1. Evaluation & Management Coding A Refresher November, 2014 Seniors Wellness Group of Michigan, P.C.

2. Documenting the medical record should complement and augment the patient care process; the clinician’s record should facilitate the provision of optimal care to one’s patients. Keep in mind that Medicare does not know your patients. The only information it has in making its determinations during an audit is the documentation submitted by the provider and each patient record “stands alone” in this process. You are not expected to write a book but rather, it is simply expected for the information to show the medical necessity of the service and that the documentation supports the level of service billed. The Medical Record Is (or you want it to become) Your Friend, Not Your Enemy!

3. Nature of the Presenting Problem A presenting problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for encounter, with or without a diagnosis being established at the time of the encounter Indicates the level of care and coding warranted by the P’s illness

4. 5 Types or Levels of Severity of the NPP Minimal: a problem that may not require the presence of the physician, but service is provided under the physician’s supervision. (v codes) Self-limited or minor: a problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status OR has a good prognosis with management/compliance. (e.g., adjustment disorder, acute) Low severity: a problem where the risk of morbidity without treatment is low; there is little to no risk of mortality without treatment; full recovery without functional impairment is expected (e.g., adjustment disorder, chronic; one stable chronic illness) Moderate severity: a problem where the risk of morbidity without treatment is moderate; there is moderate risk of mortality without treatment; uncertain prognosis OR increased probability of prolonged functional impairment. (e.g., dementia, mild – moderate or non-aggressive agitation; MD, SE, moderate; GAD; two or more stable chronic illnesses; mild-moderate exacerbation of chronic illness) High severity: a problem where the risk of morbidity without treatment is high to extreme; there is a moderate to high risk of mortality without treatment OR high probability of severe, prolonged functional impairment. (e.g., psychosis, mania, delirium, MD, recurrent, severe; Bi-Polar; aggressive and self-injurious behavior or threat of)

5. NPP Presenting problems of higher severity warrant higher levels of E & M Care This concept correlates with CMS’ mandate for “Medical Necessity” as a requirement for reimbursement of services Medical Necessity: services that are reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. Services that are determined to be necessary must be reasonable in frequency (times p/day or week) and duration (over a span of time: hours, days or weeks) and are not mainly for the convenience of the patient or provider of service

6. Determination of the Extent Of History (includes HPI, ROS & PFSH) – depends on clinical judgment and NPP Problem Focused – Chief Complaint, brief HPI or problem Expanded Problem Focused – Chief Complaint, brief HPI, problem pertinent system review Detailed – Chief Complaint, extended HPI, problem pertinent system review extended to include a review of a limited number of additional systems; pertinent past, family, and/or social Hx directly related to P’s problems Comprehensive - Chief Complaint, extended HPI, review of systems that is directly related to the problem (s) identified in the HPI plus a review of all additional body systems; complete past, family, and/or social Hx

7. Determination of the Extent Of Examination (MSE) – depends on clinical judgment and NPP Problem Focused – a limited examination of the affected organ system Expanded Problem Focused – a limited examination of the affected organ system and other symptomatic or related organ systems Detailed – an extended examination of the affected organ system and other symptomatic or related organ systems Comprehensive – A general multisystem examination or a complete examination of a single organ system

8. Determination of the Complexity of Medical Decision Making – refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by: The number of possible diagnoses or the number of management options The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed The risk of significant complications, morbidity, and/or mortality, as well as comorbidities, associated with the P’s presenting problem(s), the diagnostic procedure(s), and/or possible management options 4 Types of MDM – Straightforward, Low Complexity, Moderate Complexity, High Complexity To qualify for a given type of decision making, 2 of 3 above-noted elements must be met or exceeded

9. CPT Codes – Nursing Home, New Patient 99306 - Comprehensive Hx & Exam, MDM of High complexity; problem(s) are usually of high severity; typical time = 45 mins. HPI = 4 elements/status of 3 chronic conditions; PFSH = Complete/all 3; ROS = Complete/9 or more; MSE = Comprehensive/All, including 3 Vitals 99305 - Comprehensive Hx & Exam, MDM of Moderate complexity; problem(s) are usually of moderate severity; typical time = 35 mins. HPI = 4 elements/status of 3 chronic conditions; PFSH = Complete/all 3; ROS = Complete/9 or more; MSE = Comprehensive/All, including 3 Vitals 99304 – Detailed Hx & Exam, MDM of Low complexity; problem(s) are usually of low severity; typical time = 25 mins. HPI = 4 elements/status of 3 chronic conditions; PFSH = Pertinent/Med & Psych Only; ROS = Detailed/2 - 9; MSE = Detailed/9 or more

10. CPT Codes – Nursing Home, Established Patient 99310 - Comprehensive Interval Hx & Exam, MDM of High complexity; patient is usually unstable or has developed a significant new problem ; typical time = 35 mins. HPI = 4 elements/status of 3 chronic conditions; PFSH = Complete/2 of 3 areas; ROS = Complete/9 or more; MSE = Comprehensive/All, including 3 Vitals 99309 – Detailed Interval Hx & Exam, MDM of Moderate complexity; patient has usually developed a significant complication or a significant new problem ; typical time = 25 mins. HPI = 4 elements/status of 3 chronic conditions; PFSH = Complete/2 of 3 areas; ROS = Extended/2 - 9; MSE = Detailed/9 or more 99308 – Expanded Problem-focused Interval Hx & Exam, MDM of Low complexity; patient usually is responding inadequately or has developed a minor complication; typical time = 15 mins. HPI = 1 -3 elements/status of 1 or 2 chronic conditions; PFSH = Pertinent/Med & Psych Only; ROS = 1 (Pertinent to Problem); MSE = Detailed/6 – 8 elements 99307 – Problem-focused Interval Hx & Exam, Straightforward MDM; patient is usually stable, recovering or improving; typical time = 10 mins. HPI = current status of condition; PFSH = None; ROS = None; MSE = Problem-focused/1 – 5 elements

11. General Considerations for Determining Proper Level of Services “Complexity of Medical Decision Making” represents the complexity of establishing a diagnosis and/or selecting management options; it reflects the amount of cognitive work done by the clinician The evaluation is easier for a P with an established Dx than one in which the condition is undiagnosed If the current clinical status of the P includes no acute or severe symptoms (in terms of risks of mortality and/or increased morbidity or prolonged impairment in functionality), there may be no basis for coding at the highest level of service (e.g., 99306, 99310, 99328, 99337) Multiple problems requiring more complex evaluation and care usually warrant a Level 4 (out of 5) or Level 3 (out of 4) service, unless all problems are of Low or High severity; highest level services typically fit “worst-case” scenarios, i.e., P’s who experience potentially life-threatening consequences or the threat of significant prolonged functional impairment as a result of serious illness Levels 3 & 4 services are likely to encompass the majority; requiring some degree of diagnostic evaluation and active medication management to cure or stabilize an illness Improving, resolving, controlled or stable conditions are less complex than worsening or inadequately controlled ones or ones failing to change as expected (document current status of condition along these lines for P’s with established Dx’s); likely to be Level 2 (for F/U) services On the basis of quality of care, an Expanded Problem-focused exam is likely to be necessary during initial in-patient visits or th elevell of care should appropriately exceed Level 1 for every encounter Include references in DX Impressions as applicable – “possibly”, “probable”, “rule-out”, which indicates the need for further work-up and higher level of service Treatment Options include instructions to P’s, family, nursing care staff, therapies, medications, referral for therapies, requests for consultation Comorbidities/Underlying diseases or other factors that increase the complexity of MDM by increasing the risk of complications, morbidity and/or mortality always should be documented Assessment of Risk relates to the disease process between the present and the next encounter Always initially look at the 2 elements of MDM that are intrinsic to every visit, i.e., 1) Levels of Risk, and 2) Number of Dx OR Treatment Options

12. Number of Dx or Treatment Options If a single PP is improving, resolving, or stable during F/U, Complexity is likely to be LOW or Straightforward and the service coded accordingly (99307/99308, 99334/99335), unless there are 3 or more separate conditions that require evaluation (e.g., Alzheimer’s, MD, GAD), which would correspond with Moderate Complexity If a PP is worsening during F/U, it can be weighted “2” and corresponds with Low Complexity. However, each additional worsening PP is added to this value at “2” and therefore 2 or more worsening problems are likely to establish High Complexity Based on the criteria of medical necessity, to be considered as one of the Number of Diagnoses, an illness must be actively related to the problems of the day’s visit. Any inactive or unrelated problems, would not be included. Even though DSM-V has discontinued use of the 5-Axes system, clinicians should continue to list and/or discuss medical conditions that are important to the understanding or management of an individual’s mental disorder Alternative treatment options can be included that might be considered if the primary treatment proves unsuccessful “Doing Nothing” is a treatment option, e.g., “Continue current psychotropic drug regimen; benefits outweigh the risks.”

13. Risk of complications and/or Morbidity or Mortality Highest level of risk in any one category (i.e., PP, Dx Procedures Ordered, Treatment Options) determines overall risk Ensure that the documented level of risk for at least 1of the 3 categories equals or exceeds the level warranted by severity of the NPP Active medication management (i.e., making decisions about the use of medications and documenting this) represents Moderate Risk 1 stable chronic illness (e.g., even schizophrenia) corresponds with Low Risk, 2 or more Stable chronic illnesses or 1 or more with mild exacerbation corresponds with Moderate risk

14. Amount and/or Complexity of Data Reviewed A review of reports and/or tests from clinicians from the same group is not counted separately, but is part of the routine history gathering Review and/or ordering of clinical lab tests = 1 point Review and/or ordering of “medicine” tests (e.g., EKG, Allergy Testing, Endocrinology Testing, Neuropsychological Testing) = 1 point Decision to obtain old records and/or obtain Hx from someone other than P = 1 point Obtaining HX from someone other than P = 1 point Review and summarization of old records and/or obtaining Hx from someone other than P and/or discussion of case with another health care provider = 2 points Screening tests such as AIMS, DISCUS, MMSE, GDS, etc. that are self-administered by the clinician = 4 points/Extensive

15. Counseling Diagnostic results, impressions and recommended procedures Prognosis Risks and benefits of treatment options Instructions for treatment and/or follow-up Importance of compliance with chosen treatment options Risk factor reduction Patient and family education

16. Coordination of Care Involves arranging ongoing care for the patient with other providers

17. Time If C & CC dominates (more than 50%) the encounter, time may determine the level of service Documentation must include: Total Time of the Visit, Actual or Estimated Time Spent in C & CC, and a description of its content “Total Time” includes the review of the P’s chart and history, examination of the P, writing notes, and communicating with other professionals and P’s family members Documentation may refer to: prognosis, differential dx, risks, benefits of treatment, instructions, compliance, risk reduction or discussion with another heal care provider CPT “Time Rule” – if the actual/total time of the visit falls between the “typical times” of 2 sequential CPT codes, then the actual/total time can be rounded up or down to the nearest typical time; e.g., a unit of time is attained when the mid-point is passed When coding based on Time the rules for documentation based on Complexity do not apply, so the documentation of your patient exam can be completed in your preferred style

18. Prolonged Services When using the companion codes 99356 and 99357, the entire time of the visit that meets criteria for the use of these codes must be face-to-face with the patient and/or family and other caregivers These codes should be used only under unusual circumstances that have created the need for the ”prolonged” service (e.g., acute/severe crisis creating a potential need for hospitalization of the patient and extensive coordination of care with other health care professionals and interested parties) Alternatively, consider using a companion code of Psychotherapy (90833, 90836, 90838) following completion of the core E/M service if extending the time of your visit by providing supportive counseling to the patient (documented separately from the E/M service). When doing so, you must document both services separately, i.e., E/M service using the standard SWGM Psychiatric Note and Psychotherapy using the SWGM Therapy Note