium 800 mg daily, Synthroid 0.1 mg daily, Multivitamin, Dulcolax, Calcium 800 mg daily, Synthroid 0.1 mg daily,
Norvasc 2.5 mg daily, Aricept 10 mg at hs. Needs a flu shot. Norvasc 2.5 mg daily, Aricept 10 mg at hs. Needs a flu shot.

⚫ CC/HPI: LOCATES = ⚫ CC/HPI: LOCATES = 3

⚫ PMH/FH/SH = ?

31 32

Example Example
⚫ S: New Patient states her chest pain a couple of nights ago was ⚫ S: New Patient states her chest pain a couple of nights ago was
relieved by ginger ale, she now says the pain lasted a few minutes and relieved by ginger ale, she now says the pain lasted a few minutes and
she’s had no chest pain since. She says she is feeling fine and wants she’s had no chest pain since. She says she is feeling fine and wants
to continue living with her husband. In discussion with her husband, to continue living with her husband. In discussion with her husband,
the family is very concerned about the patient’s increasing levels of the family is very concerned about the patient’s increasing levels of
dementia and confusion. Husband questions whether he will be able to dementia and confusion. Husband questions whether he will be able to
handle her, and the ABC Retirement Home first wanted to put her in handle her, and the ABC Retirement Home first wanted to put her in
XYZ Care, which is the nursing home, but then decided she would do XYZ Care, which is the nursing home, but then decided she would do
fine in assisted living. Notes from ABC’s infirmary show that she does fine in assisted living. Notes from ABC’s infirmary show that she does
wander a lot and has disturbed other patients. Current medications: wander a lot and has disturbed other patients. Current medications:
Multivitamin, Dulcolax, Calcium 800 mg daily, Synthroid 0.1 mg daily, Multivitamin, Dulcolax, Calcium 800 mg daily, Synthroid 0.1 mg daily,
Norvasc 2.5 mg daily, Aricept 10 mg at hs. Needs a flu shot. Norvasc 2.5 mg daily, Aricept 10 mg at hs. Needs a flu shot.
⚫ CC/HPI: LOCATES = 3
⚫ CC/HPI: LOCATES = 3 ⚫ PMH/FH/SH = 2
⚫ PMH/FH/SH = 2 ⚫ ROS=0 This is PF on the chart (3 out of 3 Categories)
⚫ ROS= ?

33 34

History Parts Better History

⚫ CC: “ Chest pain” X few minutes
⚫ Hx: PF EPF Detailed Comp ⚫ HPI : Location – mid Chest sub sternal CC/Locates = ?
⚫ HPI: 1–3 1–3 4+ 4+ ⚫ Other Sx: None ROS = ?
⚫ Character : Burning PH/FH/SH = ?
⚫ ROS: 0 1 2–9 10+ ⚫ Alleviated with ginger ale
⚫ Timing: Duration - Lasted a few minutes happened 2 days ago
⚫ PFSH: 0 0 1 2(est) or ⚫ Environment – at home
Severity 4 out of 10
3(new ⚫
⚫ ROS – Gen: No weight loss, fever, chills, night sweats, rash
– CV: No dyspnea, orthopnea, exertional pain, PND, CV meds
Must meet or exceed 3 of the 3 elements – GI- No Nausea, vomiting, heartburn, GB disease, surgery
⚫ Social Hx – Pt wants to continue living with her husband. In discussion with her
husband, the family is very concerned about the patient’s increasing levels of
dementia and confusion. Husband questions whether he will be able to handle
her,
⚫ PMH - Has Alzheimer’s disease and Hypothyroidism. Current medications:
Multivitamin, Dulcolax, Calcium 800 mg daily, Synthroid 0.1 mg daily, Norvasc
2.5 mg daily, Aricept 10 mg at hs. Needs a flu shot.

35 36

6
 Better History History Parts
⚫ CC: “ Chest pain” X few minutes
⚫ HPI : Location – mid Chest sub sternal CC/Locates = 7 ⚫ Hx: PF EPF Detailed Comp
⚫ Other Sx: None ROS = 3 ⚫ HPI: 1–3 1–3 4+ 4+
⚫ Character : Burning PH/FH/SH = 2
⚫ Alleviated with ginger ale ⚫ ROS: 0 1 2–9 10+
⚫ Timing: Duration - Lasted a few minutes happened 2 days ago
⚫ Environment – at home ⚫ PFSH: 0 0 1 2(est) or
Severity 4 out of 10
⚫
⚫ ROS – Gen: No weight loss, fever, chills, night sweats, rash
3(new
–
–
CV: No dyspnea, orthopnea, exertional pain, PND, CV meds
GI- No Nausea, vomiting, heartburn, GB disease, surgery
This note is Detailed because this is the lowest
⚫ Social Hx – Pt wants to continue living with her husband. In discussion with her category that 3 or the 3 elements is completed. It
husband, the family is very concerned about the patient’s increasing levels of
dementia and confusion. Husband questions whether he will be able to handle would take 10 + body systems in the ROS to get
her,
⚫ PMH - Has Alzheimer’s disease and Hypothyroidism. Current medications: a Comprehensive rating
Multivitamin, Dulcolax, Calcium 800 mg daily, Synthroid 0.1 mg daily, Norvasc
2.5 mg daily, Aricept 10 mg at hs. Needs a flu shot.

37 38

Organized Labeled Notes make the

difference!!!!
⚫ Subjective
⚫ Identification Information with New or Established status
⚫ CC
HPI- L
⚫
⚫ O- ROS by body system: Gen, Eye, HEENT, Card, Resp, GI,GU… There is NO reason not to
⚫
⚫
C-
A- have a Detailed History with
T-
⚫
⚫ Duration- at least the CC, HPI
E–
⚫
⚫ S- (Locates), 3 questions from
⚫
⚫
PMH –
FH – PFSH and 2 systems in the
SH-
⚫
⚫ Objective ROS (general +_____)
⚫ VS-
⚫ Gen –
⚫
⚫
Body systems identified : Eye, HEENT, CV, Lung, GI, GU, MS, Neuro, Heme
Lab, radiology, and other tests reviewed If you do 10 systems in the
⚫
⚫
Assessment
Diagnosis and differentials with ICD-9 code and indicate ROS you are
Plan
⚫
⚫ Dx - Lab, xray, old chart, Comprehensive
⚫ RX – meds
⚫ PtEd – document face time with minutes spent educating and counseling
⚫ Suggested CPT E/M code:

39 40

95 vs 97 PE documentation

Documentation of Examination

1995 1997
⚫ Exam based on number ⚫ Exam based on single-
of organ systems body organ system exams –
areas examined bulleted items in each
⚫ Body areas: Head, ⚫ Systems (95-97):
neck, chest, abdomen, General, Eye, ENT, CV,
GU, Back, each Lung, GI, GU, Muskel,
extremity Skin, Neuro, Psych,
Heme/Lymph

41 42

7
 95 vs 97 Guidelines Example PE

⚫ Objective: Lungs are clear. Heart RRR

without murmur.
⚫ By 95 guidelines (organ systems)
⚫ PF EPF Detailed Comp
⚫ 1 2–7 2-7(more depth) 8+
⚫
You should always be at least Detailed by doing 2 complete systems or
Body parts: Vital signs, General Inspect (Skin, eye) and then whatever

43 44

Example Better PE

Objective: VS p 85, R 16, BP 130/85 General : no acute distress,

no rashes or lesions, no tremor,
Eye – No Exopthalmos EOM full, PERRLA Fundus WNL
Lungs are clear to auscultation and percussion
Heart RRR without murmur. No JVD,No pedal edema.
Neuro – Not oriented to time, short term memory – missed 2 of 3
objects, Reflexes all 2 +
Recent TSH was normal at 1.2.
⚫ PF EPF Detailed Comp
⚫ 1 2–7 2-7 8+
⚫ (95 - organ systems)

45 46

Medical Decision Making (MDM) Dx Mgmt Diagnostic Management

⚫ MDM Level determined by ⚫ Look at each diagnosis you documented in your

– 1. Number of diagnosis or management options Assessment
– 2. Amount and/or complexity of data (lab, reports…) ⚫ Self limited or minor diagnosis = 1 point each
– 3. Risk to the patient (morbidity/mortality) ⚫ Established problem stable = 1 point each
– MDM: Sfwd. Low Mod. High ⚫ Established problem worse = 2 points each
– Dx./Mgmt: 0-1 2 3 4+ ⚫ New problem no further W/U = 3 points each
– Data: 0-1 2 3 4+ ⚫ New problem with planned W/U = 4 points each
– Risk: Min. Low Mod High
⚫ Add up for a total
– To qualify for a specific level of complexity, 2 of the 3
– MDM: Sfwd. Low Mod. High
elements must be met or exceeded.
– Dx./Mgmt: 0-1 2 3 4+

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8
 Data – Old records lab and xray Risk of Complications

⚫ Order or review lab = 1 point ⚫ Any prescription meds = Moderate risk

⚫ Order or review X-ray = 1 point ⚫ LP, stress test, biopsy = Moderate risk
⚫ Discuss test with MD = 1 point ⚫ 2 chronic stable illness = Moderate risk
⚫ Order old records = 1 point ⚫ Meds that are controlled or monitored = High
⚫ Review and summarize old records = 1 point risk
– MDM: Sfwd. Low Mod. High
– Dx./Mgmt: 0-1 2 3 4+
– Data: 0-1 2 3 4+

49 50

Risk of Complications

⚫ Any prescription meds = Moderate risk

⚫ Any non script meds = Low Risk
⚫ LP, stress test, Bx = Moderate risk
⚫ 2 chronic stable illness = Moderate risk
⚫ 1 chronic stable illness = Low risk
– MDM: Sfwd. Low Mod. High
– Dx./Mgmt: 0-1 2 3 4+
– Data: 0-1 2 3 4+
– Risk: Min. Low Mod High
– To qualify for a specific level of complexity, 2 of the 3 elements must
be met or exceeded.

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Example Example

Assessment 1. Alzheimer’s ⚫ Dx Mgmt = 3 problems (new no work-up) = 3 points

2. Hypothyroidism. ⚫ Data = 1 (lab result) = 1 point
3. Chest pain, resolved
Plan: 1. In discussion with the family decided to place ⚫ Risk = Moderate ( on prescription meds)
the patient in the assisted living facility. He will go
and have lunch and dinner with her as he wishes, ⚫ Dx Complexity (pick 2 out of 3 ) = Moderate
and we will reassess when she comes back in
January. – MDM: Sfwd. Low Mod. High
2. Refill Synthroid 0.1 mg #30, 1 daily, 6 refills. – Dx./Mgmt: 0-1 2 3 4+
3. Reassurance that episode was not consistent with – Data: 0-1 2 3 4+
angina, though we will be alert for other episodes – Risk: Min. Low Mod High
and do further evaluation if indicated.
What is the MDM?

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9
 Putting it together: new pts
9920? Putting it together: new pts

⚫ Requires 3 of 3 elements excluding time ⚫ Requires 3 of 3 elements excluding time

Face-to- Face-to-
History Exam MDM History Exam MDM
face face
99201 PF PF Stfrwd 10 min. 99201 PF PF Stfrwd 10 min.
99202 EPF EPF Stfrwd 20 min. 99202 EPF EPF Stfrwd 20 min.
99203 D D Low 30 min. 99203 D D Low 30 min.
99204 C C Moderate 45 min. 99204 C C Moderate 45 min.
99205 C C High 60 min. 99205 C C High 60 min.

55 56

Putting it together: new pts Other factors - Time

• Requires 3 of 3 elements excluding time – all you need is
Low Risk MDM to get a 99203 (same pay as 99214) You
need moderate risk + complete Hx/PE for 99204 ⚫ Time
– lesser element
Face-to- – use if counseling > 50% of encounter time, face to face
History Exam MDM
face – Used for coordination of care
99201 PF PF Stfrwd 10 min. ⚫ Charting: “The majority of this visit was counseling
regarding X and coordination of care with Y, with a
99202 EPF EPF Stfrwd 20 min. total face-to-face time of Z minutes.”
99203 D D Low 30 min. ⚫ “Face to face time with patient X minutes, > 50% of
which was devoted to counseling re: self-
99204 C C Moderate 45 min. management of ______.”
99205 C C High 60 min.

57 58

Putting it together: Putting it together:

established pts 9921? established pts

⚫ Requires 2 of 3 elements excluding time ⚫ Requires 2 of 3 elements excluding time

Face- Face-
History Exam MDM History Exam MDM
to-face to-face
supervision supervision supervision supervision
99211 Stfrwd 5 min. 99211 Stfrwd 5 min.
only only only only
99212 PF PF Stfrwd 10 min. 99212 PF PF Stfrwd 10 min.
99213 EPF EPF Low 15 min. 99213 EPF EPF Low 15 min.
99214 D D Moderate 25 min. 99214 D D Moderate 25 min.
99215 C C High 40 min. 99215 C C High 40 min.

59 60

10
 Family Practice Management
Example available online at http://www.aafp.org/fpm.xml

ESTABLISHED PATIENT CPT codes require 2 of 3 key components

excluding time
History Exam MDM Face-to-face

99211 supervision supervision Stfrwd 5 min.

only only
99212 PF PF Stfrwd 10 min.
99213 EPF EPF Low 15 min.
99214 D D Moderate 25 min.
99215 C C High 40 min.
If only one more body area could be examined raising the Exam to D,or 2
systems in the ROS included raising the history to D this could be coded a
99214

61 62

Est Pt 99212 vs 99213 Est Pt 99213 vs 99214

Key
elements (2 Key
of 3 The margin of elements
required) 99212 99213 difference (2 of 3 The margin of
required) 99213 99214 difference
History 1-3 HPI 1-3 HPI elements Review of 1
elements Review of affected system system History 1-3 HPI 4 HPI elements 1 ROS 1 PFSH
1ROS 2 ROS
Examination 1-5 6-11 elements 1 or more 1 PFSH
elements exam element PE 6-11bullets 12 bullets 1 bullet elements
Decision 1 self- 2 self-limited or minor 1 problem and, 2 Systems 2 Systems detailed More details
making limited or problems or 1 new problem for instance, Decision 2 minor or 1 1 new prob or 3 old and Only need 2 out of
minor plus low risk (e.g. OTC OTC making new prob – 1 script 3 categories
problem medication) medication low risk

63 64

Tips Preventive Medical Services

⚫ When patient has more than 1 problem and ⚫ Preventive Medicine/Health Maintenance
multiple SOAPs – Combine into one codes provide for evaluation and
Hx/PE/Assessment /Plan for the best code management of an individual based on age
⚫ When charting one note /many problems – appropriate comprehensive medical
use labels for Hx/PE parts and systems. examination – Well check with no problems
Number each problem in the Assessment
and Plan

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11
 Health Maintenance Procedures

Age New pt Established pt ⚫ Procedure only visits

Less than 1 year 99381 99391
1-4 years 99382 99392 ⚫ Combined procedure and E&M visits
5-11 years 99383 99393
12-17 years 99384 99394
⚫ Modifier -25 must be added if unrelated
18-39 years 99385 99395 procedure
40-64 years 99386 99396
65 and over 99387 99397

67 68

CPT Coding Modifiers CPT modifiers

⚫ Provides the means for indicting that a ⚫ -21 prolonged evaluation and management
service or procedure provided was altered by service
some specific circumstance ⚫ -25 significant, separately identifiable
evaluation and arrangement service by the
same provider on the day of procedure
⚫ -50 bilateral procedure

69 70

Bill under MD or your own NPI?

Modifier 25
• Incident-to billing paid at 100% MD rate but
Must follow RULES.
⚫ Health maintenance visits
• Usually- when not directly supervised, use
⚫ Reimbursement issues
your own NPI
• Private insurers/hospitals may bill under MD
NPI – check your state and local payers for
their rules.

71 72

12
 Incident to Split-Shared Service
• Covered services provided by a participating PA may be billed as incident-
to under the supervising physician’s provider number. Services will be
reimbursed at 100% of the physician fee schedule only if all the following
are met: • Physician and PA each personally perform a
• • PA is a credentialed and participating provider and must be considered substantive portion of an E/M visit face-to-
an expense to the physician such as an employee, leased or contracted
with the supervising physician and/or group (an entity that employs the face with the same patient on the same date
physician).
• • PA can evaluate only established problems, they can not render care to a
of service (Not same time together).
new patient to address a new problem. • Billed under Physician NPI if established
• • The participating physician must provide direct supervision. The
physician must be present in the office suite patient and previously diagnosed medical
• • The physician is actively involved in the decision-making process for care condition
of the patient. The PA must document in the patient’s medical record the
active involvement of the physician in the decision-making process. • Billed under PA’s NPI if new patient or new
• • The physician provides documentation/attestation of the collaboration medical condition
in the patient’s medical record by co-signing and dating the patient’s
medical record on the date the service is rendered.

73 74

Tele-visits Payment – Medicare 2020

Doing a Detailed Hx and PE assures you of a 99214 (Established Pt) and a
• On April 30, the Centers for Medicare & Medicaid Services (CMS) issued another round of regulatory changes(www.cms.gov) 99203 (New Pt)
to expand access to care during the COVID-19 public health emergency. One of the key changes was making Medicare
payments for audio-only telephone evaluation and management (E/M) visits (CPT codes 99441-99443) equal to payments
for comparable office or outpatient visits with established patients (codes 99212-99214). The range of payments will
increase from about $14-$41 to about $46-$110, with the changes retroactive to March 1.
New Patients Established Patients
• CMS also broadened the list of services it will cover as audio-only telephone visits. Noting that some Medicare beneficiaries
do not have access to the interactive audio-video technology required for Medicare telehealth services, or choose not to use 99201 - $51 99211 - $26
it, CMS is waiving the video requirement for certain services and adding them to the list of Medicare-covered telehealth
services. As a result, Medicare beneficiaries will now be able to use audio-only telephone visits to receive annual wellness
visits (G0438-G0439), advance care planning (99497-99498), tobacco and smoking cessation counseling (99406-99407), and
99202 - $84 99212 - $50
many behavioral health and patient education services. See a partial list of covered services below, or download the full list
from CMS(www.cms.gov).
99203 - $119 99213 - $83
99204 - $182 99214 - $121
99205 - $230 99215 - $162

Seeing 3 92214 pts per hour(12 – 15 pts/day) x 980* hrs/yr = $355,740 Billed
85% Medicare pay for PA billing = $284,592 Payment
Salary/Benefits + Overhead (cost of room/support/utilities/insurance) = Your
Cost $110,000 salary + $25,000 benefit + $100,000 overhead = $235,000
• *20 hr per week patient encounters x (52 week – 3 week vac/sick/cme)
• Assume at least 20 hr per week documenting, F/U, calls, labs,

75 76

RBVU= Medicare Resource‐Based

Relative Value Scale
• amount of physician work (52% of RBVU)
• practice expense (44% of RBVU)
• professional liability expense (4% or RBVU)
• multiplied by a Geographic Practice Cost
Indices(GPCIs)
• annually adjusted conversion factor.

https://www.cms.gov/apps/physician-fee-schedule/search/search-
results.aspx?Y=0&T=0&HT=0&CT=2&H1=99214&C=62&M=5

77 78

13
 How to Improve this skill
New for 2021
• Code your notes during rotations
• Talk to the office coders and ask questions ⚫ Totally time based or Medical Decision
• Find out how billing works in all your practices Making
(both good and bad practice) ⚫ No Hx or PE elements (Better not forget
• Write great notes after doing great Hx/PE documenting these for medicolegal reasons)
⚫ Only Medicare is adapting this so….. Still
• This is a value added skill that helps you track
need old system for everybody else.
productivity and improve office functionality.
⚫ Know both systems !!!

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Code by Time 2021 Medicare MDM – Complicated!

E/M code Typical time 2021 time

99201 New Pt 10 N/A, code deleted
99202 New Pt 20 15-29
99203 New Pt 30 30-44
99204 New Pt 45 45-59
99205 New Pt 60 60-74
99211 Est Pt 5 N/A, no time listed
99212 Est Pt 10 10-19
99213 Est Pt 15 20-29
99214 Est Pt 25 30-39
99215 Est Pt 40 40-54

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New Pay Rate Telemedicine codes

2019 rate (proposed, for
2020 National National
New patient 2018 rate 2021 rate (final) Code Description Work non-facility facility
comparison only)
RVU’s payment payment
99201 $45 $44 $44
Online digital evaluation and management
99202 $76 $135 $130 service, for an established patient, for up to
99421 0.25 $15.52 $13.35
7 days, cumulative time during the 7 days;
99203 $110 $135 $130
5-10 minutes
99204 $167 $135 $130 99422 11-20 minutes 0.50 $31.04 $27.43
99205 $211 $135 $212 99423 21 or more minutes 0.80 $50.16 $43.67
Established 2019 rate (proposed, for
(Qualified non-physician health care
2018 rate 2021 rate (final) professional online assessment, for an
patient comparison only)
G2061 established patient, for up to seven days, 0.25 $12.27 $12.27
99211 $22 $24 $24 cumulative time during the 7 days; 5-10
minutes);
99212 $45 $93 $90
G2062 11-20 minutes 0.44 $21.65 $21.65
99213 $74 $93 $90
G2063 21 or more minutes 0.69 $33.92 $33.56
99214 $109 $93 $90

99215 $148 $93 $149 https://codingintel.com/cpt-codes-online-digital-evaluation-and-management-services/

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 References

⚫ “How to Get All the 99214s you Deserve”, Family

Practice Management: Tools for Today’s Family
Physician, October 2003.
⚫ “Coding on the Basis of Time for Physician Services”,
Family Practice Management: Tools for Today’s
Family Physician, June 2003.

⚫ www.aafp.org
⚫ https://www.aapa.org/advocacy-
central/reimbursement/

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