1. DOCUMENTATION REQUIREMENTS
E/M Codes

2. Codes accounting for the errors What codes should have been used
Targeted Codes
99214 : established patient, outpt. visit – presenting problems are usually moderate to high severity
99212: established patient, outpt. Visit – presenting problems usually self limited or minor
99233: subsequent hospital care – usually patient is unstable, developed a significant complication or a significant new problem
99231: subsequent hospital care – usually a stable, recovering, or improving patient
Codes accounting for the errors What codes should have been used

3. Principles of Documentation:
MR should be complete & legible
Documentation for each patient encounter should include:
Reason for encounter & relevant history
Physical exam & findings
Prior diagnostic test results
Assessment
Clinical impression or diagnosis
Plan for care
Date
Legible identity of the observer

4. Principles of Documentation Cont.
If not documented, the rationale for ordering diagnostic & ancillary services should be easily inferred
Past & present diagnosis should be accessible to the treating/consulting physician
Appropriate risk factors should be identified
Pt’s progress, response to & changes in treatment & diagnosis revision should be documented
CPT & ICD-9 codes on claim must be supported by MR documentation

5. Evaluation and Management Codes -Developed jointly by HCFA & the AMA
How to stay on the good side of HCFA

6. MEDICAL NECESSITY
Inpatient : Does the diagnosis code support the medical need for the service performed?
If not, does the documentation in the record support the necessity?
Outpatient : Level of Visit Codes

7. The 7 Components: KEY 1) History 2) Examination
3) Medical Decision Making
4) Counseling
5) Coordination of Care
6) Nature of Presenting Problem
7) Time
KEY

8. Expanded Problem Focused
E & M Determination
Level
History
Examination
Med. Decision Making I
Prob. Focused
Problem Focused
Straightforward II
Expanded Prob. Focused
Expanded Problem Focused
III
Detailed
Low Complexity IV
Comprehensive
Moderate Complexity V
High Complexity

9. The 7 Components: KEY 1) History 2) Examination
3) Medical Decision Making
4) Counseling
5) Coordination of Care
6) Nature of Presenting Problem
7) Time
KEY

10. Documentation of History:
Level of service is based on 4 types:
1) problem focused
2) expanded problem focused
3) detailed
4) comprehensive
History elements (some or all):
 chief complaint, CC  history of present illness, HPI
 review of systems, ROS  past, family and/or social history, PFSH

11. ROS & PFSH obtained Earlier w/o any change:
Do not have to re-record if there is evidence that a physician had reviewed & updated the previous one
How to documented the review:
Describe any new information,
not that there has been no change, or
note the date & location of the earlier entry
DG 1

12. ROS & PFSH may be recorded by ancillary staff or by the patient - physician must supplement or confirm the information received for documentation
If not able to obtain information - note in chart the patient’s condition & the circumstances that preclude obtaining a history
DG 2 & 3

13. at least 4 or the status of at least 3 chronic or inactive conditions
HPI Elements
1) location
2) quality
3) severity
4) duration
5) timing
6) context
7) modifying factors
8) associated signs & symptoms
Brief:
1-3
Extended:
at least 4 or the status of at least 3 chronic or inactive conditions
DG 4 & 5

14. ROS Elements musculoskeletal constitutional symptoms integumentary
neurological
psychiatric
endocrine
hematologic/lymphatic
allergic/immunologic
constitutional symptoms
eyes
ears, nose, mouth, throat
cardiovascular
respiratory
gastrointestinal
genitourinary

15. ROS Definitions
PROBLEM PERTINENT - inquires about the system directly related to the problem in HPI
EXTENDED - directly related system systems documented
COMPLETE - directly related system + all additional body systems
DG 6, 7 & 8

16. PFSH -
Pertinent - review of history areas directly related to problem in HPI
Complete - review of 2 or all 3, depending on the category on E&M code (required for comprehensive assessments)
DG 9

17. PFSH requirements for:
Initial Patients
requires 1 item from the 3 areas
applies to outpt/office, consults, observation pts, nursing home assessments, domiciliary care, home care
Est. Patients
requires 1 item from the 2 areas
applies to outpt/office, ER services, domiciliary care, home care
DG 10 & 11

18. Level of Service Determination
History
Problem Focused
Expanded
Prob. Focused
Detailed
Comprehensive
HPI
Brief
Extended
ROS
N/A
Problem Pertinent
Complete
PFSH
Pertinent
* Must have all 3 in column or choose lowest

19. The 7 Components: KEY 1) History 2) Examination
3) Medical Decision Making
4) Counseling
5) Coordination of Care
6) Nature of Presenting Problem
7) Time
KEY

20. Documentation of Examination:
Level of service is based on 4 types:
1) problem focused
2) expanded problem focused
3) detailed
4) comprehensive
Exam Types:
 cardiovascular, ENT & mouth, eyes, male & female genitourinary, hematological/lymphatic/immunologic, musculoskeletal, neurological, psychiatric, respiratory, skin

21. Documentation Guidelines:
Elements w/ mult. components require documentation of at least 1 component
“abnormal” can be used for exams of the affected or symptomatic body area
abnormal/unexpected finding in asymptomatic areas should be described
“negative” or “normal” is sufficient for unaffected or asymptomatic areas

22. General Multi-System Exams:
PROBLEM FOCUSED:
1-5 elements in  1 body areas/systems
EXPANDED PROBLEM FOCUSED:  6 elements in  1 body areas/systems
DETAILED:  2 elements in 6 ore more body areas/systems (or  12 elements in  2 areas)
COMPREHENSIVE: allelements in selected areas,  9 body areas/systems

23. Single Organ Exams: PROBLEM FOCUSED: 1-5 elements in any box
EXPANDED PROBLEM FOCUSED:  6 elements in any box
DETAILED:  12 elements in any box (eye & psychiatric  9 elements)
COMPREHENSIVE: allelements ( document every element in bold boxes & at least 1 in normal boxes)

24. The 7 Components: KEY 1) History 2) Examination
3) Medical Decision Making
4) Counseling
5) Coordination of Care
6) Nature of Presenting Problem
7) Time
KEY

25. Documentation of Medical Decision Making:
Level of service is based on 4 types:
1) straight - forward
2) low complexity
3) moderate complexity
4) high complexity
-complexity of establishing a diagnosis and/or selecting a management option

26. Complexity factors…. Pt’s # of diagnoses
the amount and/or complexity of MR, tests, & other information that must be obtained, reviewed, & analyzed
risk of significant complications, morbidity/mortality as well as co-morbidities associated with the presenting problem(s)

27. DG for # of Diagnoses or Mgmt. Options….
Established dx. - state if improved/well controlled/ resolving or worsening/failing to change as expected
new diagnosis - stated in form of differential dx. possible/probable/rule out
initiation or changes in treatment
to whom or where referrals or consults are made or from whom the advice is requested

28. DG for amount & complexity of data to review….
Types of service ordered at the time of encounter
reviewed results, initial & date report w/ the results
any further history or information obtained from MR, patient, etc.
relevant findings from above
results of discussions w/ physicians
associated w/ reviewed results
direct visualization or independent interpretation of tests/films interpreted by another physician

29. Risk DG...
Any factor that would increase the risk of complications, morbidity, mortality
procedures planned at that time
specific procedure performed at time of encounter
need for an urgent procedure to be done

30. Diagnostic Procedure Ordered Management Options Selected
Table of Risk
Level of Risk
Presenting Problem
Diagnostic Procedure Ordered
Management Options Selected
minimal
one self limited or minor problem
Lab tests w/ venipuncture
Chest x-rays
EKG/EEG
Urinalysis
Ultrasound
KOH Prep
rest
Gargles
Elastic bandages
Superficial dressings
low
2 or more self limited problems
1 stable chronic illness
Acute complicated illness
Physiologic tests not under stress
Non-cardiovascular imaging studies w/ contrast
Superficial needle biopsies
Clinical lab test
Skin biopsies
over the counter drugs
Minor surgery w/ no identified risk factors
PT or OT
IV fluids w/o additives

31. Diagnostic Procedure Ordered Management Options Selected
Table of Risk
Level of Risk
Presenting Problem
Diagnostic Procedure Ordered
Management Options Selected
Moderate
one or more chronic illness w/ mild exacerbation
2 or more stable chronic illnesses
undiagnosed new problem w/ uncertain prognosis
Acute illness w/ systemic symptoms
Acute complicated injury
Physiologic test under stress
Diagnostic endoscopies w/ no identified risk factors
Deep needle or incisional biopsy
Cardiovascular imaging studies w/ contrast & no identified risk factors
Obtain fluid from body cavity
minor surgery w/ identified risk factors
Elective major surgery w/ no identified risk factors
Prescription drug management
Therapeutic Nuclear Med.
IV fluids w/ additives
Closed treatment of fracture or dislocation w/o manipulation

32. Diagnostic Procedure Ordered Management Options Selected
Table of Risk
Level of Risk
Presenting Problem
Diagnostic Procedure Ordered
Management Options Selected
High
one or more chronic illness w/ severe exacerbation
acute/chronic illness/injury that pose a threat to life or bodily function
Diagnostic endoscopies w/ identified risk factors
Cardiovascular imaging studies w/ contrast & identified risk factors
Cardiac electrophysiological tests
Discography
Emergency major surgery
Elective major surgery w/ identified risk factors
Parental controlled substances
Drug therapy requiring intensive monitoring for toxicity
Decision not to resuscitate

33. Medical Decision Making Determination
Type of Decision Making
Straight Forward
Low
Moderate
High
# of dx. or mgmt options
Minimal
Limited
Multiple
Extensive
Data Reviewed
Risks
extensive
* 2 of 3 elements must be met or exceeded

34. Initial Patients must have 3 of 3
E & M Determination
Initial Patients must have 3 of 3
Level
History
Examination
Med. Decision Making I
99201
Prob. Focused
Problem Focused
Straightforward II
99202
Expanded Prob. Focused
Expanded Problem Focused
III
99203
Detailed
Low Complexity IV
99204
Comprehensive
Moderate Complexity V
99205
High Complexity

35. Initial Patients must have 3 of 3
E & M Determination
Initial Patients must have 3 of 3
Level
History
Examination
Med. Decision Making I
99201
Prob. Focused
Problem Focused
Straightforward II
99202
Expanded Prob. Focused
Expanded Problem Focused
III
99203
Detailed
Low Complexity IV
99204
Comprehensive
Moderate Complexity V
99205
High Complexity

36. NEW PATIENTS
One who has NOT received any professional services from the physician or any other physician of the same specialty who belongs to the same group practice within the past 3 years.

37. Established Patients must have 2 of 3
E & M Determination
Established Patients must have 2 of 3
Level
History
Examination
Med. Decision Making I
99211
Prob. Focused
Problem Focused
Straightforward II
99212
Expanded Prob. Focused
Expanded Problem Focused
III
99213
Detailed
Low Complexity IV
99214
Comprehensive
Moderate Complexity V
99215
High Complexity

38. ESTABLISHED PATIENTS 99211-99215
One who HAS received professional services from the physician of the same specilaity who belongs to the same group practice within the last 3 years.

39. EST. PT Billing
Can be billed by the nursing staff when a chief complaint exists.
Normally Required Care:
Blood pressure, weight, reactions to current meds, additional services not usually provided by a physician
NOT: finger sticks & injections
*physician must be on the premises

40. Observation Care 99218-99220 Characteristics of Observation Pts:
Report encounters by the supervising MD
Characteristics of Observation Pts:
not been admitted as an inpatient
may be physically detained in ER
clinical condition is being observed
additional time needed to clarify condition
to determine if hospitalization is needed

41. Observation to Inpatient-
MD admits pt to both w/in 24 hours – bill as initial hospital visit
Do NOT bill for an initial hospital visit & initial obs. code
Can NOT bill for an obs. discharge mgmt when admitting to inpt.

42. Global Surgical Period
Fee includes obs payment
Must use modifiers with the CPT code to receive payment
–57 indicates that the decision for surgery was made while the patient was in obs.
-24 denotes observation services are unrelated to the surgery
-79 subsequent surgical procedure
-25 separately identifiable service

43. MODIFIER -25
Indicates that E/M codes reported on the same bill are for significant and separately identifiable services

44. One last thing…
If using a template to dictate your note DON’T FORGET to state that it was “normal” or “negative”