Section 20-2-I - DEFINITIONS AND RULESDefinitions and rules pertaining to E/M services are as follows:
A.DOCUMENTATION MUST BE PATIENT SPECIFIC, PERTAIN DIRECTLY TO THE CURRENT VISIT AND SUPPORT THE EVALUATION AND MANAGEMENT SERVICES PROVIDED FOR THE INJURED WORKER. INFORMATION COPIED DIRECTLY FROM PRIOR RECORDS WITHOUT CHANGE IS NOT CONSIDERED CURRENT NOR COUNTED.B.Consultations. CPT defines a consultation as "a type of evaluation and management service provided at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient's entire care or for the care of a specific condition or problem." (This includes referrals for a second opinion.) Consultations are reimbursable only to physicians with the appropriate specialty for the services provided. In order to qualify as a consultation the following criteria must be met:
* The verbal or written request for a consult must be documented in the patient's medical record;
* The consultant's opinion and any services ordered or performed must be documented by the consulting physician in the patient's medical record; and
* The consulting physician must provide a written report to the requesting physician or other appropriate source.
A payer/employer may request a second opinion examination or evaluation for the purpose of evaluating temporary or permanent disability or medical treatment being rendered, as provided in MCA §71 -3-15(1) (Rev. 2000). This examination is considered a confirmatory consultation. The confirmatory consultation is billed using the appropriate level and site-specific consultation codes 99241-99245 for office or other outpatient consultations and 99251-99255 for inpatient consultations, with modifier 32 appended to indicate a mandated service.
Evaluation and management consultation services will continue to be reported with CPT codes 99241-99245 for outpatient consultation services and codes 99251-99255 for inpatient consultation services. The rules and guidelines regarding the definition, documentation, and reporting of consultation services as contained in CPT will apply unless superseded by these guidelines. Consultation services will be reimbursed at the lesser of the Fee Schedule maximum allowable reimbursment (MAR) or the billed amount.
C.Referral. Subject to the definition of "consultation" provided in this Fee Schedule, a referral is the transfer of the total or specific care of a patient from one physician to another and does not constitute a consultation. (Initial evaluations and subsequent services are designated as listed in the Evaluation and Management section). D.New and Established Patient Service. Several code subcategories in the Evaluation and Management section are based on the patient's status as new or established. The new versus established patient guidelines also clarify the situation in which a physician is on call or covering for another physician. In this instance, classify the patient encounter the same as if it were for the physician who is unavailable. * New Patient. A new patient is one who has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group practice, for this same injury or within the past three years.
* Established Patient. An established patient is a patient who has been treated for the same injury by any physician, of the same specialty, who belongs to the same group practice.
E.E/M Service Components. The first three components of history, examination, and medical decision making are the keys to selecting the correct level of E/M codes, and all three components must be met or exceeded in the documentation of an initial evaluation or consultation. However, in established, subsequent, and follow-up categories, only two of the three must be met or exceeded for a given code. 1. The history component is categorized by four levels: a.Problem Focused. Chief complaint; brief history of present illness or problem. b.Expanded Problem Focused. Chief complaint; brief history of present illness; problem-pertinent system review. c.Detailed. Chief complaint; extended history of present illness; problem-pertinent system review extended to include a review of a limited number of additional systems; pertinent past, family medical and/or social history directly related to the patient's problems. d.Comprehensive. Chief complaint; extended history of present illness; review of systems that is directly related to the problem(s) identified in the history of the present illness, plus a review of all additional body systems; complete past, family, and social history. 2. The physical exam component is similarly divided into four levels of complexity: a.Problem Focused. A limited examination of the affected body area or organ system. b.Expanded Problem Focused. A limited examination of the affected body area or organ system and other symptomatic or related organ system(s).c.Detailed. An extended examination of the affected body area(s) and other symptomatic or related organ system(s).d. Comprehensive. A general multi-system examination or a complete examination of a single organ system. CPT identifies the following body areas:
* Head, including the face;
* Neck;
* Chest, including breasts and axilla;
* Abdomen;
* Genitalia, groin, buttocks;
* Back; and
* Each extremity.
CPT identifies the following organ systems:
* Eyes;
* Ears, nose, mouth, and throat;
* Cardiovascular;
* Respiratory;
* Gastrointestinal;
* Genitourinary;
* Musculoskeletal;
* Skin;
* Neurologic;
* Psychiatric; and
* Hematologic/lymphatic/immunologic.
3. Medical decision making is the final piece of the E/M coding process. Medical decision making refers to the complexity of establishing a diagnosis or selecting a management option that can be measured by the following: a. The number of possible diagnoses and/or the number of management options that must be considered. b. The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed. c. The risk of significant complications, morbidity, mortality, as well as co-morbidities associated with the patient's presenting problem(s), the diagnostic procedure(s), and/or the possible management options. F.Contributory Components.1. Counseling, coordination of care, and the nature of the presenting problem are not major considerations in most encounters, so they generally provide contributory information to the code selection process. The exception arises when counseling or coordination of care dominates the encounter (more than fifty percent (50%) of the time spent). Document the exact amount of time spent to substantiate the selected code and what was clearly discussed during the encounter. Counseling is defined in CPT as a discussion with a patient and/or family concerning one or more of the following areas: a. Diagnostic results, impressions, and/or recommended diagnostic studies;c. Risks and benefits of management (treatment) options;d. Instructions for management (treatment) and/or follow-up;e. Importance of compliance with chosen management (treatment) options;f. Risk factor reduction; and g. Patient and family education. 2. E/M codes are designed to report actual work performed, not time spent. But when counseling or coordination of care dominates the encounter, time overrides the other factors and determines the proper code. For office encounters, count only the time spent face-to-face with the patient and/or family. For hospital or other inpatient encounters, count the time spent rendering services for that patient while on the patient's unit, on the patient's floor, or at the patient's bedside. G.Interpretation of Diagnostic Studies in the Emergency Room1. Only one fee for the interpretation of an x-ray or EKG procedure will be reimbursed per procedure. 2. The payer is to provide reimbursement to the provider that directly contributed to the diagnosis and treatment of the individual patient. 3. It is necessary to provide a signed report in order to bill the professional component of a diagnostic procedure. The payer may require the report before payment is rendered. 4. If more than one bill is received, physician specialty should not be the deciding factor in determining which physician to reimburse. Example : In many emergency departments (EDs), an emergency room (ER) physician orders the x-ray on a particular patient. If the ER physician interprets the x-ray making a notation as to the findings in the chart and then treats the patient according to these radiological findings, the ER physician should be paid for the interpretation and report. There may be a radiologist on staff at the particular facility with quality control responsibilities at that particular facility. However, the fact that the radiologist reads all x-rays taken in the ED for quality control purposes is not sufficient to command a separate or additional reimbursement from the payer.
5. A review alone of an x-ray or EKG does not meet the conditions for separate payment of a service, as it is already included in the ED visit.