TH2 251 Bower

Wilce Student Health Center
CODING 101
Evaluation and Management (E&M) and Procedure
Coding for Office Encounters in a Student Health Center
Michael Bower CPC


• Wilce Student Health Center at The Ohio State
University
• Autumn 2013 Enrollment 63,964 (57,466 Columbus
Campus)
• Student enrollment is a requirement to use Wilce
SHS

• 2012-2013
• 65,605 Total Patient Visits
• 28,702 Primary Care
• 9,679 Preventive Medicine
• 6,401 Dental
• 7,460 Women’s
• 13,363 Other (Specialty, PT, Injection Therapy,
Nutrition)
• 118,382 Pharmacy, Laboratory Tests, Radiology
Insurance Options
• 22% covered under Student Health Insurance Plan
• Student Health Insurance Office
• Waiver Required to Opt out of SHIP
• 61% covered under Contracted Carrier
• Wilce Student Health Center in network status with
four (4) major commercial carriers
• Also in network status with OSU Employee Healthplan
Audience Survey
• Role
• Coders, Providers, Ancillary Staff, Administration
• Current Billing Practice
• Student Health Fee
• Bill Student Health Insurance Plans
• Bill Commercial Plans
Agenda
• Evaluation and Management Codes
• History
• Exam
• Medical Decision Making
• Three Types of Encounters
• Problem-oriented
• Preventive medicine
• Office based procedures
• Coding obstacles and errors
• Q&A
Scenario Disclaimers
• Scenario documentation for this presentation is abbreviated. It
should not be construed as a complete chart note.
• E&M codes used in scenarios are for illustrative purposes.
E&M codes selected must be supported by documentation in
chart note.
• Coding practices may vary between institutions. Work with
your Compliance Office and Administration to ensure coding
practices fall within applicable state and/or federal guidelines.
• CMS guidelines offer a sound starting place. Commercial
carriers generally follow CMS guidelines – although specific
carrier rules may also apply.
Evaluation & Management Codes

• Problem oriented – Physician work captured by Evaluation and
Management Service codes (99201-99205, 99211-99215)
• New vs Established patient

• New patient – patient who has not received any professional
services, i.e., E/M service or other face to face service (e.g.,
surgical procedure) from the physician or physician group
practice (same physician specialty) within the previous 3 years.
• Established patient – anyone not considered a new patient.
Evaluation & Management Code
Selection Made Easy

• Well, easier anyway…
Key Components of E&M Codes

• Key Components of E&M
• Chief Complaint (CC)
• History (HPI, ROS, PFSH)
• Exam
Key Components – Chief Complaint

• Chief Complaint
• Concise statement of presenting problem. Often in
patients words. Documented by the provider.
Key Components – History

• History of Present Illness (HPI)
• Chronological description of present illness from initial sign to
the present
• Location - specific location of problem, e.g. right knee, throat
• Severity – description of severity or rating on pain scale, e.g.
moderate, 6/10
• Timing – when or frequency, e.g. persistent, intermittent, in the
morning
• Modifying factors – what makes problem better or worse, e.g.
OTC pain reliever, rest, exertion

• Quality – characteristic or description of sensation or pain, e.g.
dull, sharp
• Duration – length of time of symptoms, e.g. started this
morning, three (3) days
• Context – circumstances around or description of how
symptoms began, e.g. while playing basketball, after eating
week old leftovers
• Associated signs and symptoms – additional symptoms offered
by patient
• HPI Levels - Brief HPI (1-3 elements), Extended (4 or more
elements)

• Review of Systems (ROS)
• Inventory of body systems obtained through a series of
questions seeking to identify signs and symptoms the patient
may be experiencing.
• Assist provider in narrowing the range of differential diagnoses.
• While ancillary staff or patient may provide ROS in form of a
questionnaire, the provider must review for accuracy, add to it
when necessary and note the review in the chart.
• ROS Levels – None, Problem Pertinent (1 system usually related to
HPI), Extended (2-9 systems), Complete (10 or more systems)

• Past, Family and Social History (PFSH)
• Past - patient experiences with illness, injuries, operations and
treatments. Includes current medications and known allergies.
• Family – medical events in family including hereditary disease
or those that present a risk to the patient
• Social – age appropriate review of past and current activities
• PFSH Levels – None, Pertinent (1-2 new pat, 1 est pat), Complete
(3 new pat, 2-3 est pat)

• Left most element determines the level of history.
Key Components – Exam

• Physical Exam
• 1997 General Multisystem Exam – located on CMS website
1997 1-5 6-11 12+ 2+ elements

General bulleted bulleted bulleted for each of
Multisystem elements elements elements 9+ systems
in 2+
systems
Exam Type Problem- Expanded Detailed Comprehen
Focused Prob sive
Focused
Key Components – MDM

• Diagnosis / Management Options
• Self Limited Problem (1), Established Diagnosis Stable (1),
Established Diagnosis Worsening(2), New Problem No
Additional Work Up(3), New Problem Additional Work Up
Planned(4)
• Type of Data
• Order or Review Clinical Labs(1), Radiologic(1) or Other
Diagnostic Tests(1)
• Risk Assessment using Table of Risk
• Presenting Problem, Diagnostic Procedure Ordered,
Management Options Selected
• MDM Levels – Straight forward, Low, Moderate, High
Key Components – MDM

• Choose column with 2 or 3. Otherwise use the middle column.
Dx Mgmt 1- 2- 3- 4 - Extensive
Options Minimal Limited Multiple
Type of 1- 2- 3- 4 - Extensive
Data Minimal Limited Moderate
Overall Minimal Low Moderate High
Risk
Level of Straight Low Moderate High
MDM Forward
New Patient E&M code

History Problem Expanded Detailed Comprehensive Comprehensive
Type -Focused Prob
Focused
Exam Problem Expanded Detailed Comprehensive Comprehensive
Type - Prob
Focused Focused
MDM Straight Straight Low Moderate High
forward forward
Level 99201 99202 99203 99204 99205
Time 10 min 20 min 30 min 45 min 60 min
Established Patient E&M code

History N/A Problem- Expanded Detailed Comprehensive
Type Focused Prob
Focused
Exam N/A Problem- Expanded Detailed Comprehensive
Type Focused Prob
Focused
MDM N/A Straight Low Moderate High
forward
Level 992011 99212 99213 99214 99215
E&M Notes
• 1995 Exam based on Body Areas or Systems
• 1997 Exam based on General Multisystem Exam
• Used at our facility to aid in consistency of provider
documentation
• Less ambiguity
• HPI, Exam and Medical Decision Making cannot be
performed/documented by ancillary staff (RN, LPN or MA).
• These areas credit physician work and medical decision
making by gathering appropriate information in relation to
the chief complaint and therefore should be completed and
documented by the provider.
REMAIN CALM AND

KEEP CODING
Problem Oriented Scenario #1 – Sore Throat

• HPI: A 23 year old established male patient presents with a five (5)
day history of sore throat. His symptoms are worsening over the last
two (2) days. He rates his pain level 8/10 on the pain scale. He is
having trouble eating due to the pain in swallowing. He also notes
ear congestion. No current medications or drug allergies.
• ROS: Review of systems reveals patient is positive for fever, chills ,
fatigue and body aches. Patient denies nasal congestion, rhinorrhea,
sinus pain or pressure, cough or wheezing.
• Exam: Vitals: 130/72, 88, 98.6. Throat exam reveals moderate
erythema, + bilateral white tonsillar exudates. Lungs are clear to
auscultation and resonant to percussion. External auditory canals
patent with pearly TMs.
Problem Oriented Scenario #1 – Sore Throat

• Diagnostic Testing: Mono screen was negative. Direct strep was
positive for group A beta strep.
• Treatment Plan: Amoxicillin 500mg is ordered for the patient.
• Documented Dx: Streptococcal sore throat.
Problem Oriented Scenario #1 – Coding

• CPT Procedure Coding:
• 99214 – Evaluation & Management, established patient, level 4
• 86308 – Mono screen
• 87880 – Direct Strep
• 36415 – Venipuncture
• ICD 9 Coding:
• 034.0 – Streptococcal sore throat
• ICD 10 Coding:
• J02.0 – Streptococcal pharyngitis (sore throat)
• E&M Criteria - Detailed History, Expanded PF Exam, Moderate MDM

Type Focused Prob
Focused
Type Focused Prob
Focused
forward
Level 992011 99212 99213 99214 99215
Problem Oriented Scenario #2 – Ankle Sprain

• HPI: A 19 year old male presents with right ankle pain and swelling.
He twisted his ankle while running this morning. He is unable to bear
weight. His pain level is 7/10 on the pain scale. This is his first visit to
our facility.
• ROS: Patient denies numbness or tingling.
• PFSH: He has no prior history of injury to the ankle or foot.
• Exam: Vitals: 130/72, 88, 98.6. Ankle exam reveals slight swelling
and moderate tenderness to palpation over the lateral malleolus.
Limited ROM. Posterior tibial pulse is normal. Light touch sensation
of the foot is normal.
Problem Oriented Scenario #2 – Ankle Sprain

• Diagnostic Testing: Radiologic exam of the right ankle is ordered.
• Treatment Plan: Ankle brace and crutches are ordered. Patient is
fitted with right ankle brace and instruction is given for use of
crutches. Rx for pain management declined. OTC products
reviewed for pain management.
• Documented Dx: Results from radiology are pending and the
provider documents ankle sprain.

• 99202 – Evaluation & Management, new patient, level 2
• 73610 – Radiologic examination, ankle; complete, minimum 3
views
• L4350 – Ankle control orthotic, stirrup style, rigid
• E0114 – Crutches, underarm, oth than wood, adjustable or fixed,
pair

• ICD 9 Coding:
• 845.00 – Sprain and strain of ankle, unspecified site
• E001.1 – Activities involving running
• ICD 10 Coding:
• S93.401A – Sprain of unspecified ligament of right ankle, initial
encounter
• Y93.02 – Activity, running
• E&M Criteria – Expanded PF History, Expanded PF Exam, Moderate
MDM
New Patient E&M code

History Problem Expanded Detailed Comprehensive Comprehensive
Type -Focused Prob
Focused
Exam Problem Expanded Detailed Comprehensive Comprehensive
Type - Prob
Focused Focused
MDM Straight Straight Low Moderate High
forward forward
Level 99201 99202 99203 99204 99205
Problem Oriented Scenario #3 – UTI

• HPI: A 29 year old female presents with a two (2) day history of urinary
frequency. Based on our UTI protocol, a UA is ordered (diagnosis code
788.99 – Other symptoms urinary system) prior to being seen by the
provider.
• ROS: The patient denies hematuria, fever, or bilateral lower back pain.
Patient denies any vaginitis or abnormal bleeding.
• PFSH: The patient does have a history of UTIs with the most recent in 2012.
• Exam: Vitals: 130/72, 88, 98.6. External genitalia normal. Bladder & Urethra
normal. Cervix and uterus normal. Abdomen non tender, no organomegaly.
Problem Oriented Scenario #3 – UTI

• Diagnostic Testing: Urinalysis (gross and microscopic) results indicate a large
amount of blood, RBCs 30-49, bacteria, WBCs > 49/hpf and positive for
nitrites.
• Treatment Plan: Macrobid 100mg is ordered for the patient.
• Documented Dx: Acute cystitis. Hematuria.

• 99213 – Evaluation & Management, established patient, level 3
• 81003 – Urinalysis, automated without microscopy
• 81015 – Urinalysis, qualitative, microscopic only

• ICD 9 Coding:
• 595.0 – Acute cystitis
• 599.72 – Microscopic hematuria
• Note that dx 788.99 is not coded as the symptoms are an integral
part of the disease process in the first listed diagnosis code.
• ICD 10 Coding:
• N30.01 – Acute cystitis with hematuria
• E&M Criteria – Expanded PF History, Expanded PF Exam, Moderate
MDM

Type Focused Prob
Focused
Type Focused Prob
Focused
forward
Level 992011 99212 99213 99214 99215
REMAIN CALM AND

KEEP CODING
Preventive Medicine Encounters

• No Chief Complaint
• Age and gender appropriate
• History
• Past Family and Social History (PFSH)
• Exam
• Counseling/guidance/risk factor reduction interventions and
ordering of lab/diagnostic procedures
Preventive Medicine Encounters

• Physician work captured by Preventive Medicine Visit codes
(99381-99397).
• New vs Established Patient
• Patient Age ( <1yrs, 1-4yrs, 5-11yrs, 12-17yrs, 18-39yrs, 40-
64yrs, 65+yrs)
• Includes care for small problem that requires no extra
physician work.
• Code also immunization administration and products.
• Code also significant, separately identifiable E&M services on
the same date for substantial problems requiring additional
work using modifier 25.
PM Scenario #1 – Annual Gynecological Exam

• Scenario: A 21 year old female presents for her annual
gynecological exam. She is an established patient for our
practice. She is currently feeling well with no complaints.
• ROS: Patient denies breast concerns, urinary symptoms,
vaginal discharge or itching. Her last LMP was 05/20/2014.
• PFSH: Past medical history, social history and family history
reviewed. She is currently sexually active. Number of partners
in last year is 2. The patient has not had a pap smear in the
past.
• Exam: The exam revealed no abnormal findings.
• Diagnostic Testing: Cervical cytology. Urine specimen for
gonorrhea and chlamydia screening.
PM Scenario #1 – Coding
• 99395 – Periodic comprehensive preventive medicine evaluation
• 88142 – Cytopathology, cervical
• 87491 – Chlamydia trachomatis
• 87591 – Neisseria gonorrhoeae
• ICD 9 Coding:
• V72.31 – Routine gynecological examination
• V74.5 – Screening venereal disease
• ICD 10 Coding:
• Z01.419 – Encounter for gynecological examination (routine) without
abnormal findings
• Z11.3 – Encounter for screening infections with a predominantly sexual
mode of transmission
Gynecological Exam Requirements

• The requirements to bill for a routine gynecologic exam requires seven
(7) of the eleven (11) elements listed below to be completed.
• Inspection and palpation of breasts for masses or lumps, tenderness,
symmetry, or nipple discharge.
• Digital rectal exam including sphincter tone, presence of hemorrhoids,
and rectal masses.
• External genitalia (general appearance, hair distribution or lesions).
• Urethral meatus (size, location, lesions or prolapse).
• Urethra (masses, tenderness, or scarring).
• Bladder (fullness, masses, or tenderness).
• Vagina (appearance, estrogen effect, discharge, lesions, cystocele or
rectocele).
Gynecological Exam Requirements

• Cervix (appearance, lesions, or discharge).
• Uterus (size, contour, position, mobility, tenderness, consistency,
descent or support).
• Adnexa (masses, tenderness, organomegaly, or nodularity).
• Anus and perineum.
PM Scenario #2 – Annual Wellness Exam

• Scenario: A 20 year old male presents for an annual wellness
exam. He is new to our practice. He is currently feeling well
with no complaints. He does request STI screening.
• ROS: Patient denies any complaints.
• PFSH: Past medical history, social history and family history
reviewed. He is up to date on immunizations with the
exception of HPV and would like to begin the series. He is
currently sexually active. Number of partners in last year is 2.
Method of STI prevention is none.
• Exam: The exam revealed no abnormal findings.
PM Scenario #2 – Annual Wellness Exam

• Diagnostic Testing: Urine specimen for gonorrhea and
chlamydia, blood specimen for HIV and syphilis.
• Treatment Plan: HPV immunization is ordered and given.
• 99385-25 – Initial comprehensive preventive medicine
evaluation
• 87491 – Chlamydia trachomatis
• 87591 – Neisseria gonorrhoeae
• 86703 – Testing for HIV antibodies; HIV-1 and HIV-2; single
result
• 86780 – Treponema pallidum
• 90471 – Immunization administration; 1 vaccine
• 90649 – HPV vaccine, quadrivalent, 3 dose schedule
• ICD 9 Coding:
• V70.0 – Routine general medical examination
• V74.5 – Screening venereal disease
• V04.89 – Vaccination, other viral diseases
• ICD 10 Coding:
• Z00.00 – Encounter for general adult medical examination
without abnormal findings
• Z11.3 – Encounter for screening infections with a
predominantly sexual mode of transmission
• Z11.4 – Encounter for screening for human
immunodeficiency virus [HIV]
• Z23 – Encounter for immunization
PM Scenario #3 – Travel Assessment

• Scenario: A 22 year old male presents for a travel assessment.
He will be traveling to Haiti in six (6) weeks with his church
group. He will be staying in a hotel. He is up to date on his
immunizations with the exception of influenza and typhoid.
• Treatment Plan: Travel guidelines and handouts reviewed with
patient. Immunizations for influenza and typhoid are ordered
and given.
• 99401-25 – Preventive medicine counseling and/or risk
factor reduction intervention; approx. 15 minutes
• 90471 – Immunization administration; 1 vaccine
• 90472 – Immunization administration; each additional
vaccine
• 90658 – Influenza virus vaccine
• 90691 – Typhoid vaccine
• ICD 9 Coding:
• V70.3 – Other medical examination for administrative
purposes
• V04.81 – Immunization for influenza
• V03.1 – Immunization for typhoid
• ICD 10 Coding:
• Z02.89 – Encounter for other administrative examinations
• Z23 – Encounter for immunization
REMAIN CALM AND

KEEP CODING
Office Based Procedure Encounters

• Chief Complaint
• History
• History of Present Illness (HPI)
• Past Family and Social History (PFSH)
• Exam
• Diagnosis / Management Options

• Type of Data
• Risk Assessment based on Presenting Problem, Diagnostic
Procedure Ordered, Management Options Selected
• Minor surgery with no identified risk factors – Low
Management Options
• Minor surgery with identified risk factors – Moderate
Management Options
• Skin biopsy – Low Diagnostic Procedure Ordered

• Physician work captured by procedure code
• E&M service included in procedure code
• Common office based procedure codes
• Laceration repair
• Incision and drainage of abscess
• Biopsy of skin lesion
• Wart treatment
• Colposcopy
• Excision of nail

• Code also immunization administration and products.
• Code also therapeutic injection administration and products.
• Code also significant, separately identifiable E&M services on the
same date for substantial problems requiring additional work using
modifier 25.
Office Based Procedure – Laceration Repair

• Criteria for laceration repair code selection
• Complexity – Superficial, Intermediate, Complex
• Site
• Size

• Superficial Wounds
• CPT codes: 12001-12018
• Local anesthesia
• Routine debridement and decontamination
• Simple one layer closure
• Sutures, staples, tissue adhesives, cauterization without closure
• Total length of several repairs in same code category

• Superficial Wound Sites
• Scalp, neck, axillae, external genitalia, trunk and/or extremities
(including hands and feet)
• Face, ears, eyelids, nose, lips and/or mucous membrane
• Superficial Wound Sizes

• 2.5 cm or less
• 2.6 cm to 7.5 cm
• 7.6 cm to 12.5 cm
• 12.6 cm to 20.0 cm
• 20.1 cm to 30.0 cm
• > 30.0 cm

• Intermediate Wounds
• CPT codes: 12031-12057
• Local anesthesia
• Routine debridement and decontamination
• Closure of contaminated single layer wound
• Layer closure (e.g. subcutaneous tissue, superficial fascia)
• Removal of foreign material (e.g. gravel, glass)
• Total length of several repairs in same code category

• Intermediate Wound Sites
• Scalp, axillae, trunk and/or extremities
• Neck, hands, feet and/or external genitalia
• Face, ears, eyelids, nose, lips and/or mucous membrane
• Intermediate Wound Sizes

• 2.5 cm or less
• 2.6 cm to 7.5 cm
• 7.6 cm to 12.5 cm
• 12.6 cm to 20.0 cm
• 20.1 cm to 30.0 cm
• > 30.0 cm

• Complex Wounds – not performed at our facility
• CPT codes: 13100-13153
• More complicated than layered repair
• Exploration of nerves, vessels, tendons
• Vessel ligation
Procedure Scenario #1 – Laceration Repair

• HPI: A 22 year old male presents with minor lacerations to his
left hand. Patient states he broke a glass while washing dishes
approximately 30 minutes ago. He was unable to control the
bleeding at home and is here for treatment.
• Exam: The exam of laceration #1 shows a 1 cm laceration on
the palmar surface of the fourth finger. Laceration #2 shows a
1.7 cm laceration on the palmar surface of the third finger.
Both wounds were explored and no foreign bodies were found.
• Treatment Plan: Wound #1 was closed using a skin adhesive.
Wound #2 was closed with 3 Ethilon sutures.
• Documented Dx: Open wound finger.
Procedure Scenario #1 – Coding

• 12001 – Simple repair superficial wound; 2.6 cm to 7.5 cm
• ICD 9 Coding:
• 883.0 – Open wound of finger without mention of complication
• E920.8 – Accident caused by other cutting and piercing
instruments or objects
• ICD 10 Coding:
• S61.213A – Laceration w/o foreign body of left middle finger w/o
damage to nail, initial encounter
• S61.215A – Laceration w/o foreign body of left ring finger w/o
damage to nail, initial encounter
• W25.000A – Contact with sharp glass, initial encounter
Office Procedure – I&D of Abscess

• Incision and Drainage of Abscess
• Simple or single (10 day global period)
• CPT code: 10060
• Carbuncle, suppurative hidradenitis, cutaneous or
subcutaneous abscess, cyst, furuncle or paronychia
• Complicated or multiple (10 day global period)
• CPT code: 10061
• Carbuncle, suppurative hidradenitis, cutaneous or
subcutaneous abscess, cyst, furuncle or paronychia
Office Procedure – I&D of Abscess

• Incision and Drainage of Pilonidal Cyst
• Simple (10 day global period)
• CPT code: 10080
• Complicated (10 day global period)
• CPT code: 10081
Procedure Scenario #2 – I&D of Abscess

• HPI: A 24 year old female presents with pain in the left axillae.
She has a history of staph infections of the axillae. This pain
began about 3 months ago.
• Exam: The exam shows several raised evolving furuncles in the
axillae. The largest being 1.5cm x 1.5 cm in the mid posterior
left axillae.
• Treatment Plan: The area is cleansed and an incision and
drainage is performed. A small amount of blood and pus is
released.
• Diagnostic Testing: A culture is obtained.
• Documented Dx: Hidradenitis.
Office Procedure Scenario #2 – Coding

• 10060 – Incision and drainage of abscess; simple
• 87070 – Culture, bacterial; any other source except urine,
blood or stool
• ICD 9 Diagnosis Coding:

• 705.83 – Hidradenitis
• L73.2 – Hidradenitis suppurative
Office Procedure – Biopsy of Skin Lesion

• Biopsy of Skin Lesion
• Single lesion (0 day global period)
• CPT code: 11100
• Skin, subcutaneous tissue and/or mucous membrane
• Includes simple closure
• Each additional lesion (0 day global period)
• CPT code: 11101
• Skin, subcutaneous tissue and/or mucous membrane
• Includes simple closure
• List in addition to CPT code: 11100
Office Procedure – Biopsy of Skin Lesion

• Biopsy is defined as a procedure to obtain tissue for a pathologic
examination. These codes support a biopsy via means of provider
choice, including shaving or punch methods.
• Even when the entire lesion is removed, the intent of the procedure
is to obtain tissue and so the biopsy code is appropriate.
Procedure Scenario #3 – Biopsy of Lesion

• HPI: A 21 year old female presents with two slightly raised skin
lesions of the left shoulder. Patient indicates these have
changed in size and color over the last several months.
• Exam: The exam shows one 3 mm and one 4 mm raised
lesions with variable brown color.
• Treatment Plan: After reviewing diagnosis and treatment
options, a shave biopsy is performed on each lesion.
• Diagnostic Testing: Specimens are collected and sent to
pathology.
• Documented Dx: Neoplasm unspecified behavior.

• 11100 – Biopsy of skin, subcutaneous tissue; single lesion
• 11101 – Biopsy of skin, subcutaneous tissue; each additional
lesion
• 99000 – Handling of specimen for transfer from office to
laboratory
• 88305 x 2 – Level IV – Surgical pathology, gross and
microscopic examination

• 238.2 – Neoplasm of uncertain behavior; skin
• D48.5 – Neoplasm of uncertain behavior; skin
Office Procedure – Destruction of Warts

• Destruction of Warts
• Up to 14 lesions (10 day global period)
• CPT code: 17110
• Benign lesions other than skin tags or cutaneous vascular
proliferative lesions
• Includes laser surgery, electrosurgery, cryosurgery,
chemosurgery, surgical curettement.
• 15 or more lesions (10 day global period)
• CPT code: 17111
• Do NOT code 17110
Office Procedure – Destruction of Warts

• Other site specific lesion destruction codes:
• Anus 46900-46917
• Penis 54050-54057
• Vagina 57061, 57065
• Vulva 56501, 56515
Procedure Scenario #4 – Destruction Warts

• HPI: A 19 year old male presents with concerns of several wart
like lesions on the top of this left foot. They are aggravated by
his shoe when walking or running.
• Exam: The exam shows 3 small warts, each measuring approx.
3 mm, on the top of his left foot, just distal to the ankle.
• Treatment Plan: Treatment options were reviewed and the
patient elected to have these treated with liquid nitrogen.
• Documented Dx: Viral warts.

• 17110 – Destruction benign lesions, up to 14 lesions
• ICD 9 Coding:
• 078.10 – Viral warts, unspecified
• ICD 10 Coding:
• B07.9 – Viral wart, unspecified
Coding Obstacles and Errors

• E&M Code Selection
• New vs established patient codes
• Correct code level selection
• Documentation to support level selected
• Charge Capture
• Bundled and Unbundled Services
• Therapeutic Injections and Immunizations
• Administration
• Medication or Vaccine
• DME supplies

• Diagnosis Selection
• ICD-9 CM Guidelines
• General Coding Guidelines
• Chapter Specific Guidelines
• Symptoms vs Definitive Diagnosis
• Signs and symptoms routinely associated with a disease process
should not be assigned as additional codes
• Factors Influencing Health Status – V Codes
• Immunization codes
• Personal and Family History codes
• Classification of External Causes – E Codes
• E Codes are not used as first listed diagnosis codes
• Dog bite, needle stick injury

• Diagnosis Links
• Ensure services are correctly linked to all relevant diagnosis codes
assigned
• Carrier rules may apply
Questions and Answers

TH2 251 Bower

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Wilce Student Health Center

Michael Bower CPC

Wilce Student Health Center

Wilce Student Health Center

Evaluation & Management Codes

• New vs Established patient

Evaluation & Management Code

Selection Made Easy

Key Components of E&M Codes

Key Components – Chief Complaint

Key Components – History

Key Components – History

Key Components – History

Key Components – History

Key Components – History

Key Components – Exam

1997 1-5 6-11 12+ 2+ elements

Key Components – MDM

Key Components – MDM

New Patient E&M code

Established Patient E&M code

REMAIN CALM AND

Problem Oriented Scenario #1 – Sore Throat

Problem Oriented Scenario #1 – Sore Throat

Problem Oriented Scenario #1 – Coding

Established Patient E&M code

Problem Oriented Scenario #2 – Ankle Sprain

Problem Oriented Scenario #2 – Ankle Sprain

Problem Oriented Scenario #2 – Coding

Problem Oriented Scenario #2 – Coding

New Patient E&M code

Problem Oriented Scenario #3 – UTI

Problem Oriented Scenario #3 – UTI

Problem Oriented Scenario #3 – Coding

Problem Oriented Scenario #3 – Coding

Established Patient E&M code

REMAIN CALM AND

Preventive Medicine Encounters

Preventive Medicine Encounters

PM Scenario #1 – Annual Gynecological Exam

Gynecological Exam Requirements

Gynecological Exam Requirements

PM Scenario #2 – Annual Wellness Exam

PM Scenario #2 – Annual Wellness Exam

PM Scenario #3 – Travel Assessment

REMAIN CALM AND

Office Based Procedure Encounters

Office Based Procedure Encounters

Office Based Procedure Encounters

Office Based Procedure Encounters

Office Based Procedure – Laceration Repair

Office Based Procedure – Laceration Repair

Office Based Procedure – Laceration Repair

• Superficial Wound Sizes

Office Based Procedure – Laceration Repair

Office Based Procedure – Laceration Repair

• Intermediate Wound Sizes

Office Based Procedure – Laceration Repair

Procedure Scenario #1 – Laceration Repair

Procedure Scenario #1 – Coding

Office Procedure – I&D of Abscess

Office Procedure – I&D of Abscess

Procedure Scenario #2 – I&D of Abscess

Office Procedure Scenario #2 – Coding