E & M coding in mental and behavioral health

Tina Thompson

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I have a practitioner who disagrees with me on a coding issue.
I audit all of their charges that are above and 99213. when she documents its as follows
HISTORY
CC: is good
HPI: 3 areas
PMFSH: nothing she skips all
ROS: 5 areas
I SCORE HISTORY AS (EPF) expanded problem focused (because she does not document PMFSH) she states this should be scored as (detailed)?????

can I get someone else's opinion please.

Thanks
 

thomas7331

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In the introductory pages of the E&M section of the CPT book, reference the section called 'Instructions for Selecting a Level of E/M Service' where you'll find the definitions of the different levels of history and exam. In addition to an extended HPI and ROS, a detailed history contains pertinent PFSH related to the patient's problems. If the provider is not documenting any PFSH, it will cannot qualify as a detailed history. You can probably also download an E&M audit tool from your local Medicare contractor which will also show that in order to score a detailed history you need at least four elements of HPI and at least one element of PFSH.
 

cac_vo22

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coder

if it is an established patient, you will need only 2 components out of 3. It can be the combine of exam and medical decision. Use Medicare E/M worksheet to mark on the bullets. it'll tell you what level of E/M to report.

Hope this would help
Cac Vo
 

Tina Thompson

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In the introductory pages of the E&M section of the CPT book, reference the section called 'Instructions for Selecting a Level of E/M Service' where you'll find the definitions of the different levels of history and exam. In addition to an extended HPI and ROS, a detailed history contains pertinent PFSH related to the patient's problems. If the provider is not documenting any PFSH, it will cannot qualify as a detailed history. You can probably also download an E&M audit tool from your local Medicare contractor which will also show that in order to score a detailed history you need at least four elements of HPI and at least one element of PFSH.

Thanks for the verification I have all the other info you suggested but wanted another coders input for back up..
 

MJ4ever

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E&M

Hi,
https://www.cms.gov/Outreach-and-Ed...ds/eval_mgmt_serv_guide-ICN006764TextOnly.pdf

Check out requirements on page 4.

To reach a detailed HPI:
CC required,
HPI: extended (4 or more)
ROS: extended (2-9)
PFSH: pertinant (1)

I would let the provider know she needs to document pertinent (1) for PFSH with extended HPI and extended ROS with a more detailed CC to meet a detailed HPI. The cc should state the patient's condition he or she is coming in for, not good, because good doesn't explain what is wrong with the patient.

To meet a 99214 for an established patient two of the following are needed with MDM being one of them because MDM is the driving factor for the level of the E&M.

Detailed HPI,
Detailed Exam and
Moderate MDM is needed

Here is an E&M tool: https://e-medtools.com/wp-content/uploads/2014/03/Trailblazer_Medicare_Audit_v1.pdf

Hope this helps,
Barbara
 
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