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Guidelines are tricky and at first hard to understand. I have found that the only way to really try and remember how guidelines are used is to continuously go back and read the actual guidelines (as well as any important notes in the tabular.) The Handbook is a great tool to go back and touch up on things as you have questions arise. I have also gotten online and done some of my own research to try and clarify some rules. I found that making cheat sheets for myself and writing somethings down as I go along and help me, as well as memorize things as time goes on. They are tricky rules to follow and they seem to be ever changing. Best of luck! You will master these in due time :)

Personally, I learn best by hands-on.  Even if I had the ability to memorize all of those guidelines, they wouldn't help if I didn't know how to apply them.  What I do is refer to the guidelines as each problem comes up; that way it has relationship and will mean something later when I come across the same issue. Time consuming because sometimes it takes a while to find the correct guideline.

I also have a problem using some of the CPT modifiers correctly.  It's pretty obvious right hand, left eye, but some of the others seem so vague to me, for instance -25, -26.  There is a description for these modifiers beginning on page 646, somewhat helpful, but . . .  HCPCS has a full list of modifiers, about 20 pages, beginning on page 447.

Donna C

And I still don't have my brain wrapped around those E/M codes.  The codes where everything matches, yippee, and I can handle the codes where it is 2 out of 3, but I get skunked on the ones where the requirement is 3 out of 3 and the document doesn't give details that match.  

Donna, when you have an E/M that does not match, drop down to the code that does meet the requirements.  

You can't use a code higher than the lowest element.  

Thank you!! :)

OK, so let's take this one step further. If you have three of three everything is fine. Your decision is easy. It's supposed to be easy, because everything is where it should be. In other words the medical decision-making was at a certain level of history and physical exam match that level. The doctor documented enough and will be paid for what he did.

 But what if the medical decision-making was low and the documentation for the history and physical was higher? In that case the documentation for the history and physical might be excessive.  The doctor might have wanted to do that much documentation, but insurance company is not going to pay for it. In that case, when you code for the lowest level that meets the requirements, you aren't really losing anything. 

 What happens if the medical decision-making is high and the documentation for the history and physical is too low? In that case you can only code to the lower level. The doctor will lose money for the effort he put out simply because he didn't document enough.  When that happens you need to go to the doctor and explain why he's going to lose money. You explain exactly how much documentation he needs to include to allow you to code to the appropriate level. 

 You don't want your documentation to be "off-balance " either higher or lower. You want it to be right on target. If it's above or it's below, it's a training opportunity for the doctor. 

 Does that make sense? Go back to your E and M section and look at the codes again, and make certain that you can see how this works.  Can you come up with a potential scenario to explain each of these situations? In each situation what would you tell the doctor? 

I, personally, think the hardest part about this is that we are not coding for an actual physician.  Therefore, we can't take the coding question straight to him or her and ask about the documentation or physical exam or decision making.  We can only use the information that we are given.  It is similar when coding diagnoses...currently I work in data entry for Meaningful Use.  After the switch to ICD-10, one of my doctors still used ICD-9 codes.  That should not be a problem because I work on a website that will convert them.  (And I learned a ton and did well in Module I.  Thank you Andrews School!)  However, there are ICD-9 codes that do not convert because of the specificity improvement in ICD-10.  I work from home and do not have access to the physician.  So, there are times that I have to select the least specific code that matches.  If I wasn't in coding school, I would have no clue what to do.  So when I look at questions in Module II, I now remind myself that if this were an actual work situation, and there was ambiguity about the documentation, I would query the physician.  Since I cannot do that, I either ask Peggy for clarification if I'm really stumped or I remember that I can only code with what information I have in front of me.  As for the E/M section, I just started it.  I have decided to take this section very slow and re-read each section.  As I go, I am making a chart that contains ALL of the diagrams from the Keuhn book and puts them into one document that can sit in front of me as I work on the practice problems.  I don't want to have to flip back and forth between the key components when I start the exam.