Q. What is undiagnosed new problem with uncertain prognosis?
Answer: A new health issue that hasn't been identified yet, and we're not sure how it will turn out. This problem, if not treated, could lead to serious health risks. This falls in to moderate of Table A.
For example, a lump in the breast could be considered an undiagnosed new problem with uncertain prognosis. This lump be in the breast can be cancerous or non-cancerous.
Please note that this undiagnosed problem if not treated could be leading to serious health risk not moderate or low risk. If patient comes with arm pain post fall and provider say suspected Fx prior performing x ray, this will not qualify in this category of moderate.
FAQs in E/M coding
Q. What is acute illness with systemic symptoms?
Answer: Acute illness with systemic symptoms: An illness that causes systemic symptoms and has a high risk of morbidity without treatment. For systemic general symptoms, such as fever, body aches, or fatigue in a minor illness that may be treated to alleviate symptoms.
Systemic symptoms are signs of a disease or disorder that affect the whole body or multiple organ systems, rather than a single body part or organ. Some examples of systemic symptoms are fever, chills, sweats, fatigue, weight loss, or malaise.
Some examples of acute illness with systemic symptoms are pyelonephritis (kidney infection), pneumonitis (lung inflammation), or colitis (colon inflammation).
A patient with a urinary tract infection (UTI) and fever may have an acute, uncomplicated illness or an acute illness with systemic symptoms, depending on the severity and duration of the symptoms, the risk of complications, and the response to treatment.
A UTI with mild fever that responds well to antibiotics may be considered an acute, uncomplicated illness, while a UTI with high fever, flank pain, nausea, and vomiting that does not improve with antibiotics may be considered an acute illness with systemic symptoms.
Q.Types of secondary cancers, DM-HTN-CKD linkage scenario, ICD 10 Updates, Code sequencing, DM manifestations, etc.
Answer: Secondary cancers, also known as metastatic cancers, occur when cancer cells spread from the primary (original) site to other parts of the body.
Common types include:
Secondary Cancers by Organ System:
Lung metastases from breast cancer.
Liver metastases from colorectal cancer.
Brain metastases from lung cancer.
Common Routes of Metastasis:
Hematogenous (via blood).
Lymphatic (via lymph nodes).
Direct extension.
DM-HTN-CKD Linkage Scenario:
A: In coding scenarios involving Diabetes Mellitus (DM), Hypertension (HTN), and chronic kidney disease (CKD), it's important to consider the linkage and sequencing of codes:
Linkage:
DM often contributes to the development of HTN and CKD. HTN is a common comorbidity in DM patients, and both conditions may lead to CKD.
Code Sequencing:
Sequence codes based on the reason for the encounter.
If the encounter is primarily for DM management, list the DM code first.
If the encounter addresses CKD or HTN without an evident connection to DM, sequence accordingly.
Q. What is the differences between "GC" and "GE" modifiers in the context of E&M coding? When and how are these modifiers appropriately used?
Answer: GC Modifier and GE modifier are both for resident. Key difference is GC requires teaching physician's involvement along with resident and GE service is independently rendered by resident alone.
GC modifier:
When a resident or fellow provides a service under the supervision of a teaching physician, the “GC” modifier is appended to the CPT code to indicate that the service was performed by the resident but was supervised by the teaching physician.
Teaching physician must provide the attestation. Attestation should speak about he (teaching physician) is agree with residents finding and treatment plan and he has seen the patient face to face (performed the critical key portion of EM face to face with patient).
2 parts are there for attestation 1: - agree with resident, 2: - He has seen the patient face to face.
In this the billing provider is Teaching physician only while service provider is resident.
GE Modifier:
When a resident provides a service without direct supervision from a teaching physician, the “GE” modifier is appended to the CPT code to signify that the service was performed independently by the resident.
In ED Maximum up to level 3 can be coded with GE modifier.
Q. How is EM coded now (2023)?
Answer: EM is coded based on the MDM Now only. MDM needs 2 out of elements of EM. We still need appropriate History and Exam pertinent (related to the presenting) problem.
Q. What is new MDM table
Answer: New MDM table is based on the following 3 column, any 2 is needed
Number and/or complexity of problem addressed.
Amount and/or complexity of data to be reviewed and analyzed.
Risk of morbidity or mortality from diagnoses or treatments.
Q. What is Number and/or complexity of problem addressed?
Answer: It is decided based on how many conditions or problems patients have and what is there complexity
example: Patient has only HTN (which is chronic condition) it gives Table A as low, but if patient has 2 chronic conditions example (HTN and CKD) then Table A is moderate.
Q. What if patient has only HTN?
Answer: If patient has only HTN which is stable then it qualifies for low but when HTN is unstable then it qualifies as moderate.
Q. What do you mean by stable and unstable chronic condition and unstable chronic condition?
Answer: A patient who is not at his or her treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function. For example, a patient with persistently poorly controlled blood pressure for whom better control is a goal is not stable, even if the pressures are not changing and the patient is asymptomatic. The risk of morbidity without treatment is significant.
If a patient with high blood pressure, and the goal is to bring it under control. If the blood pressure remains consistently high, even without immediate threats, the patient is not stable. A patient is not considered stable if their health is not improving as desired, even if there are no immediate threats.
Q. What are the Telemedicine modifies?
Answer: 95 Modifier is used to indicate the service has been rendered via audio and video mode. This is appended with those CPT has the star symbols in front of it, identified in Appendix P.
Q. Do we use GT Modfier?
It was used earlier for Medicare payor for telemedicine services, now it is coded with 95 modifier only.
Q. What are the approved credentials?
Answer:
Approved credentials are those who have the NPI (national provider identification) number.
MD/DO: These are the main providers who can be coded for everything, like all office notes, Admission notes, progress notes, and discharge notes.
NPP: the full form is nonphysician practitioners, these providers have the NPI and can be coded separately, however these are not allowed to code admission note and discharge note independently, need cosign from MD or DO. Below are the NPPs:
Physician assistants (PAs)
Advanced practice registered nurses (APRNs)
Nurse practitioners (NPs)
Clinical nurse specialists (CNSs)
Certified nurse midwives (CNMs)
Certified registered nurse anesthetists (CRNAs)
Q. What are the EM modifiers?
Answer:
EM has mainly 3 modifiers, 25, 57, and 24.
Other Modifiers are mainly used are AI modifier, GC Modifier, and FS Modifier.
Q. What is AI Modifier?
Answer: Payor must be Medicare
AI appended to H&P note for admitting provider.
This is appended to the notes which are being coded with 99221 - 99223 or 99304 - 99306.
Critical care codes can be used instead of admit codes for the initial visit, if the patient meets the criteria for critical care.
If the critical care code is the initial visit and the physician is the admitting physician, then the AI modifier would be appropriate.
Q. What is the EP modifiers?
Answer:
Service provided as part of Medicaid early periodic screening diagnosis and treatment such as to Annual wellness visit.
Modifier EP illustrates billing of the service that the provider delivers as part of the Medicaid early periodic screening diagnosis and treatment, or EPSDT, program. This includes preventive health checkups and treatments to children from birth to young adults. A few of the types of early preventative health screening and treatments include immunization, administration and health screenings for hearing and vision problems. Modifier EP can be appended to several of the immunization administration codes, and preventive medicine, periodic and interperiodic assessments.
Q. What is NCCI Edits and MUE Edits
NCCI Edits:
CCI Edit (Correct Coding Initiative Edit) is a rule that checks for incorrect code combinations on a medical claim.
These edits define pairs CPT codes that should not be reported together for a single patient on the same date of service.
The edits include two columns: Column 1 and Column 2.
Column 1 Code (Comprehensive Code): The primary or more comprehensive procedure code.
Column 2 Code (Component Code): The secondary or less comprehensive procedure code that is generally included in the primary procedure.
Here's an example of using Modifier 59 with biopsy and excision codes:
- Code 1: 11403 (Excision of benign lesion, 2.1-3.0 cm, trunk)
- Code 2: 11106 (Biopsy of skin, lesion)
CCI Edit says: "You can't bill for both excision and biopsy of the same lesion!"
However, if the biopsy was performed on a separate lesion or a different site, you can add Modifier 59 to the biopsy code to indicate it's a separate procedure:
- Code 1: 11403 (Excision of benign lesion, 2.1-3.0 cm, trunk)
- Code 2: 11106-59 (Biopsy of skin, lesion, separate site)
The Modifier 59 overrides the CCI Edit, allowing separate payment for both procedures.
Documentation must support that:
- The biopsy was performed on a separate lesion or site
- The procedures were separate and distinct
- The Modifier 59 is justified
Without Modifier 59, the CCI Edit would prevent separate payment for the biopsy code.
MUE Edits:
"MUE" stands for "Medically Unlikely Edit". It's a set of guidelines developed by the Centers for Medicare and Medicaid Services (CMS) to prevent overcoding and ensure accurate coding practices.
MUE guidelines define the maximum number of units or services that can be reported for a specific procedure code under normal circumstances. If a provider submits a claim exceeding the MUE limit, the claim may be rejected or flagged for review.
MUE guidelines help prevent:
Overcoding: Reporting excessive services or units.
Upcoding: Reporting more intensive or complex services than performed.
Billing errors: Incorrect or inconsistent coding.
By following MUE guidelines, medical coders and healthcare providers can ensure accurate and compliant coding practices, reducing the risk of claim denials and audits.
Q. What is 59 Modifier, explain with example and what are the types of it?
59 Modifier:
Modifier 59 is used to indicate that a service or procedure was distinct and separate from other services provided on the same day.
CMS introduced specific sub-modifiers, known as the X{EPSU} modifiers, to provide more detailed information about why the services are distinct. These sub-modifiers are:
A patient visits the doctor for two different procedures on the same day:
Procedure 1: Removal of a benign skin lesion on the left arm.
CPT Code: 11402 (Excision, benign lesion including margins, except skin tag, trunk, arms, or legs; excised diameter 1.1 to 2.0 cm)
Procedure 2: Repair of a wound on the right leg.
CPT Code: 12002 (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk, and/or extremities [including hands and feet]; 2.6 cm to 7.5 cm)
Using Modifier 59:
These two procedures are typically not billed together because they might be seen as related. However, in this case, they are distinct procedures done on separate parts of the body.
Column 1 Code: 11402 (Removal of skin lesion)
Column 2 Code: 12002 (Wound repair)
To indicate that these are separate and distinct procedures, Modifier 59 is added to the second procedure:
11402: Removal of benign skin lesion on the left arm
12002-59: Simple repair of the wound on the right leg
Explanation:
The removal of the skin lesion and the repair of the wound were performed on different parts of the body (left arm and right leg).
Adding Modifier 59 to the wound repair code (12002) tells the insurance company that these are distinct and separate procedures, even though they were done on the same day.
XE - Separate Encounter:
Used to indicate that a service was performed during a separate encounter on the same day as another service.
Example: A patient has two separate visits to the physician on the same day for different issues.
XS - Separate Structure:
Used to indicate that a service was performed on a separate organ or body part.
Example: A doctor performs surgery on the left knee and a different procedure on the right knee on the same day.
XP - Separate Practitioner:
Used to indicate that a service was performed by a different practitioner.
Example: One doctor performs a procedure in the morning, and another doctor performs a different procedure on the same patient in the afternoon.
XU - Unusual Non-Overlapping Service:
Used to indicate that a service does not overlap usual components of the main service.
Example: A doctor performs two procedures that are usually considered part of one service, but in this case, they are distinct due to unusual circumstances.