Coding and Compliance Update for Pediatric Gastroenterology in 2006 © Kathleen a Mueller, RN, CPC, CCS-P, CCC, CMSCS This Manua

Coding and Compliance Update for Pediatric Gastroenterology in 2006

This manual, or parts thereof, may not be reproduced, stored in a retrieval system or transmitted in any form by any means (electronic, mechanical, photocopying, recording or otherwise) without written permission of the publisher.

Edited and Published by: Kathleen A Mueller, RN, CPC, CCS-P, CCC, CMSCS PO Box 128 Lenzburg IL 62255-0128

F 1-618-475-3617 Fax: 1-618-475-3622 E-mail: [email protected] ______Distributed by:

Kathleen A Mueller, RN, CPC, CCS-P, CCC, CMSCS 204 E Locust St Lenzburg IL 62255

This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. The information contained herein is current as of the publication date and is subject to interpretation by the insurance carriers at any time. It is sold with the understanding that the publisher is not engaged in rendering legal or accounting services. If legal or other expert assistance is required, the services of a competent professional person should be sought. From "A declaration of Principles" jointly adopted by a committee of the American Bar Association and a Committee of Publishers.

Chapter One

Gastroenterology 2007 ICD-9-CM

284.01 Constitutional red blood cell aplasia 284.09 Other constitutional aplastic anemia 284.1 Pancytopenia 284.2 Myelophthisis 288.00 Neutropenia, unspecified 288.01 Congenital neutropenia 288.02 Cyclic neutropenia 288.03 Drug induced neutropenia 288.04 Neutropenia due to infection 288.09 Other neutropenia 288.4 Hemophagocytic syndromes 288.50 Leukocytopenia, unspecified 288.51 Lymphocytopenia 288.59 Other decreased white blood cell count 288.60 Leukocytosis, unspecified 288.61 Lymphocytosis (symptomatic) 288.62 Leukemoid reaction 288.63 Monocytosis (symptomatic) 288.64 Plasmacytosis 288.65 Basophilia 331.83 Mild cognitive impairment, so stated 333.71 Athetoid cerebral palsy 528.00 Stomatitis and mucositis, unspecified 528.01 Mucositis (ulcerative) due to antineoplastic therapy 528.02 Mucositis (ulcerative) due to other drugs 528.09 Other stomatitis and mucositis ulcerative) 538 Gastrointestinal mucositis (ulcerative) 780.96 Generalized pain 780.97 Altered mental status V18.51 Family history (of), Colonic polyps V18.59 Family history (of), Other digestive disorders V45.86 Bariatric surgery status V82.71 Screening for genetic disease carrier status V82.79 Other genetic screening V85.51 Body Mass Index, pediatric, less than 5th percentile for age V85.52 BMI, pediatric, 5th percentile to less than 85th percentile for age V85.53 BMI, pediatric, 85th percentile to less than 95th percentile for age V85.54 BMI, pediatric, greater than or equal to 95th percentile for age

As you can see by the codes listed above, there are not many that would be considered primary diagnosis codes for gastroenterology. However, most of these codes would be considered a secondary/supporting diagnosis to back up the level of service billed since these are considered comorbidities/mortality factors as well.

Injection/Infusion Update Effective: January 1, 2006

2006 Old Descriptor Code Code 90760 90780 Intravenous infusion, hydration; initial, up to one hour 90761 90781 Intravenous infusion, hydration; each additional hour, up to eight (8) hours (List separately in addition to code for primary procedure) 90765 90780 Intravenous infusion, for therapy/prophylaxis/diagnosis (specify substance or drug); initial, up to one hour 90766 90781 Intravenous infusion, for therapy/prophylaxis/diagnosis (specify substance of drug); each additional hour, up to eight (8) hours (List separately in addition to code for primary procedure) 90767 90781 Intravenous infusion, for therapy/prophylaxis/diagnosis (specify substance or drug); addition sequential infusion, up to one hour (List separately in addition to code for primary procedure) 90768 N/A Intravenous infusion, for therapy/prophylaxis/diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure 90772 90782 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular 90773 90783 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intra-arterial 90774 90784 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug 90775 N/A Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance or drug (List separately in addition to code for primary procedure) 96401 96400 Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic 96402 96400 Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic 96409 96408 Chemotherapy administration, intravenous; push technique, single or initial substance/drug 96411 96408 Chemotherapy administration, intravenous; push technique, each additional substance/drug ( List separately in addition to code for primary procedure) 96413 96410 Chemotherapy administration, intravenous infusion technique; up to one hour, single or initial substance/drug 96415 96412 Chemotherapy administration, intravenous infusion technique; each additional hour, one to eight (8) hours) (List separately in addition to code for primary procedure) 96416 96414 Chemotherapy administration, intravenous initiation of prolonged chemotherapy infusion (more than eight hours), requiring us of a portable or implantable pump 96417 96414 Chemotherapy administration, intravenous infusion technique; each addition sequential infusion, (different substance/drug) up to one hour (List separately in addition to code for primary procedure) 96523 N/A Irrigation of implanted venous access device for drug delivery systems

Guidelines

If a significantly separately identifiable evaluation and management (E&M) service is performed, the appropriate E&M service code should be reported utilizing modifier 25 in addition to codes G0347- G0354. For an E&M service provided on the same day, a different diagnosis is not required.

If performed to facilitate a therapeutic/diagnostic infusion or injection, the following are included and are not reported separately: • Use of local anesthesia • IV start • Access to indwelling IV, subcutaneous catheter or port • Flush at conclusion of infusion, and • Standard tubing, syringes and supplies

When multiple drugs are administered, report the service(s) and the specific materials or drugs for each.

When administering multiple infusions, injections or combinations, only one “initial” service code should be reported, unless protocol requires that two separate IV sites must be used. The “initial” code that best describes the key or primary reason for the encounter should always be reported irrespective of the order in which the infusions or injections occur. If an injection or infusion is of a subsequent or concurrent nature, even if it is the first such service within that group of services, then a subsequent or concurrent code from the appropriate section should be reported (eg, the first IV push given subsequent to an initial one-hour infusion is reported using a subsequent IV push code).

When reporting codes for which infusion time is a factor, us the actual time over which the infusion is administered.

Hydration Codes 90760-90761 are intended to report a hydration IV infusion to consist of a pre-packaged fluid and electrolytes (eg, normal saline, D5-½ normal saline+30mEq KCl/liter), but are not used to report infusion of drugs or other substances. Hydration IV infusions typically require direct physician supervision for purposes of consent, safety oversight, or intraservice supervision of staff. Typically such infusions require little special handling to prepare or dispose of, and staff that administer these do not typically require advanced practice training. After initial set-up, infusion typically entails little patient risk and thus little monitoring.

Therapeutic, Prophylactic, and Diagnostic Injections and Infusions A therapeutic, prophylactic, or diagnostic IV infusion or injection (90765-90799) (other than hydration) is for the administration of substances/drugs. The fluid used to administer the drug(s) is incidental hydration and is not separately reportable. These services typically require direct physician supervision for any or all purposes of patient assessment, provision of consent, safety oversight, and intra-service supervision of staff. Typically, such infusions require special consideration to prepare, dose or dispose of, require practice training and competency for staff who administer the infusions, and require periodic patient assessment with vital sign monitoring during the infusion.

Intravenous or intra-arterial push is defined as: a) an injection in which the health care professional who administers the substance/drug is continuously present to administer the injection and observe the patient, or b) an infusion of 15 minutes or less.

(Do not report 90765-90779 with codes for which IV push or infusion is an inherent part of the procedure (eg, administration of contrast material for a diagnostic imaging study))

Chemotherapy Administration Chemotherapy administration codes 96401-96549 apply to parenteral administration of non- radionuclide anti-neoplastic drugs; and also to anti-neoplastic agents provided for treatment of noncancer diagnoses (eg, cyclophosphamide for auto-immune conditions) or to substances such as monoclonal antibody agents, and other biologic response modifiers. These services can be provided by any physician. Chemotherapy services are typically highly complex and require direct physician supervision for any or all purposes of patient assessment, provision of consent, safety oversight and intra-service supervision of staff. Typically, such chemotherapy services require advanced practice training and competency for staff who provide these services; special considerations for preparation, dosage or disposal; and commonly, these services entail significant patient risk and frequent monitoring. Examples are frequent changes in the infusion rate, prolonged presence of nurse administering the solution for patient monitoring and infusion adjustments, and frequent conferring with the physician about these issues.

If performed to facilitate the infusion or injection, the following services are included and are not reported separately: a. Use of local anesthesia b. IV start c. Access to indwelling IV, subcutaneous catheter or port d. Flush at conclusion of infusion e. Standard tubing, syringes and supplies f. Preparation of chemotherapy agent(s) (For declotting a catheter or port, use 36550)

Report separate codes for each parenteral method of administration employed when chemotherapy is administered by different techniques. The administration of medications (eg, antibiotics, steroidal agents, antiemetics, narcotics, analgesics) administered independently or sequentially as supportive management of chemotherapy administration, should be separately reported using 90760, 90761, 90765, 90779 as appropriate.

Report both the specific service as well as code(s) for the specific substance(s) or drug(s) provided. The fluid used to administer the drug(s) is considered incidental hydration and is not separately reportable.

When administering multiple infusions, injections or combinations, only one "initial" service code should be reported, unless protocol requires that two separate IV sites must be used. The “initial” code that best describes the key or primary reason for the encounter should always be reported irrespective of the order in which the infusions or injections occur. If an injection or infusion is of a subsequent or concurrent nature, even if it is the first such service within that group of services, then a subsequent or concurrent code from the appropriate section should be reported (eg, the first IV push given subsequent to an initial one-hour infusion is reported using a subsequent IV push code).

When reporting codes for which infusion time is a factor, use the actual time over which the infusion is administered.

DELETED CODES (90780 and 90781 have been deleted. To report, see 90760, 90761, 90765-90768)

(90782 has been deleted. To report, use 90772)

(90783 has been deleted. To report, use 90773)

(90784 has been deleted. To report, use 90774)

(90788 has been deleted. To report, use 90772)

(90799 has been deleted. To report, use 90779)

(96400 has been deleted. To report, see 96401, 96402)

(96408 has been deleted. To report, use 96409)

(96410 has been deleted. To report, use 96413)

(96412 has been deleted. To report, use 96415(

96414 has been deleted. To report, use 96416)

REMICADE INFUSION

In order to bill for the infusion of Infliximab in the physician office, the physician/provider has to be on site and in the office suite when the service is provided.

An ambulatory surgical center is not a Medicare approved site for infusion therapy.

Approved diagnosis: 555.0-555.9 Regional enteritis (Crohn’s) 556.0-556.9 Ulcerative Colitis 565.1 Anal fistula 569.81 Fistula of intestine, excluding rectum and anus 696.0 Psoriatic arthropathy (to be billed only with 720.81) 724.0 Rheumatoid arthritis 720.0 Ankylosing spondylitis

The following are different billing scenarios.

Example #1: Remicade only with just oral Benadryl given upon arrival. Time of administration 3 hours.

96413 one unit 96415 two units J1745 Remicade based upon mg of dosage (calculated per 10 mg)

Example #2: Remicade plus infusion for hydration when symptoms of volume depletion are present. Remicade administration 3 hours. Hydration 1 ½ hours. Total time 4 ½ hours.

96413 one unit 96415 two units 90761-59 one unit (hydration is bundled into the Remicade infusion unless Hypovolemia or dehydration is present and modifier 59 would be required. Diagnosis code of hypovolemia would also be assigned to 90761. J1745 Remicade based upon mg of dosage (calculated per 10 mg)

Example #3: Remicade infusion plus IV Benadryl 50 mg prior to infusion. Time of infusion 2 hour 20 minutes

96413 one unit 96415 one unit (would have to last at least 31 minutes to pick up that additional hour) 90775 one unit (add on to infusion) J1200 Benadryl up to 50 mg J1745 Remicade based upon mg of dosage (calculated per 10 mg)

Example #4: Remicade infusion plus SoluMedrol infusion. Time of infusion for SoluMedrol 45 minutes. Remicade infusion 2 hours 45 minutes.

96413 one unit 96415 two units 90767 one unit (each additional sequential infusion) J1745 Remicade based upon mg of dosage (calculated per 10 mg) J2930 SoluMedrol up to 125 mg

Endoscopy Coding: List all Components

Have you been listing just one CPT code for your endoscopy billing, thinking that it would be a double billing otherwise?

The Special Rules for endoscopies allow multiple billing of certain endoscopic procedures:

For example, how would you bill a colonoscopy with biopsy of the sigmoid (45380) and colonoscopy with polypectomy by snare in the transverse colon (45385)? How should we get paid?

1. First we must consider that each of these codes, (45385) and (45380) include the value of a diagnostic colonoscopy (45378). Using the Medicare fee schedule, the relative value units (RVUs) for 45378 is 6.26 in a facility.

2. Next, determine which procedure of the two (45385) and (45380) has the highest RVUs. Code 45385 has a value of 8.85 and code 45380 has a value of 6.75 This means the higher value code 45385 will be paid at 100%.

3. The lesser value code, 45380, will be paid at full price minus the cost of the diagnostic service (45378), or 6.75 RVUs minus 6.26 RVUs, or .49 RVUs.

4. Do not list 45378 on the claim.

5. You will need no modifier on the first procedure and modifier 59 on the second procedure. This tells the insurance carrier that the biopsy site was separate from the polypectomy site.

6. Don t forget to access the comment box on your HCFA-1500 form. Your software should have a place to insert on-form comments. In that comment box, enter transverse colon next to 45385 and sigmoid colon next to 45380.

Billing the above example:

7. 45385

8. 45380-59

Why? As long as multiple techniques were used in different sites, the procedures are separately billable.

Coding Tip:

C Check the current edition of national correct coding initiative.

Tips for Endoscopy Reports

C Make sure that there is a pre-operative and post-operative diagnosis. Even if the endoscopy is negative, go back to the original reason for the procedure as the diagnosis for the endoscopy.

C Be specific as to how the biopsy/polypectomy was performed; i.e., snare, hot biopsy forceps, ablation, etc. The phrase “multiple polypectomies” does not give us enough information to submit a claim.

C LOCATION! LOCATION! LOCATION! In order to get paid for different techniques in different sites within the intestine, the location of the lesion is essential in order to apply the appropriate modifier -59.

C If a Clo-test was done, this is billed as a biopsy. Make sure that this is mentioned in the report. Too often, this is only contained in pathology.

C Wait for pathology report before assigning diagnosis code. Neoplasm uncertain behavior does not mean that the area looks suspicious, it means that there is atypia or dysplasia. Suspect Crohn’s disease does not mean you have Crohn’s disease.

C MOST IMPORTANT!!!! The procedure note has to be legible. The solution: DICTATE YOUR NOTE!!!!

GI Specialists Procedural Listing (RVUs for 2006 as published in November 21, 2005, Federal Register)

CPT Facility Office DESCRIPTION RVUs RVUs ESOPHAGOSCOPY 43200 2.79 5.86 Esophagoscopy; diagnostic 43201 3.34 6.88 with submucosal injection(s), any substance (Botox, India ink, steroids, saline, etc) 43202 2.98 7.60 with biopsy(s) 43204 5.58 5.58 with injection sclerosis of esophageal varices 43205 5.58 5.58 with band ligation of varices 43215 4.03 4.02 with removal of foreign body 43216 3.66 3.66 with hot biopsy forceps or bipolar cautery 43217 4.35 10.13 with snare technique 43219 4.39 4.39 with insertion of tube or stent 43220 3.24 3.24 with balloon dilation (less than 30 mm diameter) 43226 3.56 3.56 with guidewire dilation 43227 5.32 5.32 with control of bleeding, any method 43228 5.65 5.65 with ablation not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique (APC, laser) 43231 4.73 4.73 with endoscopic ultrasound examination (EUS) 43232 6.63 6.63 with transendoscopic ultrasound-guided fine needle aspiration/biopsy(s) FNA 43234 3.05 7.52 Upper gastrointestinal endoscopy, simple primary examination (eg, with small diameter flexible endoscope)(separate procedure) EGD: THE SCOPE GOES BEYOND THE PYLORUS/ GASTRIC OUTLET 43235 3.60 7.76 EGD; diagnostic 43236 4.34 9.55 with directed submucosal injection(s), any substance 43237 6.00 6.00 with endoscopic ultrasound examination limited to the esophagus 43238 7.42 7.42 with transendoscopic ultrasound-guided fine needle aspiration/biopsy(s), esophagus (includes endoscopic ultrasound examination limited to the esophagus) 43239 4.28 8.82 with biopsy(s) 43240 10.02 10.02 with transmural drainage of pseudocyst 43241 3.90 3.90 with transendoscopic intraluminal tube or catheter placement 43242 10.57 10.57 with transendoscopic ultrasound-guided fine needle aspiration/biopsy(s) 43243 6.69 6.69 with injection sclerosis of esophageal and/or gastric varices 43244 7.38 7.38 with band ligation of esophageal and/or gastric varices 43245 4.74 4.74 with dilation of gastric outlet for obstruction, any method 43246 6.35 6.35 with directed placement of percutaneous gastrostomy tube (PEG) 43247 5.02 5.02 with removal of foreign body 43248 4.69 4.69 with guidewire dilation of esophagus 43249 4.33 4.33 with balloon dilation of esophagus (less than 30 mm diameter) 43250 4.77 4.77 with hot biopsy forceps or bipolar cautery 43251 5.46 5.46 with snare technique 43255 7.05 7.05 with control of bleeding, any method (epinephrine, endoclip, APC, cautery, etc) 43256 6.37 6.37 with transendoscopic stent placement (includes predilation) 43257 8.07 8.07 with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of GERD (Stretta) 43258 6.66 6.66 with ablation not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique (APC, laser, etc) 43259 7.54 7.54 with endoscopic ultrasound examination (EUS) ERCP 43260 8.67 8.67 diagnostic, with or without collection of specimen(s) by brushing or washing 43261 9.12 9.12 with biopsy(s) 43262 10.71 10.71 with sphincterotomy/papillotomy 43263 10.59 10.59 with pressure measurement of sphincter of Oddi (pancreatic duct or common bile duct) 43264 12.86 12.86 with removal of stone(s) from biliary and/or pancreatic ducts 43265 14.43 14.43 with destruction, lithotripsy of stone(s), any method 43267 10.71 10.71 with insertion of nasobiliary or nasopancreatic drainage tube 10

CPT Facility Office DESCRIPTION RVUs RVUs 43268 10.81 10.81 with insertion of tube or stent into bile or pancreatic duct 43269 11.88 11.88 with removal of foreign body and/or change of tube or stent 43271 10.71 10.71 with balloon dilation of ampulla, biliary and/or pancreatic duct(s) 43272 10.71 10.71 with ablation not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique 74328 0.96 Endoscopic catheterization of the biliary ductal system, radiological supervision and interpretation 74329 NONE Endoscopic catheterization of the pancreatic ductal system, radiological supervision and interpretation 74330 1.23 Combined endoscopic catheterization of the biliary and pancreatic ductal systems, radiological supervision and interpretation DILATIONS 43450 2.18 4.13 Dilate esophagus, by unguided sound or bougie, single or multiple passes (Maloney) 43453 2.35 7.70 Dilate esophagus, over guidewire 43456 3.87 16.55 Dilate esophagus, by balloon or dilator, retrograde (eg, thru gastrostomy site) 43458 4.58 9.97 Dilate esophagus with balloon (30 mm diameter or larger) for achalasia 43460 5.59 5.59 Esophagogastric tamponade, with balloon (Sengstaaken type) G-TUBES NO CODES EXIST FOR REMOVAL OF G-TUBES. AN VISIT SHOULD BE BILLED SINCE THERE WILL BE AN EVALUATION & MANAGEMENT COMPONENT PRIOR TO REMOVAL 43750 7.11 7.11 Percutaneous placement of gastrostomy tube (ONLY TO BE UTILIZED IF ONE PHYSICIAN PERFORMED THE PROCEDURE WITHOUT ENDOSCOPIC TECHNIQUE) 43752 1.09 1.11 Naso- or oro-gastric tube placement, , requires fluro 43760 1.64 3.28 Change gastrostomy tube 43761 2.80 3.31 Reposition gastric feeding tube, any method, through the duodenum for enteric nutrition 44500 0.68 0.68 Introduction of long GI tube ENTEROSCOPY NOT INCLUDING ILEUM 44360 3.88 3.88 Enteroscopy (Push) beyond second portion of duodenum, not including ileum; diagnostic 44361 4.28 4.28 Enteroscopy (Push) beyond second portion of duodenum, not including ileum; with biopsy(s) 44363 5.14 5.14 Enteroscopy (Push) beyond second portion of duodenum, not including ileum; with removal of foreign body 44364 5.49 5.49 Enteroscopy (Push) beyond second portion of duodenum, not including ileum; with snare technique 44365 4.91 4.91 Enteroscopy (Push) beyond second portion of duodenum, not including ileum; with hot biopsy forceps or bipolar cautery 44366 6.46 6.46 Enteroscopy (Push) beyond second portion of duodenum, not including ileum; with control of bleeding, any method (epinephrine, endoclip, cautery, APC, etc) 44369 6.58 6.58 Enteroscopy (Push) beyond second portion of duodenum, not including ileum; with ablation not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique 44370 7.14 7.14 Enteroscopy (Push) beyond second portion of duodenum, not including ileum; with transendoscopic stent placement (includes predilation) 44372 6.49 6.49 Enteroscopy (Push) beyond second portion of duodenum, not including ileum; with placement of percutaneous jejunostomy tube (PEJ tube) 44373 5.18 5.18 Enteroscopy (Push) beyond second portion of duodenum, not including ileum; with conversion of percutaneous gastrostomy tube (PEG) to percutaneous jejunostomy tube (PEJ)

ENTEROSCOPY INCLUDING ILEUM 44376 7.70 7.70 Enteroscopy (Push) beyond second portion of duodenum, including ileum; 11

CPT Facility Office DESCRIPTION RVUs RVUs 44377 8.06 8.06 Enteroscopy (Push) beyond second portion of duodenum, including ileum; with bx 44378 10.34 10.34 Enteroscopy (Push) beyond second portion of duodenum, including ileum; with control of bleeding, any method 44379 11.00 11.00 Enteroscopy (Push) beyond second portion of duodenum, including ileum; with transendoscopic stent placement (includes predilation) PROCTOSCOPY 45300 0.70 1.95 Diagnostic 45303 0.82 19.17 With dilation, any method 45305 1.62 3.75 With biopsy(s) 45307 1.53 4.08 With removal of foreign body 45308 1.36 2.91 With removal by hot biopsy forceps or bipolar cautery 45309 3.07 5.04 With removal by snare technique 45315 2.18 4.41 With removal of multiple tumors, polyps, or other lesions by hot biopsy forceps, bipolar cautery or snare technique 45317 2.31 4.08 With control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) 45320 2.45 4.65 With ablation not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique (eg, laser) 45321 1.86 1.86 With decompression of volvulus 45327 2.50 2.50 With transendoscopic stent placement (includes predilation) FFS 45330 1.54 3.31 FFS; diagnostic 45331 1.83 4.31 FFS; with biopsy(s) 45332 2.75 6.95 FFS; with removal of foreign body 45333 2.74 6.81 FFS; with removal by hot biopsy forceps or cautery 45334 4.08 4.08 FFS; with control of bleeding, any method 45335 2.26 4.78 FFS; with directed submucosal injection(s), any substance 45337 3.57 3.57 FFS; with decompression of volvulus, any method 45338 3.53 7.74 FFS; with removal by snare technique 45339 4.68 6.86 FFS; with ablation not amenable to removal by hot biopsy forceps, cautery or snare 45340 2.87 8.21 FFS; with balloon dilation, 1 or more strictures 45341 3.87 3.87 FFS; with endoscopic ultrasound examination (EUS) 45342 5.89 3.87 FFS; with ultrasound guided intramural or transmural fine needle biopsy (FNA) 45345 4.31 4.31 FFS; with stent placement (includes predilation) ILEOSCOPY 44380 1.68 1.68 diagnostic 44382 2.02 2.02 with biopsy(s) 44383 4.42 4.42 with stent placement (includes predilation) POUCHES 44385 2.72 5.33 Pouchoscopy (abdominal or pelvic); diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) 44386 3.20 8.98 Pouchoscopy (abdominal or pelvic); with biopsy, single or multiple COLONOSCOPY THROUGH STOMA 44388 4.23 8.17 Colonoscopy through stoma; diagnostic 44389 4.67 10.04 Colonoscopy through stoma; with biopsy(s) 44390 5.63 11.27 Colonoscopy through stoma; with removal of foreign body 44391 6.34 13.40 Colonoscopy through stoma; with control of bleeding, any method 44392 5.64 10.75 Colonoscopy through stoma; with removal by hot biopsy forceps or bipolar cautery 44393 7.12 12.17 Colonoscopy through stoma; with ablation not amenable to removal by hot biopsy forceps, bipolar cautery or snare 44394 6.52 12.63 Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by snare 44397 6.89 6.89 Colonoscopy through stoma; with transendoscopic stent placement (includes predilation)

COLONOSCOPY 45378 5.46 10.13 Colonoscopy with or without colon decompression

CPT Facility Office DESCRIPTION RVUs RVUs 45378-53 1.54 3.31 Discontinued colonoscopy 45379 6.88 12.73 Colonoscopy with removal of foreign body 45380 6.51 11.97 Colonoscopy with biopsy(s) 45381 6.16 11.62 Colonoscopy with directed submucosal injection(s), any substance 45382 8.29 16.05 Colonoscopy with control of bleeding, any method 45383 8.56 14.26 Colonoscopy with ablation not amenable to removal by hot biopsy forceps, bipolar cautery or snare 45384 6.89 11.87 Colonoscopy with removal by hot biopsy forceps or bipolar cautery 45385 7.75 13.52 Colonoscopy with removal by snare technique 45386 6.74 17.36 Colonoscopy with balloon dilation, 1 or more strictures 45387 8.71 8.71 Colonoscopy with stent placement (includes predilation) 45391 7.48 7.48 Colonoscopy with ultrasound examination 45392 9.44 9.44 Colonoscopy with ultrasound guided intramural or transmural fine needle aspiration/biopsy(s )FNA DILATION 45900 4.41 4.41 Reduction of procidentia (separate procedure) under anesthesia (10 DAY GLOBAL) 45905 4.00 4.00 Dilate anal sphincter under anesthesia (10 DAY GLOBAL) 45910 4.75 4.75 Dilate rectal stricture under anesthesia (10 DAY GLOBAL) 45915 5.53 7.76 Remove fecal impaction or foreign body under anesthesia (10 DAY GLOBAL) 45990 2.76 2.76 Digital Rectal exam UNDER ANESTHESIA 46505 4.97 6.05 Chemodenervation of anal sphincter (BOTOX) (10 DAY GLOBAL) HEMORRHOIDS 46221 4.00 4.90 Hemorrhoidectomy (eg, rubber band) (10 DAY GLOBAL SURGICAL PACKAGE) 46500 2.92 3.88 Inject hemorrhoid with sclerosing solution (10 DAY GLOBAL SURGICAL PACKAGE) 46934 6.76 8.88 IRC destruction of internal hemorrhoids (90 DAY GLOBAL SURGICAL PACKAGE) ANOSCOPY 46600 0.89 2.11 diagnostic 46604 2.05 10.58 with dilation, any method 46606 1.33 4.69 with biopsy(s) 46608 2.32 6.08 with removal of foreign body 46610 2.08 5.51 with removal by hot biopsy forceps or bipolar cautery 46611 2.78 5.34 with removal by snare 46612 3.60 7.82 with removal of multiple tumors, polyps, or other lesions by hot biopsy forceps, bipolar cautery or snare 46614 3.05 4.54 with control of bleeding, any method 46615 4.08 5.50 with ablation not amenable to removal by hot biopsy forceps, bipolar cautery or snare ANORECTAL BIOPSY 45100 6.48 6.48 Suction biopsy of anorectal wall, (eg, congenital megacolon) (90 DAY SURGICAL PACKAGE) LIVER BIOPSY 47000 2.65 5.10 Biopsy of liver, needle 76942-26 0.92 0.92 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation 76003-26 0.74 0.74 Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) PARACENTESIS 49080 1.89 5.42 Initial 49081 1.78 3.94 Subsequent 49420 3.52 3.52 Insertion of intraperitoneal cannula or catheter for drainage or dialysis; temporary GUIDANCE PROCEDURES

CPT Facility Office DESCRIPTION RVUs RVUs 74350-26 1.04 1.04 Percutaneous placement of gastrostomy tube, radiological supervision and interpretation 74360-26 0.75 0.75 Intraluminal dilation of strictures and/or obstructions (eg, esophagus), radiological supervision and interpretation OTHER PROCEDURES 64530 2.33 6.14 Injection, anesthetic agent; celiac plexus, with or without radiologic monitoring 64680 4.23 9.53 Destruction by neurolytic agent, with or without radiologic monitoring; celiac plexus 96570 1.58 1.58 Photodynamic therapy by endoscopic application of light to ablate abnormal tissue via activation of photosensitive drug(s); first 30 minutes (List separately in addition to code for endoscopy or bronchoscopy procedures of lung and esophagus) 83013 Helicobacter pylori; breath test analysis for urease activity, non-radioactive isotope (eg, C-13) 83014 Helicobacter pylori; drug administration 84620 Xylose absorption test, blood and/or urine 89100 0.84 2.47 Duodenal intubation and aspiration; single specimen (eg, simple bile study or afferent loop culture) plus appropriate test procedure 89105 0.69 2.75 Duodenal intubation and aspiration; collection of multiple fractional specimens with pancreatic or gallbladder stimulation, single or double lumen tube 90901 0.57 1.08 Biofeedback training by any modality 90911 1.26 2.51 Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry CPT Facility Office ESOPHAGEAL STUDIES RVUs RVUs (modifier 26= non-ownership and is added to all facility studies) THE PASSAGE/INSERTION OF THE ESOPHAGEAL PROBE IS INCLUDED AND NOT SEPARATELY BILLABLE 91010 5.78 5.78 Esophageal motility (manometric study of the esophagus and/or gastroesophageal 91010-26 1.75 1.75 junction) study; 91010-TC 4.03 4.03 91011 6.86 6.86 Esophageal motility (manometric study of the esophagus and/or gastroesophageal 91011-26 2.10 2.10 junction) study; with mecholyl or similar stimulant 91011-TC 4.76 4.76 91012 7.35 7.35 Esophageal motility (manometric study of the esophagus and/or gastroesophageal 91012-26 2.04 2.04 junction) study; with acid perfusion studies 91012-TC 5.31 5.31 91020 6.09 6.09 Gastric motility (manometric) studies 91020-26 2.00 2.00 91020-TC 4.09 4.09 91022 5.98 5.98 Duodenal motility (manometric) studies 91022-26 2.02 2.02 91022-TC 3.96 3.96 91030 3.40 3.40 Esophagus, acid perfusion (Bernstein) test for esophagitis 91030-26 1.27 1.27 91030-TC 2.13 2.13 91034 6.33 6.33 Esophagus, GE reflux test; with nasal catheter pH electrode(s) placement, recording, 91034-26 1.37 1.37 analysis and interpretation 91034-TC 4.96 4.96 91035 12.51 12.51 Esophagus, GE reflux test; with mucosal attached telemetry pH electrode placement, 91035-26 2.21 2.21 recording, analysis and interpretation (Bravo) 91035-TC 10.30 10.30 91037 4.02 4.02 Esophageal function test, GE reflux test with nasal catheter intraluminal impedance 91037-26 1.37 1.37 electrode(s) placement, recording, analysis and interpretation 91037-TC 2.65 2.65 (Sandhill) 91038 3.44 3.44 Esophageal function test, GE reflux test with nasal catheter intraluminal impedance 91038-26 1.55 1.55 electrode(s) placement, recording, analysis and interpretation; prolonged (greater 91038-TC 1.89 1.89 than 1 hour, up to 24 hours) (Sandhill) 91040 12.22 12.22 Esophageal balloon distension provocation stud 91040-26 1.37 1.37 (For atypical chest pain) 91040-TC 10.85 10.85 14

CPT Facility Office DESCRIPTION RVUs RVUs 91052-26 1.11 Gastric analysis test with injection of stimulant of gastric secretion (eg, histamine, insulin, pentagastrin, calcium and secretin) 91055-26 1.26 Gastric intubation, washings, and preparing slides for cytology (separate procedure) 91060-26 0.62 Gastric saline load test 91065 1.69 1.69 Breath hydrogen test (eg, for detection of lactase deficiency), fructose intolerance, 91065-26 0.28 0.28 bacterial overgrowth, or oro-cecal gastrointestinal transit) 91065-TC 1.41 1.41 91100 1.43 3.94 Intestinal bleeding tube, passage, positioning and monitoring 91105 0.49 2.50 Gastric intubation, and aspiration or lavage for treatment (eg, for ingested poisons) 91110 25.98 25.98 Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), esophagus 91110-26 5.01 5.01 through ileum, with physician interpretation and report 91110-TC 20.97 20.97 91120 12.06 12.06 Rectal sensation, tone, and compliance test (ie, response to graded balloon 91120-26 1.38 1.38 distention) 91120-TC 10.68 10.68 91122 7.07 7.07 Anorectal manometry 91122-26 2.49 2.49 91122-TC 4.58 4.58

CPT Facility Office INJECTIONS/INFUSIONS RVUS RVUs 90760 1.67 Hydration 1st hour (greater than 15 minute administration) 90761 0.53 Hydration, each additional hour up to 8 90765 2.04 IV for therapeutic or prophylaxis, 1st hour 90766 0.68 Each additional 1 hour up to 8 90767 1.12 Each sequential infusion 90768 0.65 Each concurrent infusion (piggyback) 90772 0.49 IM or subcutaneous injection 90774 1.52 IV push initial (less than 15 minute administration) 90775 0.71 Each additional IV push 96413 4.55 Chemotherapy 1st hour (Monoclonal antibody-Infliximab) is classified as a chemotherapeutic agent 96415 1.03 Chemotherapy each additional hour up to 8 hours 90772 0.49 IM injection 90774 1.51 IV push medication J1745 Remicade per 10 mg J1720 Solu-Cortef up to 100 mg J1710 Solu-Cortef up to 50 mg J0704 Celestone Soluspan per 4 mg J1200 Benadryl up to 50 mg J2920 SoluMedrol up to 40 mg J2930 SoluMedrol up to 125 mg J3420 B-12 up to 1000 mcg

VISITS NEW PATIENT 99201 0.63 0.97 New patient level 1 99202 1.24 1.72 New patient level 2 99203 1.91 2.56 New patient level 3 15

CPT Facility Office DESCRIPTION RVUs RVUs 99204 2.83 3.62 New patient level 4 99205 3.76 4.58 New patient level 5

ESTABLISHED PATIENT 99211 0.24 0.57 Nurse visit 99212 0.64 1.02 Established patient level 2 99213 0.94 1.39 Established patient level 3 99214 1.56 2.18 Established patient level 4 99215 2.50 3.17 Established patient level 5

OBSERVATION DISCHARGE 99217 1.87 Observation discharge

OBSERVATION ADMISSION 99218 1.78 Observation admit level 1 99219 2.96 Observation admit level 2 99220 4.16 Observation admit level 3

INPATIENT ADMISSION 99221 1.80 Inpatient admit level 1 99222 2.98 Inpatient admit level 2 99223 4.15 Inpatient admit level 3

SUBSEQUENT HOSPITAL VISITS 99231 0.90 Inpatient visit level 1 99232 1.47 Inpatient visit level 2 99233 2.09 Inpatient visit level 3

INPATIENT DISCHARGE 99238 1.87 Hospital discharge less than 30 minutes 99239 2.55 Hospital discharge more than 30 minutes

CPT Facility Office ADMIT & DISCHARGE SAME CALENDAR DATE RVUs RVUs At Least 8 hour stay and face to face admission and rounding discharge 99234 3.58 Level 1 99235 4.72 Level 2 99236 5.89 Level 3

OUTPATIENT CONSULT 99241 0.91 1.33 Level 1 99242 1.85 2.43 Level 2 99243 2.48 3.24 Level 3 99244 3.66 4.56 Level 4 99245 4.87 5.90 Level 5

INPATIENT CONSULT 99251 0.95 Level 1 99252 1.91 Level 2 99253 2.61 Level 3 99254 3.75 Level 4 99255 5.17 Level 5

CRITICAL CARE 99291 5.48 6.77 Critical care first 31 minutes 99292 2.74 3.00 Critical care each additional 30 minutes

CPT Facility Office DESCRIPTION RVUs RVUs ER 99281 0.44 Level 1 99282 0.73 Level 2 99283 1.64 Level 3 99284 2.56 Level 4 99285 4.01 Level 5

Date______Pediatric GI Name______

Procedure Dx 1)______2)______3)______4)______

Requesting MD______OP______IP______F/U______Signature______Esoph EGD Colon ERCP Entero Entero Ileum Colon Flex Procto Other Guidance Ileum Via via Stoma Stoma Diagnostic 43200 43235 45378 43260 44360 44376 44380 44388 45330 45300 Liver biopsy Dilation Bx 43202 43239 45380 43261 44361 44377 44382 44389 45331 45305 47000 74360-26 Remove FB 43215 43247 45379 43269 43263 44390 45332 45307 US for bx Stricture Hot Bx 43216 43250 45384 44365 44392 45333 45308 76942-26 74360-26 Snare 43217 43251 45385 44364 44394 45338 45309 Fluoro for bx ERCP Ablation 43228 43258 45383 43272 44369 44393 45339 45320 71003-26 Bile duct Control Bleeding 43227 43255 45382 44369 44378 44391 45334 45317 Motility 74328-26 Dilation/guidewire 43226 43248 45303 91010-26 Panc Duct Dilation/balloon 43220 43249 45386 43271 45340 45303 Wireless 74329-26 Dilation–pylorus 43245 Capsule Both STRETTA 43257 Endoscopy 74330-26 Inject/tattoo 43201 43236 45381 45335 91110-26 Δ G Tube Insert tube only 43241 43267 24° pH/imped 43760 Insert tube/stent 43219 43256 45387 43268 44370 44379 44383 44397 45345 45327 91038-26 PEG PEG/PEJ tube 43246 44372 pH/imped <1° 74350-26 Convert G to J 44373 91037-26 Place Tube Variceal Sclerosis 43204 43243 Bravo 74350-26 Abnd ligation 43205 43244 91035-26 Sphincterotomy 43262 Nasal pH Pouchoscopy SOM 43263 91034-26 44385 Remove stones 43264 Paracentesis Anoscopy Lithotripsy 43265 49080 46600 Volvulus 45337 45321 F/U paracentes Dilate/Achalasia EUS esophagus 43237 49081 43458 + endo EUS 43231 43259 45391 45341 FNA or bx 43232 43242 45392 45342 Dilate/Maloney FNA/ esophagus 43238 43450 + endo Pseudocyst drain 43240 Signs & Symptoms 578.1 Hematemesis 562.11 Diverticulitis Hernia 787.6 Incontinence feces 562.13 Diverticulitis w hem 553.3 Hiatal hernia 285.1 Anemia 782.4 Jaundice 562.10 Diverticulosis Malnutrition Acute blood loss 789.04 LLQ pain 565.10 Fistula, anal 263.0 Moderate 285.9 Anemia 789.02 LUQ pain 537.4 Fistula, duodenal 261 Severe protein calorie 787.01 Nausea, vomiting 578.9 Hemorrhage GI tract Neoplasms 280.0 Anemia 789.05 Periumbilic pain 455.2 Hemorrhoids int bldg Wait for path Chronic blood loss 789.03 RLQ pain 751.3 Hirschsprung’s Tubes 280.9 Anemia, iron 789.01 RUQ pain 564.1 IBS V55.1 Change g-tube Deficiency unspec 787.03 Vomiting 751.2 Imperforate anus V55.4 Change j-tube Esophagus 751.4 Malrotation 536.42 Comp. Mech. Tube 793.3 Abn biliary Study 530.0 Achalasia 578.1 Melena 536.41 Comp. Infection,Tube 794.9 Abn HIDA scan 530.6 Diverticulum 564.81 Neurogenic bowel 536.49 Comp. Pain, tube 793.4 Abn GI study 530.85 Barrett’s 569.42 Pain, anal/rectal 790.4 Abn liver enzymes 530.12 Esophagitis, acute 569.0 Rectal polyp OTHER CODES 794.8 Abn liver scan 530.11 Esophagitis reflux 569.2 Stenosis rectum/anus (WRITE IN) 792.1 Abn Hemacult 530.19 Esophagitis, other 569.41 Ulcer, anus &/or rectum 783.21 Abn weight loss 530.81 GERD 789.5 Ascites 530.3 Stricture 532.00 Ulcer, duodenum, acute 787.3 Bloating, gas pain 530.20 Ulcer w/o bldg w/hem 787.99 Change in bowel 530.21 Ulcer w/ bleeding 532.31 Ulcer, duodenum, acute habits Stomach 564.00 Constipation 535.10 Gastritis, chronic 532.40 Ulcer, duodenum, chronic 564.5 Diarrhea, chronic 535.00 Gastritis, acute w/hem 564.4 Diarrhea GI surgery 537.0 Pyloric stenosis 532.70 Ulcer, duodenum, chronic 750.5 Pyloric stenosis NB 787.2 Dysphagia 531.30 Ulcer, gastric, acute 569.82 Ulcer, colon 789.06 Epigastric Pain Intestines 556.0 Ulcerative colitis 783.41 Failure to thrive 751.1 Atresia, sm intestine Liver/Biliary 783.3 Feeding difficulties 751.2 Atresia, lg intestine 574.51 Choledocholithiasis 779.3 Feeding difficulties 751.5 Cloaca 576.2 Obstruction, CBD 19

newborn 558.9 Colitis, other 576.5 Spasm, sphinc Oddi 789.07 Generalized 564.09 Constipation Pancreas abdominal pain 555.1 Crohn’s lg intestine 577.2 Cyst, pseudocyst 787.1 Heartburn 555.0 Crohn’s sm intestine 577.0 Pancreatitis, acute 789.1 Hepatomegaly 555.9 Crohn’s disease 577.1 Pancreatitis, chronic

Inpatient Billing Month/Year

Diagnosis 1.______2.______3.______4.______5. ______6. ______

Please insert reason(diagnosis) for each visit into the date column using the numeric indicators (1, 2, 3, 4, etc.) 1 2 3 4 5 6 7 8 9 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 2 2 2 2 3 3 6 7 8 9 0 1 Consult IP 99251 99252 99253 99254 99255 OP/ER 99241 99242 99243 99244 99245

Admit IP Observ 99221 99218 99222 99219 99223 99220

Follow up Hospital Visit 99231 99232 99233

Prolonged (>30 IP OP min) 99356 99354 Must be Added to Visit code

TOPS Same Day Discharge Admit&D/C 99238 99217 99234 Discharge > 30 min 99239 99235 99236 Critical Care (1st 30-74 min) 99291 Critical care each additional 30 99292 min

Medicare Claims Processing Manual Chapter 12 - Physicians/Nonphysician Practitioners

30.6.10 – Consultation Services (Codes 99241 - 99255)

(Rev.788, Issued: 12-20-05, Effective: 01-01-06, Implementation: 01-17-06)

A. Consultation Services versus Other Evaluation and Management (E/M) Visits

Carriers pay for a reasonable and medically necessary consultation service when all of the following criteria for the use of a consultation code are met:

• Specifically, a consultation service is distinguished from other evaluation and management (E/M) visits because it is provided by a physician or qualified nonphysician practitioner (NPP) whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. The qualified NPP may perform consultation services within the scope of practice and licensure requirements for NPPs in the State in which he/she practices. Applicable collaboration and general supervision rules apply as well as billing rules;

• A request for a consultation from an appropriate source and the need for consultation (i.e., the reason for a consultation service) shall be documented by the consultant in the patient’s medical record and included in the requesting physician or qualified NPP’s plan of care in the patient’s medical record; and

• After the consultation is provided, the consultant shall prepare a written report of his/her findings and recommendations, which shall be provided to the referring physician.

The intent of a consultation service is that a physician or qualified NPP or other appropriate source is asking another physician or qualified NPP for advice, opinion, a recommendation, suggestion, direction, or counsel, etc. in evaluating or treating a patient because that individual has expertise in a specific medical area beyond the requesting professional’s knowledge. Consultations may be billed based on time if the counseling/coordination of care constitutes more than 50 percent of the face-to-face encounter between the physician or qualified NPP and the patient. The preceding requirements (request, evaluation (or counseling/coordination) and written report) shall also be met when the consultation is based on time for counseling/coordination. A consultation shall not be performed as a split/shared E/M visit.

B. Consultation Followed by Treatment

A physician or qualified NPP consultant may initiate diagnostic services and treatment at the initial consultation service or subsequent visit. Ongoing management, following the initial consultation service by the consultant physician, shall not be reported with consultation service codes. These services shall be reported as subsequent visits for the appropriate place of service and level of service. Payment for a consultation service shall be made regardless of treatment initiation unless a transfer of care occurs.

Transfer of Care

A transfer of care occurs when a physician or qualified NPP requests that another physician or qualified NPP take over the responsibility for managing the patients’ complete care for the condition and does not expect to continue treating or caring for the patient for that condition.

When this transfer is arranged, the requesting physician or qualified NPP is not asking for an opinion or advice to personally treat this patient and is not expecting to continue treating the patient for the condition. The receiving physician or qualified NPP shall document this transfer of the patient’s care, to his/her service, in the patient’s medical record or plan of care.

In a transfer of care the receiving physician or qualified NPP would report the appropriate new or established patient visit code according to the place of service and level of service performed and shall not report a consultation service.

C. Initial and Follow-Up Consultation Services

Initial Consultation Service

In the hospital setting, the consulting physician or qualified NPP shall use the appropriate Initial Inpatient Consultation codes (99251 – 99255) for the initial consultation service.

In the nursing facility setting, the consulting physician or qualified NPP shall use the appropriate Initial Inpatient Consultation codes (99251 – 99255) for the initial consultation service.

The Initial Inpatient Consultation may be reported only once per consultant per patient per facility admission.

In the office or other outpatient setting, the consulting physician or qualified NPP shall use the appropriate Office or Other Outpatient Consultation (new or established patient) codes (99241 – 99245) for the initial consultation service.

If an additional request for an opinion or advice, regarding the same or a new problem with the same patient, is received from the same or another physician or qualified NPP and documented in the medical record, the Office or Other Outpatient Consultation (new or established patient) codes (99241 – 99245) may be used again. However, if the consultant continues to care for the patient for the original condition following his/her initial consultation, repeat consultation services shall not be reported by this physician or qualified NPP during his/her ongoing management of this condition.

Follow-Up Consultation Service

Effective January 1, 2006, the follow-up inpatient consultation codes (99261 – 99263) are deleted.

In the hospital setting, following the initial consultation service, the Subsequent Hospital Care codes (99231 – 99233) shall be reported for additional follow-up visits.

In the nursing facility setting, following the initial consultation service, the Subsequent Nursing Facility (NF) Care codes (new CPT codes 99307 – 99310) shall be reported for additional follow-up visits. Effective January 1, 2006, CPT codes 99311 – 99313 are deleted and not valid for Subsequent NF visits.

In the office or other outpatient setting, following the initial consultation service, the Office or Other Outpatient Established Patient codes (99212 – 99215) shall be reported for additional follow-up visits. 22

The CPT code 99211 shall not be reported as a consultation service. The CPT code 99211 is not included by Medicare for a consultation service since this service typically does not require the presence of a physician or qualified NPP and would not meet the consultation service criteria.

D. Second Opinion E/M Service Requests

Effective January 1, 2006, the Confirmatory Consultation codes (99271 – 99275) are deleted.

A second opinion E/M service is a request by the patient and/or family or mandated (e.g., by a third-party payer) and is not requested by a physician or qualified NPP. A consultation service requested by a physician, qualified NPP or other appropriate source that meets the requirements stated in Section A shall be reported using the initial consultation service codes as discussed in Section C. A written report is not required by Medicare to be sent to a physician when an evaluation for a second opinion has been requested by the patient and/or family.

A second opinion, for Medicare purposes, is generally performed as a request for a second or third opinion of a previously recommended medical treatment or surgical procedure. A second opinion E/M service initiated by a patient and/or family is not reported using the consultation codes.

In both the inpatient hospital setting and the NF setting, a request for a second opinion would be made through the attending physician or physician of record. If an initial consultation is requested of another physician or qualified NPP by the attending physician and meets the requirements for a consultation service (as identified in Section A) then the appropriate Initial Inpatient Consultation code shall be reported by the consultant. If the service does not meet the consultation requirements, then the E/M service shall be reported using the Subsequent Hospital Care codes (99231 – 99233) in the inpatient hospital setting and the Subsequent NF Care codes (99307 – 99310) in the NF setting.

A second opinion E/M service performed in the office or other outpatient setting shall be reported using the Office or Other Outpatient new patient codes (99201 – 99205) for a new patient and established patient codes (99212 – 99215) for an established patient, as appropriate. The 3 year rule regarding “new patient” status applies. Any medically necessary follow-up visits shall be reported using the appropriate subsequent visit/established patient E/M visit codes.

The CPT modifier -32 (Mandated Services) is not recognized as a payment modifier in Medicare. A second opinion evaluation service to satisfy a requirement for a third party payer is not a covered service in Medicare.

E. Consultations Requested by Members of Same Group

Carriers pay for a consultation if one physician or qualified NPP in a group practice requests a consultation from another physician in the same group practice when the consulting physician or qualified NPP has expertise in a specific medical area beyond the requesting professional’s knowledge. A consultation service shall not be reported on every patient as a routine practice between physicians and qualified NPPs within a group practice setting.

F. Documentation for Consultation Services

Consultation Request

A written request for a consultation from an appropriate source and the need for a consultation must be documented in the patient’s medical record. The initial request may be a verbal interaction between the requesting physician and the consulting physician; however, the verbal conversation shall be documented in the patient’s medical record, indicating a request for a consultation service was made by the requesting physician or qualified NPP.

The reason for the consultation service shall be documented by the consultant (physician or qualified NPP) in the patient’s medical record and included in the requesting physician or qualified NPP’s plan of care. The consultation service request may be written on a physician order form by the requestor in a shared medical record.

Consultation Report

A written report shall be furnished to the requesting physician or qualified NPP.

In an emergency department or an inpatient or outpatient setting in which the medical record is shared between the referring physician or qualified NPP and the consultant, the request may be documented as part of a plan written in the requesting physician or qualified NPP’s progress note, an order in the medical record, or a specific written request for the consultation. In these settings, the report may consist of an appropriate entry in the common medical record.

In an office setting, the documentation requirement may be met by a specific written request for the consultation from the requesting physician or qualified NPP or if the consultant’s records show a specific reference to the request. In this setting, the consultation report is a separate document communicated to the requesting physician or qualified NPP.

In a large group practice, e.g., an academic department or a large multi-specialty group, in which there is often a shared medical record, it is acceptable to include the consultant’s report in the medical record documentation and not require a separate letter from the consulting physician or qualified NPP to the requesting physician or qualified NPP. The written request and the consultation evaluation, findings and recommendations shall be available in the consultation report.

G. Consultation for Preoperative Clearance

Preoperative consultations are payable for new or established patients performed by any physician or qualified NPP at the request of a surgeon, as long as all of the requirements for performing and reporting the consultation codes are met and the service is medically necessary and not routine screening.

H. Postoperative Care by Physician Who Did Preoperative Clearance Consultation

If subsequent to the completion of a preoperative consultation in the office or hospital, the consultant assumes responsibility for the management of a portion or all of the patient’s condition(s) during the postoperative period, the consultation codes should not be used postoperatively. In the hospital setting, the physician or qualified NPP who has performed a preoperative consultation and assumes responsibility for the management of a portion or all of the patient’s condition(s) during the postoperative period should use the appropriate subsequent hospital care codes to bill for the concurrent care he or she is providing. In the office setting, the appropriate established patient visit codes should be used during the

24 postoperative period.

A physician (primary care or specialist) or qualified NPP who performs a postoperative evaluation of a new or established patient at the request of the surgeon may bill the appropriate consultation code for evaluation and management services furnished during the postoperative period following surgery when all of the criteria for the use of the consultation codes are met and that same physician has not already performed a preoperative consultation.

I. Surgeon’s Request That Another Physician Participate In Postoperative Care

If the surgeon asks a physician or qualified NPP who had been treating the patient preoperatively or who had not seen the patient for a preoperative consultation to take responsibility for the management of an aspect of the patient’s condition during the postoperative period, the physician or qualified NPP may not bill a consultation because the surgeon is not asking the physician or qualified NPP’s opinion or advice for the surgeon’s use in treating the patient. The physician or qualified NPP’s services would constitute concurrent care and should be billed using the appropriate subsequent hospital care codes in the hospital inpatient setting, subsequent NF care codes in the SNF/NF setting or the appropriate office or other outpatient visit codes in the office or outpatient settings.

J. Examples That Meet the Criteria for Consultation Services

For brevity, the consultation request and the consultation written report is not repeated in each of these examples. Criteria for consultation services shall always include a request and a written report in the medical record as described above.

EXAMPLE 1:

An internist sees a patient that he has followed for 20 years for mild hypertension and diabetes mellitus. He identifies a questionable skin lesion and asks a dermatologist to evaluate the lesion. The dermatologist examines the patient and decides the lesion is probably malignant and needs to be removed. He removes the lesion which is determined to be an early melanoma. The dermatologist dictates and forwards a report to the internist regarding his evaluation and treatment of the patient. Modifier -25 shall be used with the consultation service code in addition to the procedure code. Modifier -25 is required to identify the consultation service as a significant, separately identifiable E/M service in addition to the procedure code reported for the incision/removal of lesion. The internist resumes care of the patient and continues surveillance of the skin on the advice of the dermatologist.

EXAMPLE 2:

A rural family practice physician examines a patient who has been under his care for 20 years and diagnoses a new onset of atrial fibrillation. The family practitioner sends the patient to a cardiologist at an urban cardiology center for advice on his care and management. The cardiologist examines the patient, suggests a cardiac catheterization and other diagnostic tests which he schedules and then sends a written report to the requesting physician. The cardiologist subsequently periodically sees the patient once a year as follow-up. Subsequent visits provided by the cardiologist should be billed as an established patient visit in the office or other outpatient setting, as appropriate. Following the advice and intervention by the cardiologist the family practice physician resumes the general medical care of the patient.

EXAMPLE 3:

A family practice physician examines a female patient who has been under his care for some time and diagnoses a breast mass. The family practitioner sends the patient to a general surgeon for advice and management of the mass and related patient care. The general surgeon examines the patient and recommends a breast biopsy, which he schedules, and then sends a written report to the requesting physician. The general surgeon subsequently performs a biopsy and then periodically sees the patient once a year as follow-up. Subsequent visits provided by the surgeon should be billed as an established patient visit in the office or other outpatient setting, as appropriate. Following the advice and intervention by the surgeon the family practice physician resumes the general medical care of the patient.

I. Examples That Do Not Meet the Criteria for Consultation Services

EXAMPLE 1: Standing orders in the medical record for consultations.

EXAMPLE 2: No order for a consultation.

EXAMPLE 3: No written report of a consultation.

EXAMPLE 4: The emergency room physician treats the patient for a sprained ankle. The patient is discharged and instructed to visit the orthopedic clinic for follow-up. The physician in the orthopedic clinic shall not report a consultation service because advice or opinion is not required by the emergency room physician. The orthopedic physician shall report the appropriate office or other outpatient visit code.

DEFINITION OF A GLOBAL SURGICAL PACKAGE (CMS)

Components of a Global Surgical Package for Surgeries

The Medicare (HCFA) approved amount for surgery includes the following services when furnished by the physician who performed the surgery:

Pre-operative visits- These visits begin the day before the day of the surgery with surgeries that have a 90 day global compared to the day of surgery with surgeries that have a 0 or 10 day global.

Intraoperative services- Services that are normally a usual and necessary part of a surgical procedure.

Complications following surgery- All additional medical or surgical services required of the surgeon within the global period of the surgery because of complications which do not require additional trips to the operating room.

Post-operative visits- Follow-up visits within the global days after the surgery that are related to recovery from surgery

Post-surgical pain management by the surgeon.

Supplies

Miscellaneous services- Items such as dressings, local incisional care, removal of operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts and splints; insertion, irrigation and removal of urinary catheters; routine intravenous lines, nasogastric and rectal tubes; changes and removal of tracheostomy tubes.

SERVICES NOT INCLUDED IN THE GLOBAL BILL (CMS)

THE INITIAL EVALUATION OF THE PROBLEM BY THE SURGEON WHERE YOU DISCUSS WITH THE PATIENT THE NEED FOR SURGERY.

History and physical exam done more than a day before surgery.

Re-operations for complications.

Treatment that isn’t part of normal recovery from surgery.

Immunosuppressive drug therapy for organ transplant.

Dialysis, inpatient/outpatient.

Critical care services unrelated to the surgery.

Treatment for post-op complications requiring a return trip to the OR.

Diagnostic tests and procedures including diagnostic x-rays.

Clearly distinct surgical procedures during the post-operative period which aren’t reoperations or treatment for complications.

Visits unrelated to the diagnosis for which the surgical procedure is performed.

HOSPITAL DAY GUIDELINES

INITIAL HOSPITAL CARE (ADMISSION) 99221 99222 99223 Typically, the problems requiring Typically, the problems requiring Typically, the problems requiring admission are low severity. admission are moderate severity. admission are high severity. The evaluation and management The evaluation and management The evaluation and management requires: requires: requires: detailed or comprehensive history comprehensive history comprehensive history; detailed or comprehensive exam; comprehensive exam; and comprehensive exam; and and medical decision making of medical decision making of high medical decision making that is moderate complexity complexity straightforward or low complexity

INITIAL OBSERVATION CARE 99218 99219 99220

Typically, the problems requiring Typically, the problems requiring Typically, the problems requiring observation are low severity. observation are moderate severity. observation are high severity. The evaluation and management The evaluation and management The evaluation and management requires: requires: requires: detailed or comprehensive history comprehensive history comprehensive history detailed or comprehensive exam; comprehensive exam; and comprehensive exam; and and medical decision making of medical decision making of high medical decision making that is moderate complexity complexity straightforward or low complexity

SUBSEQUENT HOSPITAL CARE (VISITS)

99231 99232 99233

Patient is stable, improving, Patient has developed a new Patient has developed a major no new problems, complications, problem or complication. New complication or significant new medications, or therapies. Nearing medicine, therapy or treatment problem. Patient is unstable or discharge date. is ordered. Patient has abnormal worsening. Patient condition 15 minutes lab values, x-ray or shows negative requires close monitoring and response to therapy or meds. significant effort and skill by the 25 minutes physician. 35 minutes

ADMISSION AND DISCHARGE SERVICES ON THE SAME CALENDAR DATE

For 2001, these services can only be billed if a patient stays longer than 8 hours before discharge on the same calendar date. If the patient stays less than 8 hours, only an admission may be billed.

99234 99235 99236

Typically, the presenting problems Typically, the presenting problems Typically, the presenting problems are of low severity. are of moderate severity. are of high severity. The evaluation and management The evaluation and management The evaluation and management all three components: requires all three components; requires all three components: detailed or comprehensive history; comprehensive history; comprehensive history; detailed or comprehensive exam; comprehensive exam; and comprehensive exam; and and medical decision making of medical decision making of medical decision making of moderate complexity high complexity straightforward or of low complexity

DISCHARGE SERVICES

OBSERVATION CARE

99217

Observation care discharge of a patient from observation status includes final examination of the patient, discussion of the hospital stay, instructions for continuing care, and preparation of discharge records.

HOSPITAL DISCHARGE SERVICES

Hospital discharge of patient from inpatient status includes final examination of the patient, discussion of the hospital stay, even if the time spent by the physician on that date is not continuous, instructions for continuing care to all relevant care givers, and preparation of discharge records, prescriptions, and referral forms.

99238 99239

30 minutes or less more than 30 minutes

Time to complete discharge must be documented in the patient record in order to bill 99239!!!!!!!

31 32 One of three components for Medical Decision Making. The highest level from any one column determines the overall risk. Level of Risk Presenting Problem(s) Diagnostic Procedures Ordered Management Options Selected Minimal One self limited or minor Laboratory tests Rest 99201-99202 problem, eg, Cold, insect bit, requiring venipuncture Gargles 99241-99242 tinea corporis Chest x-rays Elastic bandages 99251-99252 EKG/EEG Superficial dressings 99281-99282 U/A 99212 Ultrasound, eg, echocardiography KOH prep Low Two or more self-limited Physiologic tests not Over the counter drugs 99203, 99213, or minor problems under stress, eg, pulmonary Minor surgery with no 99243, 99253, One, stable chronic illness, function tests identified risk factors 99283, 99213, eg, well controlled Non-cardiovascular Physical therapy 99221, 99218, hypertension, non-insulin imaging studies with contrast, Occupational therapy 99231 dependent diabetes, cataract, eg, barium enema IV fluids without BPH Superficial needle additives biopsies Clinical laboratory tests requiring arterial puncture Skin biopsies Moderate One or more chronic Physiologic tests under Minor surgery with 99204, 99214, illnesses with mild stress, eg, cardiac stress test, identified risk factors 99244, 99254, exacerbation, progression, or fetal contraction stress test Elective major surgery 99284, 99222, side effects of treatment Diagnostic endoscopies (open, percutaneous or 99219, 99232 Two or more stable with no identified risk factors endoscopic) with no chronic illnesses Deep needle or identified risk factors Undiagnosed new problem incisional biopsy Prescription drug with uncertain prognosis, eg, Cardiovascular imaging management lump in breast studies with contrast and no Therapeutic nuclear Acute illness with systemic identified risk factors, eg, medicine symptoms, eg, pyelonephritis, arteriogram, cardiac cath IV fluids with additives pneumonitis, colitis Obtain fluid from body Closed treatment of Acute complicated injury, cavity, eg, lumbar puncture, fracture or dislocation eg, head injury with brief loss of thoracentesis, Paracentesis without manipulation consciousness High One or more chronic Cardiovascular imaging Elective major surgery 99205, 99215, illnesses with severe studies with contrast with (open, percutaneous or 99245, 99255, exacerbation, progression or identified risk factors endoscopic) with 99285, 99223, side effects of treatment Cardiac identified risk factors 99220, 99233 Acute or chronic illnesses electrophysiological tests Emergency major or injuries that pose a threat to Diagnostic endoscopies surgery (open, life or bodily function, eg, with identified risk factors percutaneous or pulmonary embolus, severe Discography endoscopic) respiratory distress, progressive Parenteral Controlled severe rheumatoid arthritis, Substances psychiatric illness with potential Drug therapy threat to self or others, requiring monitoring peritonitis, acute renal failure for toxicity An abrupt change in Decision not to neurologic status, eg, seizure, resuscitate or de- TIA, weakness, sensory loss escalate care because of poor prognosis

33 34 Selecting an Evaluation and Management Code the Easy Way The following matrices summarize the three components at a glance. Select the principal component from each matrices, follow the decision steps and then match your answers to The E/M Matrices for office visits, hospital visits, consultations, and confirmatory consultations for quick and easy code selections. TWO OF THE THREE COLUMNS IN THE TABLE MATCH FOR THE TYPE OF DECISION MAKING. Key Component Matrices

Diagnosis/Management Tests ordered, reviewed, Morbidity or Mortality Type of Medical Decision Making Options or to be ordered SEE TABLE OF RISK when 2 of 3 columns match

Self Limited/Minor Minimal or None Minimal Straightforward Minor problem 1 TEST SEE TABLE OF RISK

Low Limited or None Low Low Complexity 1 chronic problem 2 TESTS SEE TABLE OF RISK controlled

Moderate Moderate Moderate Moderate Complexity 2 controlled chronic 3 TESTS SEE TABLE OF RISK problems 1 uncontrolled chronic problem 1 new problem, requires workup

High Extensive High High Complexity 2 uncontrolled chronic 4 OR MORE TESTS SEE TABLE OF RISK illnesses acute/life threatening illness Documentation Requirements Complexity Level New patient, Consult or Admission Established Patient (Column 4 in table) History, exam, & MDM History, exam & MDM (ALL MUST MATCH) (2 OF 3 MUST MATCH) Straightforward 99201, 99241, 99251, Problem focused history: HPI 1-3 99211-Usually used for nurse visit 99271, 99281 ROS NONE, PFSH NONE Problem focused exam: 1-5 BULLETS (1997) OR 1 ORGAN SYSTEM (1995)

99202, 99242, 99252, Expanded problem focused history 99212-Problem focused history 99272, 99282 HPI 1-3, ROS 1 SYSTEM, PFSH NONE HPI 1-3, ROS NONE, PFSH NONE OR Expanded problem focused exam Problem focused exam AT LEAST 6 BULLETS OR 2-4 ORGAN 1-5 BULLETS OR 1 ORGAN SYSTEM SYSTEMS (1995)

Low Complexity 99203, 99243, 99253, Detailed history: HPI 4 OR MORE 99213-Expanded problem focused history 99273, 99283, 99221, ROS 2-9 SYSTEMS, PFSH 1 HPI 1-3, ROS 1 SYSTEM, PFSH NONE OR 99218 Detailed exam Expanded problem focused exam AT LEAST 12 BULLETS OR 5-7 ORGAN AT LEAST 6 BULLETS OR 2-4 ORGAN SYSTEMS SYSTEMS Moderate Complexity 99204, 99244, 99254, Comprehensive history 99214-Detailed history 99274, 99284, 99222 HPI 4 OR MORE, ROS 10 OR MORE HPI 4 OR MORE, ROS 2-9 SYSTEMS 99219 PFSH 2-3 PFSH 1 OR Comprehensive exam Detailed exam 2 BULLETS FROM 9 ORGAN SYSTEMS AT LEAST 12 BULLETS OR 5-7 ORGAN OR 8-13 ORGAN SYSTEMS SYSTEMS High Complexity 99205, 99245, 99255, Comprehensive history 99215-Comprehensive history OR 99275, 99285, 99223, Comprehensive exam Comprehensive exam 99220 SAME AS ABOVE SAME AS ABOVE FOR NEW PATIENT

35 36 Patient History Form Last Name First Name MI Date of Birth

Mother/Guardian Occupation: How many brother and sisters? Father/Guardian Occupation Who does the patient live with? Primary Care Physician/Pediatrician: Other doctors involved with your care:

REVIEW OF SYSTEMS Has the patient ever been diagnosed with any of the following? If yes, please check any that apply and explain in the space provided. Is your family physician aware of any symptoms/illnesses that you have checked below? ο Yes ο No SYSTEM NO YES SYSTEM NO YES SYSTEM NO YES SYSTEM NO YES Birth History Cardiac Neurologic Ear, Nose, & Throat Normal High blood pressure Seizures Loose Teeth Premature Low blood pressure Weakness Nosebleeds Cesarean Irregular heartbeat Migraines Deafness Prematurity Chest pain Previous stroke Psychosocial Apnea/Bradycardia Respiratory Musculoskeletal Alcoholism Intubation Asthma Muscle Disease Substance Abuse BPD Pneumonia Arthritis Depression ECMO Bronchitis Neck pain Anxiety disorders Gastrointestinal Chronic Cough Back pain Breast Diarrhea Hoarseness Blood Disorders Lumps Constipation Tracheostomy Skin Cancer Rectal Bleeding Genitourinary Rash Please list below: Heartburn Kidney Disease Bruises Any symptoms/diseases Trouble swallowing Frequent urine infection Ophthalmic not listed above? Nausea Endocrine/Metaboli Cataracts c Vomiting Diabetes Glaucoma Abdominal Pain Thyroid Disorders Blindness PAST HISTORY Please explain any YES answers in detailed description in the box provided. Have you ever had any surgery or been ο No Surgeries Dates Hospitalizations other than Dates Hospitalized? surgery ο Yes Have you had any problems with anesthesia? No ____ Yes _____ If yes, please list below:

Are you currently or have you ever used any ο No Alcohol: How many drinks ο per day _____ ο per week _____ ο per month ______Tobacco or alcohol products? ο Yes

Tobacco: How many packs per day ο ______For how many years? ______Are you or have you ever used recreational /illicit ο No If yes, what kind? drugs? ο Yes For how long? Are you currently taking any medications or drugs ο No Medication Dose Times Medication Dose Times (including over-the-counter, prescription, birth ο Yes control pills)?

Do you have any allergies (including ο No environmental, medication, food, and reaction to ο Yes previous blood transfusion)? FAMILY HISTORY: Please indicate if your parents, brothers, sisters and/or children have had any of the following conditions: Condition Relation to patient Condition Relation to patient Condition Relation to patient Colon/ Rectal Cancer Kidney problems Heart Disease No ___ Yes __ No ___ Yes_____ No ____ Yes ____ Stomach Cancer Ulcerative Colitis Crohn’s Disease No ___ Yes ___ No ___ Yes ___ No ___ Yes ___ Breast Cancer Ovarian Cancer Bleeding Problems No ___ Yes ___ No ___ Yes ___ No ___ Yes ___

______Person Completing This Form/Relationship to Patient Reviewed by Provider Date(s)

37 38 Date: ______TO BE COMPLETED BY PHYSICIAN Patient: ______

Patient Evaluated at the Request of : ______Chief Complaint: ______History of Present Illness: (Location, Quality, Timing, Severity, Duration, Context, Modifying Factors, Assoc. signs/symptoms) (1-3 brief, 4+ extended) OR Status of Chronic or Inactive Conditions (3 or more = extended w/o HPI)______

PHYSICAL EXAMINATION Constitutional Weight: BP: P: T: Height: Appearance: ο Well nourished ο Ill Appearing οCachectic ο Obese Psychiatric Normal Abnormal Skin Normal Abnormal Affect Color Orientation Texture Mood Surface Eyes Ear, Nose, Mouth, Throat Lips Sclera Pupils/Iris Teeth/Gums Conjunctiva Oropharynx Neck Thyroid Respiratory Auscultation Neck Effort Cardiovascular Heart sounds Abdomen Liver Spleen Rhythm Anus Rectal Peripheral Hemacult Pulses Tenderness Rate Masses

Genitourinary Male: Musculoskeletal Gait Prostate External Strength/Tone Genitalia Female: Neurologic Cranial nerves External Sensation Genitalia Lymphatic Cervical Other Findings Axillary Groin Other

Impression/: 1. ______2. ______3. ______Diagnosis 4. ______5. ______6. ______Tests/Labs Reviewed: X-ray ______CT scan ______UGI ______U/S ______CBC ______Chemistry ______U/A ______Other ______(If normal, list date performed. If abnormal, list results. )Tests/Labs Ordered: X-ray ______CT scan ______UGI ______BE ______MRI ______Serology ______U/S ______CBC ______Chemistry ______U/A ______pH studies ______Manometry _____ Hepatitis workup ______Other ______(Please place the numeric indicator of the impression/diagnosis in the blank next to the test ordered.) Plan: Diagnostic/Surgical Procedure(s) Recommended: ______

Surgical Procedure Scheduled? Yes ______Date ______Time ______Not Scheduled? ______Reason ______Other Recommendations:______

New Prescription for: ______

Refill Prescription for: ______The nature, alternatives, indications, risks, prep and anesthesia plan for the above procedure(s) were discussed with the patient and/or guardian and all questions were

39 answered. The patient and/or guardian verbalized an understanding and consented to undergo the above procedure(s). Yes ______No ______MD

40 41 ESTABLISHED PATIENT VISIT FORM

DATE: ______PATIENT: ______DOB: ______ACCT: ______Chief Complaint: ______History of Present Illness: (Location, Quality, Timing, Severity, Duration, Context, Modifying Factors, Assoc. signs/symptoms) (1-3 brief, 4+ extended) OR Status of Chronic or Inactive Conditions (3 or more = extended w/o HPI)______

Medication Dose Frequency Medication Dose Frequency

ROS UNCHANGED since History recorded on ______EXCEPT FOR ______PFSH UNCHANGED since History recorded on ______EXCEPT FOR ______

PHYSICAL EXAMINATION Constitutional Weight: BP: P: T: Height: Appearance: ο Well nourished ο Ill Appearing οCachectic ο Obese Psychiatric Normal Abnormal Ear, Nose, Mouth, Throat Lips Affect Orientation Teeth/Gums Mood Oropharynx Eyes Sclera Respiratory Auscultation Conjunctiva Effort Cardiovascular Heart Abdomen Liver sounds Spleen Rhythm Anus Rectal Peripheral Hemacult Pulses Tenderness Rate Masses

Additional Findings

Impression/: 1. ______2. ______3. ______Diagnosis 4. ______5. ______6. ______Tests/Labs Reviewed: X-ray ______CT scan ______UGI ______U/S ______CBC ______Chemistry ______U/A ______Other ______(If normal, list date performed. If abnormal, list results.) Tests/Labs Ordered: X-ray ______CT scan ______UGI ______BE ______MRI ______U/S ______CBC ______Chemistry ______U/A ______Other ______(Please place the numeric indicator of the impression/diagnosis in the blank next to the test ordered.) Diagnostic/Surgical Procedure(s) Recommended: ______Surgical Procedure Scheduled? Yes ______Date ______Time ______Not Scheduled? ______Reason ______Other Recommendations:______

New Prescription for: ______

Refill Prescription for: ______The nature, alternatives, indications, risks, prep and anesthesia plan for the above procedure(s) were discussed with the patient and/or guardian and all questions were answered. The patient and/or guardian verbalized an understanding and consented to undergo the above procedure(s). Yes ______No ______ASA Class ______

Face-to-face time with patient ______. Time spent in counseling and/or coordination of care ______.

Discussion: ______

______MD 42