Laureen: This question came in, and I’m going to warn you up front. This is from a student so if this seems like total Greek and you’re like, “I thought I know coding, what is she talking about?” This comes from our teaching technique.
Q: Can you tell me if some of the leveling exercise answers may be incorrect? For the E/M. It says to “drop the lowest” on the 2 of 3 Office established patient so I ended up getting several wrong when I did that.
A: Let me show you this technique that I’ve been teaching since 1999. It’s matured over the years. But what I did for myself because I’m a very visual person and when I see a lot of words, it just feels like Charlie Brown’s teacher – wah, wah, wah – and I have to make things more simple. So, this is a system that I developed for myself when I first went to take the CPC Exam Evaluation. Shared it with my first class, they loved it, and I’ve been using it ever since.
Basically, what I did is I looked at the three key components for evaluation and management. That’s history, exam, and medical decision making. They each have four levels, if you will, and they go off in level of difficulty. The higher they go up, the higher you can expect to get paid for the E/M, the higher your overall E/M level.
CPC Exam Evaluation and Management Exercises Leveling Exercise – Video
For history and exam, they share the same terms – problem focused, expanded problem focused, detailed, and comprehensive. I just converted them to the first letter – P, E, D, C. For medical decision making, it’s straightforward, low, moderate, high (S, L, M, H). The idea is on board exam questions and also in real life if you’re coding off of a chart that you’re looking to convert, you’re trying to find the answer or the level to history, what is the level of exam, what is the level of medical decision making, so you can put it all together.
What I instruct my students to do is to write those letters to the left of the bullets in their E/M section of their manual. So, I did a little screenshot to show you what my manual look. I only took little clips of the codes instead of the whole thing because all we’re really interested in for this method are the bullets, so this is for your bulleted-type E/M codes. If it’s a time-paced code, like, critical care; then this doesn’t apply.
Leveling, if you look at 99201’s definition, you’ll see at the end it says, “…which requires these 3 key components,” that’s why I wrote 3 of 3 in the margin for this. For the established patient, if you look at 99212, it’s saying “which requires at least 2 of these 3 key components” so that’s called 2 of 3.
So, you’re going to get letters all over the place. They’re not always going to be a PPS or an EES or a DDL, you might get problem focused history (P), and then in the second bullet an expanded problem focused exam, and then maybe low medical decision making. So now you’ve got each of those scores, if you will, let’s call it a score, on different levels of E/M; so the problem focused history shows up on a level 1 or 99201. For shorthand, you’ll hear people in the industry say a level 3, a level 4; they’re just referring to the last number of the code instead of saying 99201, 99202.
In my example of PEL, the P is showing up at a level 1, the E is showing up at a level 2, and the L is showing up at a level 3. So, what do we code it as? We call that leveling. So, a PEL, when it’s 3 of 3, the little rhyme up here, when it’s 3 of 3 you code to the lowest, because it requires all 3 components to be met. So, even though we had one of them on level 3, we don’t have all 3 of them on level 3, so we can’t code it a level 3.
Now we try to make it fit a level 2. We’ve got the second bullet met. We’ve got the third bullet exceed it; so we’re looking pretty good. But the first bullet is too low, this is a 3 of 3 situation, so we can’t code it a level 2, so we’re going to go all the way down to a level 1. And that’s why this little saying works: when it’s 3 of 3, code to the lowest. That problem focused history pulled it all the way down to a level 1, that’s why physician education comes into play a lot with this because normally history is where physicians are weak in their documentation and they are asking the patient, they are getting that information, they’re just not documenting it well. Therefore, we as coders can’t code it; if it’s not documented, it’s not done. That’s what this whole leveling thing is about.
I did one column. These are the all new patient codes, so your level 1, 2, 3, 4 and 5. What you’ll notice with the bulleted E/M codes, the first bullet is always history. The second bullet is always exam. The third bullet is always medical decision making. So, there’s at least consistency there and they always go in order.
So just looking at the first bullet, you can see we’ve got the problem focused, the expanded problem focused, the detailed, and then comprehensive shows up on a level 4 and a level 5. The exam does the same thing for this particular sub-category of E/M, office, new. Then, medical decision making, straightforward and straightforward; shows up in level 1 and 2. Then we’ve got low on level 3, moderate on level 4, and high on level 5.
Now, if you go to another section of E/M, say, home health or home services, there are lots of different sub-categories of E/M, it’s going to change. That’s why you always have to get into the right location first. So, my technique, I have my students write in the margin of their exam booklet or on the document if they’re doing it for real-world coding – locate your HEM and Time.
So, next to the word “locate” you draw a line and you’re writing the category of E/M it is; in this case it’s a new office patient and the column on the right it’s established office patient. Then, the HEM, we’re just putting a line to fill in what is the level of history, what is the level of exam, what is the level of medical decision making? In my case, I just put the letters, I don’t write it all out.
Then, the last thing – Time. I put with the question mark: Is time a factor? If so, then you code according to the time instead of the 3 key components of history, exam, and medical decision making.
So, now that you have an overview of the system, the student was asking about PPL. She was struggling with the 2 of 3 concept; so she was understanding 3 of 3, code to the lowest, and actually that does make it easier for coding purposes, but harder for the physician to get a higher level.
For the PPL, using this system, she found the “P” on a level 2 or 99212, the second “P” on a level 2, and the “L” on a level 3. And the answer key said it was level 2. She thinks it’s incorrect but actually it is correct, and I’ll show you why.
A PPL, both the Ps show up on level 2 for the established, and the “L” shows up on level 3. The saying for 2 of 3 is: “When it’s 2 of 3, drop the lowest and code to the next lowest.” We’re able to drop one of the Ps, but not the second one. So, that’s why the overall E/M level is a 99212 for a PPL. We can drop one of the three bullets, but not two of the three bullets.
So, that’s the system. It works really good; it really helps you to understand any other E/M tool out there. They’ve got this special slide rules and grids and things like that. Once you can figure it out from the manual, which is pretty much all you can bring into the board exam, it’s going to help you to understand all those other tools. Hopefully, that will help you with understanding 3 of 3 and 2 of 3, and how to do the leveling.
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