Professional Documents
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doc042009
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Procedure
Review the Clinic E&M Technical Criteria and become familiar with the layout of the form. Each time an
intervention is performed on a patient, mark it on the form designated for charging that patient. Please
note that not all interventions will occur in each clinic.
The charging system consists of five levels of intervention (levels I-V). Staff should select all
interventions done for the patient that are supported by documentation in the medical record. Contributory
factors can be used to increase the intervention level by one, to a maximum of Level V. For example, if
the highest intervention you performed for an established patient was vital signs, your intervention would
be Level I. If you also arrange for scheduling and coordination of an ancillary service of that patient, it
counts as a contributory factor, increasing the intervention to Level II for that patient.
Three or more documented interventions levels I-IV will increase the technical component to the next
level; a contributory factor in this case will also increase the technical component to the next level. The
contributory factors must be documented, but will not affect the charge, as the highest level has already
been attained.
Some supplies used in the clinics can be separately charged; please continue to charge for supplies using
current practice.
Guideline for selecting new vs. established patient visits for technical services
The CPT codes used to report visits differentiate between new and established patients. Effective January 1,
2009 per the November 24, 2008 OPPS Final Rule published in the federal register (73FR68679), a new
patient (on the technical side) is one who has NOT been registered as either an inpatient or outpatient
of the hospital within the past 3 years. An established patient is one who has been registered as an
inpatient or outpatient of the hospital within the past 3 years. Staff should determine in the Hospital
Information System if the patient has a registration listed within the last 3 years of the date of service prior
to the appointment and designate them appropriately based on this determination. CPT codes for new
patients to be used are 99201, 99202, 99203, 99204, and 99205. CPT codes for established patients to be
used are 99211, 99212, 99213, 99214, and 99215. For technical charges, there is no acknowledgment of
consult status those CPT codes apply to only physician charges.
Procedure only (no separate E/M): some areas may wish to issue this form to every patient as an internal
control for reconciliation at the end of the day. In that case, if the purpose of the visit is for a procedure
only and there is no separately identifiable evaluation and management service provided, the patient label
would be attached, this item would be selected and no further information is required.
Vital signs
Suture and staple removal
Administration of medication
Administration of single disposable enema
Application of preformed splint(s)/elastic
bandages/slings/or immobilizer
*Note: Education and assessment time is cumulative. Each non-physician provider documents the
education and assessment services provided and the time spent. All provider time is then added together
to determine the total time of education and/or assessment provided during the visit.
Contributory Factors
Contributory factors are services or other factors that, when present, may increase the E&M level
from one level to the next highest level. Only one factor is required to for this increase to a
higher level. These factors apply to levels I through IV you cannot increase a level V to critical
care using the contributory factors. Evidence of contributory factors must be documented in the
record.
For example, your patient meets a level II intervention and has two contributory factors. These
factors, regardless of the number, increase the intervention by only one level. You cannot
increase a level II intervention selection to a level IV intervention by using contributory factors
alone.
The following factors are used to increase level I to level II, level II to level III, level III to level
IV, or level IV to level V.
Contributory Factors
Altered mental status
Arrangements for social service intervention
Isolation
Simultaneous care by greater than one staff
member
Special needs requiring additional facility
resources
Scheduling/coordination of care