General / Hot Coding Topics

394.x-398.x and 424.x: Clarify the Role of ‘Rheumatic’

Use this cheat sheet to aid your non-congenital valve disorder coding

 

Code Descriptor Role of ‘Rheumatic’

 
MITRAL VALVE ONLY

 
394.0 Mitral stenosis Use if specified as rheumatic or unspecified. If specified as non-rheumatic, use 424.0.
394.1 Rheumatic mitral insufficiency Specific to rheumatic cases. For others, use 424.0.
394.2 Mitral stenosis with insufficiency Use if specified as rheumatic or unspecified. If specified as non-rheumatic, use 424.0.
394.9 Other and unspecified mitral valve disease Use if specified as rheumatic or unspecified. If specified as non-rheumatic, use 424.0.
424.0 Mitral valve disorders Use if specified as non-rheumatic. Also use for mitral insufficiency of unspecified cause.
AORTIC VALVE ONLY
395.0 Rheumatic aortic stenosis Specific to rheumatic cases. For others, use 424.1.
395.1 Rheumatic aortic insufficiency Specific to rheumatic cases. For others, use 424.1.
395.2 Rheumatic aortic stenosis with insufficiency Specific to rheumatic cases. For others, use 424.1.
395.9 Other and unspecified rheumatic aortic diseases Specific to rheumatic cases. For others, use 424.1.
424.1 Aortic valve disorders Use if specified as non-rheumatic or unspecified. If specified as rheumatic, see 395.x.
BOTH MITRAL AND AORTIC VALVES

 
396.0 Mitral valve

...

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July 13, 2011
General / Hot Coding Topics

4 Common Interventional PM Procedures You Can’t Afford To Miss

Get the lowdown on when to code separately for fluoroscopy.

If your physician performs interventional pain management (IPM) services, you’ll need to be up to speed on four top IPM procedures to make sure you’re earning full deserved reimbursement for your claims.

Difference: Pain management specialists are physicians who study pain and perform less invasive injections (soft tissue, peripheral nerve, and joint injections) and medication management to help relieve patients’ pain. One common pain management procedure is trigger point injection (20552, Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s]) or 20553, single or multiple trigger point[s], 3 or more muscle[s]). An interventional pain management specialist’s scope includes spinal diagnostic and therapeutic procedures and other invasive techniques like nerve stimulator or opioid pump insertion, says Scott Groudine, MD, an anesthesiologist in Albany, N.Y. When submitting claims, you’ll use specialty designation 72 for pain management or 09 for interventional pain management.

Learn the Most Common Injections

All injections are not created equal – and they’re not coded the same. Here’s your guide to four types of treatments that commonly fall under the IPM umbrella.

Facet injections: CPT® includes a range of codes describing the various sites and levels associated with paravertebral facet joint and facet joint nerve injections. You’ll find these in code family 64490-64495 (Injection(s), diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with image guidance [fluoroscopy or CT]). If your physician uses ultrasound guidance during the injection procedure, turn to the Category III code section of CPT® instead. There you’ll find codes 0216T-0218T (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with ultrasound guidance). You’ll choose the appropriate code based on the anatomic injection site...

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July 13, 2011
General / Hot Coding Topics

ICD-10: I42.- Requires More Cardiomyopathy Details Than 425.4 Does

Tip: A diagnosis that falls under an ICD-9 ‘other’ code may have its own ICD-10 code.

Under ICD-9, when the manual doesn’t offer a code specific to your diagnosis, you usually choose one of the catch-all “other specified” codes available, such as 425.4 (Other primary cardiomyopathies). When you start applying ICD-10 codes in October 2013, you may find that your catch-all code has been divided into more specific options. Here’s how the ICD-10 counterparts for 425.4 will look.

ICD-9 coding rules: Cardiomyopathy literally means disease of the heart muscle and can refer to many types of heart disease. ICD-9 offers one code for “other” primary cardiomyopathies: 425.4. It’s appropriate for cardiomyopathy NOS, congestive, constrictive, familial, hypertrophic, idiopathic, nonobstructive, obstructive (but see 425.1 for hypertrophic obstructive), and restrictive. Code 425.4 is also appropriate for cardiovascular collagenosis.

ICD-10 changes: ICD-10 divides your options for “other” cardiomyopathy among three codes:

  • I42.2, Other hypertrophic cardiomyopathy
  • I42.5, Other restrictive cardiomyopathy
  • I42.8, Other cardiomyopathies.

Code I42.2 will be appropriate for other cardiomyopathy: hypertrophic, nonobstructive. Code I42.5 will be appropriate for other cardiomyopathy: restrictive, constrictive NOS. Code I42.8 is appropriate for any other cardiomyopathies not listed elsewhere, including newborn and obscure of Africa, as well as cardiovascular collagenosis.

Caution: Check the index and full I42.- range in the tabular list before choosing an “other” code. For example, several of the diagnoses that fall under 425.4 in ICD-9 do not fall under the “other” cardiomyopathy codes in ICD- 10. Specifically, obstructive cardiomyopathy is coded to I42.1 under ICD-10, congestive falls under I42.0, and familial and idiopathic fall under I42.9.

Remember: When ICD-10 goes into effect on Oct. 1, 2013, you should apply the code set and official guidelines in effect for the date of service reported. Learn more at www.cms.gov/ICD10/ and www.cdc.gov/nchs/icd/icd10cm.htm#10update.

Be ready...

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July 8, 2011
General / Hot Coding Topics

What Do DRG’s LOS Columns Mean?

Question: In the CMS DRG datasheet, what is the difference between the column titled “Geometric Mean LOS” and the one labeled “Arithmetic Mean LOS”? Answer: The geometric mean length of stay or (GMLOS) is the national mean length of stay for ea...

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July 8, 2011
Coding Challenge / General

Choosing for Tympanostomy Anesthesia

Question: I’m looking for the anesthesia code for a tympanostomy of the left ear, performed on a 10-month-old child. What’s the correct choice? Answer: The correct code is 00126 (Anesthesia for procedures on external, middle, and inner ear includin...

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July 7, 2011
General / Hot Coding Topics / Provider News

Avoid EHR Penalties with These Proposed Additional Exemptions

Check whether your group might fall into one of four new categories.

The push toward e-prescribing is in full swing, with physicians possibly being subjected to a one percent payment hit on CMS claims in 2012 if you don’t successfully participate in e-prescribing this year (and larger hits in 2013 and 2014). If your physicians haven’t yet met e-prescribing criteria, take hope: CMS has proposed four additional ways that eligible professionals (EPs) can potentially avoid the adjustment in 2012.

The imminent penalty for physicians who don’t e-prescribe “has created quite a bit of concern about circumstances where doctors will potentially be penalized, not necessarily because of failure to electronically prescribe, but more so because of some complexities with regard to the measurement,” said Michael Rapp, MD, JD, director of the quality measurement and health assessment group at CMS, during a May 26 CMS Open Door Forum.

Previously, physicians could apply for a hardship exemption only if they could prove a lack of access to the internet in their area or limited access to pharmacies that accepted electronic prescribing. Under the new proposal, EPs would be eligible to request a hardship exemption that CMS would determine on a case-by-case basis if they meet one of the following additional four criteria, Rapp said.

1. Registering With Intent to Adopt EHR Technology
Practitioners who intend to start participating in the HER (Electronic Health Record) Incentive Program might still be getting their technology in place, so they may not have e-prescribed ten times within the first six months of 2011, as is required to avoid the penalty. The new proposal aims to offer those practices a potential exemption.

2. Prescribing Meds That Legally Cannot Be Electronically Transmitted
Many state, local, or...

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July 7, 2011
Coder's Cranium / General / Hot Coding Topics

Answer 3 Questions Before You Code CTS Shots

Verify evidence of previous treatments for successful claims.

If you’re coding for a patient’s carpal tunnel syndrome (CTS) injection, double check for previous, less invasive CTS treatments before getting too far with your claim. If the physician administers an injection during the patient’s initial visit for CTS, you could be facing a denial. Some payers allow CTS injection therapy only when other treatments have failed. Check out these FAQs to make each CTS coding scenario a snap.

Should the Physician Try Other Treatments Before 20526?

Yes. The FP would likely try less invasive treatments before resorting to CTS injection (20526, Injection, therapeutic [e.g. local anesthetic, corticosteroid], carpal tunnel), confirms Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver. These treatments might include, but are not limited to:

  • splinting (or bracing)
  • medication (non-steroidal anti-inflammatory)
  • occupational therapy.

If the patient’s symptoms don’t improve after these attempts, the physician may then proceed with a corticosteroid injection of the carpal tunnel, Hammer says.

Caveat: Check with the payer if you are unsure of its “previous treatment” requirements. Even evidence of previous treatments might not be enough to convince some insurers, says Jacqui Jones, a physician office manager in Klamath Falls, Ore. “We have had a couple of contracted HMOs [health maintenance organizations] impose conservative nonsurgical treatment – even with previous treatment and positive nerve conduction velocities ordered by another physician,” says Jones.

What Diagnoses Support Carpal Tunnel?

Patients that become candidates for CTS injections may present initially with “complaints of progressively worse numbness and tingling (782.0, Disturbance of skin sensation) in their hand and wrist, particularly the thumb, index, and middle finger,” Hammer explains. As the CTS...

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July 1, 2011
Coding Challenge / General

Use -79 for Repeat Wart Freezing Within Global Period

Question: Eight days after an initial wart freezing, the patient returns, and the physician freezes another wart. Is the second procedure bundled into the first, or can we report it with a modifier? Answer: You may be able to report the second occurren...

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July 1, 2011
General / Hot Coding Topics

Multiple X-Ray Charges OK for Different Purposes

Question: A new patient presented to the office because of an injured left ankle she hurt while doing yard work. The FP performed a detailed history and examination. He suspected a fracture and ordered a two-view ankle x-ray, which revealed a bimalleolar fracture. The physician provided local anesthesia and used closed treatment to manipulate the fracture. He then ordered a second two-view ankle x-ray to confirm proper alignment. Notes indicated moderate medical decision making. Can I code both ankle x-rays in this scenario?

Answer: Since the physician ordered separate x-rays for different purposes (identifying the fracture, then ensuring proper bone placement), you can code for both. On the claim, report the following:

  • 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history;, a detailed examination; and medical decision making of low complexity) for the evaluation and management service that diagnosed the fracture and led to the decision to treat it.
  • 27810 (Closed treatment of bimalleolar ankle fracture [e.g., lateral and medial malleoli, or lateral and posterior malleoli or medial and posterior malleoli]; with manipulation) for the fracture care
  • 73600 (Radiologic examination, ankle; 2 views) x 2 for the x-rays (one before the surgery, and one to ensure proper bone placement postsurgery)
  • 824.4 (Fracture of ankle; bimalleolar, closed) appended to 99203, 27810, and 73600 to represent the patient’s ankle fracture
  • E016.X (Activities involving property and land maintenance, building and construction) appended to 99203, 27810, and 73600 to represent the cause of the patient’s ankle fracture. The nature of the “yard work” that the patient was doing will determine the appropriate last digit of this code.

Modifier alert: Be sure to check with your payer before filing...

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July 1, 2011
General / Hot Coding Topics

338.3 Example Boosts Your Non-Chemo Encounter Coding Savvy

Be sure your coding complies with ICD-9 official guidelines for pain management.

If you don’t know when to check ICD-9 official guidelines, you may have just a 50-50 chance of choosing the proper order for your diagnosis codes.

Case in point: Patients may present to the office for treatment related to pain caused by a neoplasm. In such cases, you will need to determine, which diagnosis codes to report, and you will need to decide what order to list the codes in on your claim. With that in mind, consider how you should code the scenario below.

Start by Examining the Neoplasm-Related Pain Case

Read the following scenario and determine proper ICD-9 coding based on the information given. You’ll find a helpful hint on which section of the official guidelines to review if you get stuck.

Scenario: The physician documents that a patient with lung cancer (middle lobe, primary malignant neoplasm) presented to the office for the purpose of pain management. The pain is documented as acute and caused by the neoplasm.

Hint: See section I.C.6.a.5 of the Official Guidelines for instructions on properly coding these sorts of encounters. The CDC posts ICD-9 guidelines online at: www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm

Next, Determine Which Neoplasm and Pain Codes Apply

For this scenario, before you can decide what order to put the codes in, you will need to decide which codes to report.

Neoplasm: For a primary malignant neoplasm of the lung’s middle lobe, you should report 162.4 (Malignant neoplasm of middle lobe bronchus or lung), says Denae M. Merrill, CPC, HCC coding specialist in Michigan.

Pain: To choose the proper pain diagnosis code, you want to be sure you keep in mind that the neoplasm is the cause. The ICD-9 index entry for pain has several subentries to consider:

  • Cancer associated
  • Neoplasm

...

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June 27, 2011
General / Hot Coding Topics / Provider News

E/M + Bronchoscopy + PFT: Unlock the Secrets to Signs and Symptoms Coding

Keep your CCI edits in mind for PFT bundles.

When a patient presents with common respiratory conditions, your pulmonologist should perform an extensive history and examination, and may order several diagnostic tests before he can settle with a definite diagnosis to report in the claim. Along with the primary diagnosis (if achieved), you should report the patient’s signs and symptoms or else risk an audit.

Consider this scenario: The pulmonologist sees a patient for fever, shortness of breath, chest pain, weight loss, and fatigue. After undergoing a detailed history and examination, the patient becomes suspect for hypersensitivity pneumonitis, otherwise known as extrinsic allergic alveolitis (495.x). The physician orders a diagnostic bronchoscopy with fluoroscopic guidance, as well as a spirometry to verify the patient’s condition. To justify each service performed by the same provider or group, you might be accumulating payer inquiries or denials. This 2-step technique should carry you through potentially puzzling spirometry-E/M coding situations.

1. Don’t Leave Out Signs and Symptoms On Your Claim

 First on your to-do list is to report the patient’s signs and symptoms. In this case, you would code 780.6 (Fever and other physiologic disturbances of temperature regulation), 786.05 (Shortness of breath), 786.50 (Unspecified chest pain), 783.21 (Loss of weight), and 780.79 (Other malaise and fatigue). Because these signs and symptoms resemble other respiratory problems, the physician performs a level four E/M and orders some diagnostic tests. Report the procedures with: 31622 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed [separate procedure]) for the bronchoscopy with fluoroscopic guidance. Your physician is likely to perform this on a separate date. 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) for the pulmonary function test (PFT); and 99214 (Office...

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June 24, 2011
Coder's Cranium / General / Hot Coding Topics / Provider News

Modifier 57 Remains Handy Post Removal of Consult Codes

Take a hint from a CPT®’s global period when choosing between modifiers 25 or 57

Contrary to popular thinking, modifier 57 does not apply exclusively for consultation codes only. Medicare may have stopped paying for consult codes, but this doesn’t mean you have to stop using modifier 57. Here are two tips on how you can use this modifier to suit your practice’s needs.

Background: Starting January 1, 2010, the Centers for Medicare and Medicaid Services (CMS) eliminated consult codes from the Medicare fee schedule.

Non-Consult Inpatient Codes Keep Modifier 57 Alive

With CMS eliminated consult codes (99241-99245, 99251- 99255) for Medicare patients, you might have wondered if modifier 57 (Decision for surgery) would remain useful. The answer? You can still use this modifier for a non-consult inpatient E/M code, so long as your documentation supports it. This is because any major procedure includes E/M services the day before and the day of the procedure in the global period, says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. “The only way you can be paid properly for an E/M performed the day before the major surgery or the day of the surgery is to indicate that it was a decision for surgery (modifier 57), which also indicates to the payer that the major procedure was not a pre-scheduled service,” she explains.

Past: Say the pulmonologist carries out a level four inpatient consult in which she figures out the patient requires thoracoscopy with pleurodesis for his recurring, persistent pleural effusion (511.9). The physician decides to perform thoracoscopy with pleurodesis the day after the consult. In this case, appending modifier 57 to the E/M code (99254, Inpatient consultation for a new or established patient, which requires these 3...

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June 24, 2011
General / Hot Coding Topics / Provider News

CMS Offers Great News With Fee Schedule Changes

Boost co-surgery, multiple surgery, and bilateral surgery pay for these select procedures

You’ll no longer have to eat the cost of your services if your physician acts as co-surgeon on spine revisions. Thanks to several Fee Schedule changes that CMS recently enacted. CMS had good news in MLN Matters article MM7430, which had an effective date of Jan. 1, 2011 and an implementation date of July 5, 2011.

Look for Potential Co-Surgery Payment for These Codes:

CMS will change the co-surgery indicator for spine revision codes 22212 and 22222 from “0” to “1”. Keep in mind that supporting documentation is required when billing for a co-surgeon with these procedures, so don’t forget to submit that with your claim or you’ll be looking at bad news.

Remember: If you’re billing for co-surgery, append modifier 62 (Two surgeons) to your procedure code. For modifier 62 claims, most payers pay an additional fee (generally 125 percent of the “usual” fee for the procedure, split evenly between the two surgeons). Avoid reimbursement problems by checking these claims carefully. To claim co-surgeons, each surgeon must perform a distinct portion of a single CPT procedure, and each surgeon must dictate and submit his own operative report for his portion of the surgery.

Benefit From Surgical Assist Changes:

Practices that perform sinus endoscopies will also get a potential boost from the fee schedule changes, now that you’ll see the assistant at surgery indicator change for codes 31233 and 31235 from “1” (Assistant at surgery may not be paid) to “0” (Payment restrictions for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity).

You’ll append modifier 80 to the assistant’s surgical codes if the assisting surgeon is a physician. In cases when a non-physician assists at surgery on Medicare patients, append...

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June 24, 2011
General / Hot Coding Topics / ICD-10

Qualedix, Inc. Partners with the Coding Institute to Bring Enhanced Quality and Education to its Managed Services Solution for ICD-10 Testing

Naples, FL (June 15, 2011) –Qualedix, an advanced healthcare testing organization, today announced it has partnered with the Coding Institute, LLC, a company dedicated to offering accurate healthcare solutions, that will provide native ICD-10 coding expertise and educational services to the industry leading Simplicedi testing platform.

The combined market offerings enable greater accuracy, speed and a true clinical approach to tackling the arduous task of testing thousands of new ICD-10 codes for providers and payers alike.

“At Qualedix, we strive for excellence in our data solutions for the industry and clinical knowledge is paramount to effectively remediate and test ICD-10 changes across the healthcare industry. The Coding Institute brings to a new echelon of quality and expert knowledge to better effectively serve the market through our testing managed services,” said Mark Lott, CEO of Qualedix. “Also, all of our clients need education to assist in the transition period and we are proud to have TCI as our education and training partner.”

“The Coding Institute is excited about the opportunity to partner with Qualedix to provide unmatched testing and training to help healthcare professionals implement ICD-10 compliantly and efficiently,” said Jennifer Godreau, BA, CPC, CPMA, CPEDC, Director of the SuperCoder.com and Consulting & Revenue Cycle Solutions divisions of the Coding Institute.  “As the healthcare industry’s most advanced ICD-10 testing and education methodology, this managed services solution identifies key areas of focus for hospitals, insurers, and providers and allows us to prevent incorrect coding and revenue losses.”

About Qualedix

Qualedix is a professional healthcare IT quality assurance and software testing firm delivering outsourced managed testing services that leverage our expertise in healthcare and software development lifecycles. Qualedix has developed highly strategic methodologies and techniques designed to deliver critical, cost-effective solutions for 5010 and ICD-10 with highly technical testing experts, healthcare business acumen,...

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June 22, 2011
Coder's Cranium / General / Hot Coding Topics

CMS Proposes New Glaucoma, Skin Cancer, Dementia Codes

 

Many new codes abound in final update to proposed ICD-9-CM code set

If you’ve felt that your skin cancer diagnoses could use a bit more specificity, ICD-9 will deliver this October if the proposed list of new, deleted, and revised diagnosis codes becomes final. The list of ICD-9 changes was recently posted to the CMS Website, and includes the final full set of changes that the agency will make to ICD-9 codes. After the new codes take effect on Oct. 1, CMS will only add new ICD- 9 codes on an emergency basis as it prepares to switch over the diagnosis coding system to ICD-10.

 

Seek Out Skin Cancer Changes

You’ll find a significant expansion to the 173.x (Other malignant neoplasm of skin) categories, including changes to 173.0x (…Skin of lip), 173.1x (Eyelid, including canthus), 173.2x (Skin of ear and external auditory canal), 173.3x (Skin of other and unspecified parts of face), 173.4x (Scalp and skin of neck), 173.5x (Skin of trunk, except scrotum), 173.6x (Skin of upper limb, including shoulder), 173.7x (Skin of lower limb, including hip), 173.8x (Other specified sites of skin), and 173.9x (Skin, site unspecified).

 Among these changes, for example, you’ll find the following new codes to delineate various types of skin cancers:

  • 173.60 —Unspecified malignant neoplasm of skin of upper limb, including shoulder
  • 173.61 — Basal cell carcinoma of skin of upper limb, including shoulder
  • 173.62 — Squamous cell carcinoma of skin of upper limb, including shoulder
  • 173.69 — Other specified malignant neoplasm of skin of upper limb, including shoulder.

 The changes in the other skin cancer categories referenced above follow this pattern, with the fifth digit of “0” referring to an unspecified malignant neoplasm, “1” denoting a basal cell cancer, “2” referring to a squamous cell carcinoma,” and “9”...

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June 22, 2011
General / Provider News

HPI Know-How Helps You Catch Level 4 and 5 E/M Opportunities

 

Beware of CPT® and Medicare differences when counting HPI elements.

Not accurately accounting for the history of presentillness (HPI) documented by your oncologist could result in missing appropriate opportunities to report level 4 or 5 E/M visits. Ensure you’re not missing higher paying possibilities by reviewing this guide to capturing HPI elements.

Brush Up on What Qualifies as an HPI Element

HPI is one of the three parts comprising an outpatient E/M history. It describes the patient’s present illness or problem, from the first sign/symptom to the current status, and typically drives a provider’s decisions about the physical examination and treatment. “The information gathered during the physical exam (PE) portion of a patient’s evaluation often only shows a very limited picture of the patient’s problem. However, speaking with a patient and gathering the history of the patient’s problem” can help fill out the picture, explains Amanda S. Stoltman, CCS-P, compliance coder at Urology Associates in Muncie, Ind.

 Start counting:

HPI also will often determine the level of service you’ll report. You’ll count the HPI elements to help you determine which level of service you can report. There are seven or eight HPI elements, depending on which source you are following. For Medicare, the eight elements are as follows: 

  • Location
  • Quality
  • Severity
  • Duration
  • Timing
  • Context
  • Modifying factors
  • Associated signs and symptoms.

Medicare includes the above list in both the 1995 and 1997 E/M Documentation Guidelines, available at www.cms.gov/MLNEdWebGuide/25_EMDOC.asp.

In contrast: CPT® lists only seven HPI elements in the E/M Services Guidelines, with duration not making the list. Therefore, for Medicare and payers following its guidelines, you should consider duration and timing separately. With payers that follow AMA rules, however, be aware that they don’t consider duration and timing to be two separate elements. Rumor has it...

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June 22, 2011