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Training Guide Clinical Evaluation Criteria for Technical


Services
TRAINING GUIDE FOR USE OF CLINIC EVALUATION & MANAGEMENT (E&M)
CRITERIA FOR TECHNICAL CHARGES
Introduction
The following guidelines pertain to all aspects of generating an evaluation and management (E&M) visit
technical charge in the clinics of University of Illinois Medical Center at Chicago (UIMC). It is important
to have a standardized and consistent methodology for reporting E&M visits performed. The guidelines
developed for UIMC are based on the expert panel recommendations produced by the American Hospital
Association (AHA) and the American Health Information Management Association (AHIMA) at the
request of the Centers for Medicare and Medicaid Services (CMS). CMS has not yet mandated uniform
criteria for hospitals to adopt; therefore, it is the responsibility of each individual hospital to develop
standards and criteria by which clinic charges are to be made. Upon submission of a bill, the payer
expects that clinic charges are consistent with UIMC-specific methodology.
The level of interventions on the Clinic E&M Criteria sheet represent hospital (technical) resources
consumed and used during a clinic visit; therefore, physician services are NOT considered in applying the
technical coding level. Hospital resources may include use of the room and associated utilities, nursing
time, medical assistant time, clerical time, other non-physician staff member time and supplies. This
charge represents the hospital overhead costs associated with all services that do not have a separate
procedure charge.
Procedures that have separate CPT codes include an evaluation and management component. You do not
routinely charge for a separate E/M service in addition to the procedure. The purpose of the patient visit
should help guide staff members in determining whether a charge should be initiated for an office visit (E
and M) only, a distinct procedure only, or whether there is evidence of both a procedure and identifiably
distinct evaluation and management service. In some circumstances, an event that occurs during a
procedure could lead to a separately billable E and M service. Conversely, a visit that starts out as an E
and M service, could result in a separately billable procedure performed. In either case, the appropriate
modifier must be attached to reflect a distinct E and M service when a procedure is also billed.

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.

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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.

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Technical Staff Interventions


Interventions not listed or defined below should be self-explanatory and charged only once per episode
unless indicated on the charge criteria. The guidelines stated are separated into the major sections as listed
on the Clinic E&M Criteria.
Level I Interventions (99201, 99211)
Registration/check-in
Exam room utilization
Blood pressure check/recheck ONLY
Weight check only

Patient appointment confirmation and check-in on


arrival
Clean, set up and stock room
Select if only BP is taken without other VS.

Providing instructions of patient on proper


specimen collection (mid-stream urine, sputum).
Patient is performing collecting. Does not include
Specimen collection (patient self-collects)
venipuncture, which has its own CPT code.
Three or more interventions at this level = level II (99202/99212)
Level II Interventions (99202, 99212)

Single specialized clinical measurement

Vital signs
Suture and staple removal

Wound management 15 sq cm or less


Heplock flush

*Face-to-face education up to 5 minutes


Create/update medication list (1-5 meds)

Examples: BMI, positional blood pressure, head


circumference , cardiac monitor rhythm strip done
by a nurse or tech
Initial set only; includes pains screen/score only.
If comprehensive pain assessment is performed
and documented by non-MD clinician, select level
4 pain screening and assessment. Pulse
oximetry is considered a vital sign if performed
routinely on all patients.
Performed by a non-physician
When not separately billable. Includes cleansing,
assessment, measurement, photographing, ankle
brachial index, or dressing of wound. Includes
steri-strips and other adhesives, butterflies and eye
patch. For multiple wounds, add the total size of
all wounds.
Documentation to support the content of
education, time involved, and any factors that
impacted time required. Education may be
performed by any health care professional
(excluding physicians), such as dieticians, nurses
and pharmacists. Includes face-to face review of
written instructions by assistive personnel
Examples: Crutch training, diabetic teaching,
counseling regarding diet, exercise, and other
lifestyle changes.
Includes collection and recording current

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prescribed, OTC meds and herbal supplements at


the time of service via interview of patient, review
of records, and/or transcribed from current Rx
containers. If patient education on medication
management is also provided, also select and
document appropriate patient education category
by time criteria (eg face-to-face education 6 to 15
minutes)
Other assessments not otherwise specified (fall
risk, nutritional, etc.) may be performed by any
health care professional (excluding physicians),
such as dieticians, nurses and pharmacists.
Nature, scope, and time length of assessment
must be documented. Patient self-assessments
*Face-to-face assessment up to 5 minutes
are excluded.
Face-to-face review with pt of currently
documented allergies; significant problems;
Review summary list elements w/pt; no
surgical procedurespatient confirms all
updates
information is current with no updates required
Three or more interventions at this level = level III (99203/99213)
Level III Interventions (99203, 99213)

Administration of medication
Administration of single disposable enema
Application of preformed splint(s)/elastic
bandages/slings/or immobilizer

Create/update summary list elements

*Face-to-face education 6-15 min

Routes of administration include oral, topical,


rectal, parenteral, nasogastric and sublingual. For
injections, use specific CPT code
Preformed is off-the-shelf. Not to be used for
fracture or dislocation injuries (those procedures
are separately billable).
Includes collection and recording lists of allergies
(especially medications and products), significant
medical problems, and significant procedures at
the time of service via interview or patient and/or
review or records. If medication list is also
created/updated, also select and document
appropriate medication list category by volume
criteria (eg Create/update medication list 1-5
meds)
Documentation to support the content of
education, time involved, and any factors that
impacted time required. Education may be
performed by any health care professional
(excluding physicians), such as dieticians, nurses
and pharmacists. Includes face-to face review of
written instructions by assistive personnel
Examples: Crutch training, diabetic teaching,
counseling regarding diet, exercise, and other
lifestyle changes.

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Examples: Control bleeding, ice, monitor vital


signs, cool body, remove stinger from insect bite,
First aid procedures
cleanse and remove secretions
Foreign body removal from skin,
Without anesthesia or incision, when not a
subcutaneous or soft tissues
separately billable procedure
This is integral to current interventions and/or
patients condition. Examples: Additional vital
Frequent monitoring/
signs, assessment of cardiovascular, pulmonary or
assessment as evidenced by two sets of vital neurological status, assessment of pain scale,
signs or assessments (including initial set)
pulse oximetry or peak flow assessment.
Initiation or adjustment from baseline oxygen
regimen. Includes conversion to hospital-supplied
oxygen with rate adjustments, as well as initiation
O2 administration
of oxygen administration.
Other than venipunctures. Includes collection of
specimen (not the performance of lab test), e.g.
throat culture collection. Does not Include
Specimen collection by nurse, medical
collection of blood from a completely implanted
assistant or tech
vascular access device (36540).
When not separately billable. Includes cleansing,
assessment, measurement, photographing, ankle
brachial index, or dressing of wound. Includes
steri-strips and other adhesives, butterflies and eye
patch. For multiple wounds, add the total size of
all wounds. Note: For multiple wounds, add the
Wound management 15-24 sq cm
total size of all wounds.
Includes collection and recording current
prescribed, OTC meds and herbal supplements at
the time of service via interview of patient, review
of records, and/or transcribed from current Rx
containers. If patient education on medication
management is also provided, also select and
document appropriate patient education category
by time criteria (eg face-to-face education up to 15
Create/update medication list (6-9 meds)
minutes)
Other assessments not otherwise specified (fall
risk, nutritional, etc.) may be performed by any
health care professional (excluding physicians),
such as dieticians, nurses and pharmacists. Nature,
scope, and time length of assessment must be
documented. Patient self-assessments are
*Face-to-face assessment 6-15 min
excluded.
Three or more interventions at this level = level IV (99204/99214)
Level IV Interventions (99204, 99214)

Pain screening AND assessment

Documentation of comprehensive pain assessment


when performed by RN or other non-physician
clinician. Pain screening score only (without
assessment) is reported as Vital Signs (level 1)

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Includes collection and recording current


prescribed, OTC meds and herbal supplements at
the time of service via interview of patient, review
of records, and/or transcribed from current Rx
containers. If patient education on medication
management is also provided, also select and
document appropriate patient education category
Create/update medication list (10 or more
by time criteria (eg face-to-face education up to
meds)
15 minutes)
Includes pelvic exam, eye exam/slit lamp exam of
eye, other exams without specific CPT codes.
Chaperoning. Documentation must support
assistance/presence in room unless written
Assist physician with exam
protocol exists.
Care of devices or catheters (both indwelling and
in & out) (vascular or nonvascular) and ostomy
Catheter or ostomy device care
devices (other than insertion or reinsertion)
Documentation to support the content of
education, time involved, and any factors that
impacted time required. Education may be
performed by any health care professional
(excluding physicians), such as dieticians, nurses
and pharmacists. Includes face-to face review of
written instructions by assistive personnel
Examples: Crutch training, diabetic teaching,
counseling regarding diet, exercise, and other
*Face-to-face education 16-30 min
lifestyle changes.
This is integral to current interventions and/or
patients condition. Examples: Additional vital
signs; assessment of cardiovascular, pulmonary or
neurological status; assessment of pain scale;
Frequent monitoring and assessment with
pulse oximetry or peak flow assessment; urgent
greater than 2 sets of vital signs
and emergent care interventions
When not separately billable. Includes cleansing,
assessment, measurement, photographing, ankle
brachial index, or dressing of wound. Includes
steri-strips and other adhesives, butterflies and eye
patch. For multiple wounds, add the total size of
Wound management 25-50 sq cm
all wounds.
Other assessments not otherwise specified (fall
risk, nutritional, etc.) may be performed by any
health care professional (excluding physicians),
such as dieticians, nurses and pharmacists. Nature,
scope, and time length of assessment must be
documented. Patient self-assessments are
*Face-to-face assessment 16-30 min
excluded.
Three or more interventions at this level = level V (99205/99215)

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Level V Interventions (99205, 99215)


Assessment, crisis intervention and supervision
of imminent behavioral crisis threatening self or
others
Continuous eye irrigation with therapeutic lens

*Face-to-face education >30 min


Continuous monitoring and assessment
Suctioning (nasotracheal or orotracheal)

Wound management >50 sq cm


Airway insertion

*Face-to-face assessment >30 min

Includes Morgan lens


Documentation to support the content of
education, time involved, and any factors that
impacted time required. Education may be
performed by any health care professional
(excluding physicians), such as dieticians,
nurses and pharmacists. Includes face-to face
review of written instructions by assistive
personnel Examples: Crutch training, diabetic
teaching, counseling regarding diet, exercise,
and other lifestyle changes.
Includes urgent care
When not separately billable. Includes
cleansing, assessment, measurement,
photographing, ankle brachial index, or
dressing of wound. Includes steri-strips and
other adhesives, butterflies and eye patch. For
multiple wounds, add the total size of all
wounds.
Other assessments not otherwise specified
(fall risk, nutritional, etc.) may be performed
by any health care professional (excluding
physicians), such as dieticians, nurses and
pharmacists. Nature, scope, and time length of
assessment must be documented. Patient selfassessments are excluded.

*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.

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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

Ex: Pt with dx of Alzheimers


Includes reporting of child abuse, battery,
elder abuse etc.; Coordinating consultation
with social work or social service agency

Mandatory Reporting to law enforcement,


protective services, Infection control, etc.

Includes booking future appointments while


the patient is present such as admission to the
hospital, Surgicenter; scheduling diagnostic
testing, etc. This does not include scheduling
of routine return to clinic visits.
Patient discharged to place other than home
new admission to the hospital, skilled nursing
facility, etc
Includes gunshot, sexually transmitted disease
and infection reporting

Isolation
Simultaneous care by greater than one staff
member
Special needs requiring additional facility
resources

Includes prisoner precautions and holding

Scheduling/coordination of care

Admission or transfer to hospital or other


facility

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