Presentation is loading. Please wait.

Presentation is loading. Please wait.

Evaluation & Management Coding and Documentation 101 – the basics Stephanie Ann Call, MD MSPH VCU Internal Medicine Training Program The Practice of Medicine.

Similar presentations


Presentation on theme: "Evaluation & Management Coding and Documentation 101 – the basics Stephanie Ann Call, MD MSPH VCU Internal Medicine Training Program The Practice of Medicine."— Presentation transcript:

1 Evaluation & Management Coding and Documentation 101 – the basics Stephanie Ann Call, MD MSPH VCU Internal Medicine Training Program The Practice of Medicine Series

2 Learning Objectives At the end of this session, residents will be able to At the end of this session, residents will be able to describe what medical documentation facilitates describe what medical documentation facilitates identify three key components in selecting the levels of E/M services identify three key components in selecting the levels of E/M services select the appropriate level of an E&M service for a new and established patient in either the outpatient or inpatient setting select the appropriate level of an E&M service for a new and established patient in either the outpatient or inpatient setting identify resources for compliance identify resources for compliance

3 Evaluation and Management (E&M) Documentation One of most commonly billed procedures One of most commonly billed procedures May be billed for new or established patients May be billed for new or established patients Includes office, hospital, nursing home visits, consultations, phone and overall management, ICU care, discharge planning Includes office, hospital, nursing home visits, consultations, phone and overall management, ICU care, discharge planning 1995/1997 Medicare guidelines – can use both 1995/1997 Medicare guidelines – can use both Medicare Physician Guide: A Resource for Residents, Practicing Physicians, and Other Health Care Professionals – physicianguide.pdf Medicare Physician Guide: A Resource for Residents, Practicing Physicians, and Other Health Care Professionals – physicianguide.pdf Chapter 5 – E&M Documentation Chapter 5 – E&M Documentation Great references and resource lists Great references and resource lists

4 Why document? Medical /legal issues Medical /legal issues To tell the story of the patient – communicate to others To tell the story of the patient – communicate to others To have the opportunity for reimbursement for the service provided To have the opportunity for reimbursement for the service provided E&M documentation is the pathway that translates a physicians patient care work into the claims and reimbursement mechanism E&M documentation is the pathway that translates a physicians patient care work into the claims and reimbursement mechanism Medicare … if it is not documented, it wasnt done. Medicare … if it is not documented, it wasnt done.

5 What does documentation facilitate? The ability to evaluate and plan the patients treatment The ability to evaluate and plan the patients treatment The ability to monitor patients health over time The ability to monitor patients health over time Communication and continuity of care among healthcare professionals Communication and continuity of care among healthcare professionals Appropriate utilization review and quality of care evaluations Appropriate utilization review and quality of care evaluations Collection of data for research and evaluation Collection of data for research and evaluation

6 General Principles of Documenting Legibility – all documents MUST be legible Legibility – all documents MUST be legible Defined as easily read by peers (other clinicians) Defined as easily read by peers (other clinicians) Required information: Required information: Patient name, MR, date of service on each page Patient name, MR, date of service on each page Date AND time (for inpatient) Date AND time (for inpatient) Reason for encounter, relevant history, PE findings Reason for encounter, relevant history, PE findings Review of lab, x-ray data, other ancillary services Review of lab, x-ray data, other ancillary services Assessment, clinical impression or diagnosis Assessment, clinical impression or diagnosis Plan of care (including d/c plan if appropriate) Plan of care (including d/c plan if appropriate) Legible identity of observer (authenticated) Legible identity of observer (authenticated)

7 General Principles of Documenting If not documented, rationale for ordering diagnostics or ancillary services should be easily inferred If not documented, rationale for ordering diagnostics or ancillary services should be easily inferred Past and present diagnoses should be accessible to physician – can be in chart Past and present diagnoses should be accessible to physician – can be in chart Appropriate health risk factors should be identified Appropriate health risk factors should be identified Patient progress, response to and changes in treatment should be documented Patient progress, response to and changes in treatment should be documented

8 General Principles of Documenting Documentation should support the intensity of the evaluation or treatment, including thought processes and complexity of medical decision making Documentation should support the intensity of the evaluation or treatment, including thought processes and complexity of medical decision making All entries should be dated and authenticated by physician signature All entries should be dated and authenticated by physician signature CPT and ICD-9-CM codes reported should reflect documentaton in the medical records CPT and ICD-9-CM codes reported should reflect documentaton in the medical records

9

10 Components of an E&M service Seven components use to define level of E&M service (exceptions to rule if predominantly counseling or coordination of care) Seven components use to define level of E&M service (exceptions to rule if predominantly counseling or coordination of care) Key components Key components History History Examination Examination Medical Decision Making Medical Decision Making Contributory components Contributory components Counseling Counseling Coordination of Care Coordination of Care Nature of Presenting Problem Nature of Presenting Problem Time Time

11 Components of an E&M service Seven components use to define level of E&M service (exceptions to rule if predominantly counseling or coordination of care) Seven components use to define level of E&M service (exceptions to rule if predominantly counseling or coordination of care) Key components Key components History History Examination Examination Medical Decision Making Medical Decision Making Contributory components Contributory components Counseling Counseling Coordination of Care Coordination of Care Nature of Presenting Problem Nature of Presenting Problem Time Time Used in selecting level of E/M service (some exceptions)

12 Determining Level of Service Table to determine appropriate level of service based on documentation (as a reflection of complexity of care provided) in three key component areas Table to determine appropriate level of service based on documentation (as a reflection of complexity of care provided) in three key component areas Each key component has graded levels Each key component has graded levels Different criteria for new patient vs established Different criteria for new patient vs established Different criteria for inpatient vs outpatient Different criteria for inpatient vs outpatient Procedure codes identified by tables – determine the level of service and amount of reimbursement (99201, 99202, 99203, etc) Procedure codes identified by tables – determine the level of service and amount of reimbursement (99201, 99202, 99203, etc)

13 Key Components History History Physical Examination Physical Examination Decision Making Decision Making

14 History – elements (4) Chief complaint (CC) Chief complaint (CC) Required for ALL levels of E/M coding Required for ALL levels of E/M coding Reason for encounter Reason for encounter If follow up … follow up for … If follow up … follow up for … NOT routine f/u NOT routine f/u Must be documented by resident, NP, PA or attending Must be documented by resident, NP, PA or attending History of Present Illness (HPI) History of Present Illness (HPI) Review of Systems (ROS) Review of Systems (ROS) Past, Family, Social History (PFSH) Past, Family, Social History (PFSH)

15 History HPI elements HPI elements Location Location Quality Quality Severity Severity Duration Duration Timing Timing Context Context Modifying Factors Modifying Factors Associated Signs and Symptoms Associated Signs and Symptoms Level of History Level of History Brief – status of 1-2 chronic conditions or 1-3 above Brief – status of 1-2 chronic conditions or 1-3 above Extended – status of 3 chronic conditions or 4+ above Extended – status of 3 chronic conditions or 4+ above

16 History Review of Systems (ROS) Review of Systems (ROS) Do not have to write a notation for all systems Do not have to write a notation for all systems Document the positive and pertinent negatives Document the positive and pertinent negatives all other systems negative – include number checked all other systems negative – include number checked Should have usual template Should have usual template Level for ROS based on number of systems Level for ROS based on number of systems Problem pertinent – related to problem only +/- Problem pertinent – related to problem only +/- Extended – positive and pertinent responses for 2-9 systems Extended – positive and pertinent responses for 2-9 systems Complete ROS is 10+ Complete ROS is 10+ ROS ROS Constitutional, eyes, ears, nose, throat, cv, respiratory, gi, gu, musculoskeletal, skin, neuro, psych, endo, heme, lymph, allergic, immunological Constitutional, eyes, ears, nose, throat, cv, respiratory, gi, gu, musculoskeletal, skin, neuro, psych, endo, heme, lymph, allergic, immunological

17 History Past, Family and Social (PFSH) Past, Family and Social (PFSH) Past History – review of patients past illnesses, injuries, treatments Past History – review of patients past illnesses, injuries, treatments Includes major illness, injury, operations, prior hospitalizations, current meds, allergies Includes major illness, injury, operations, prior hospitalizations, current meds, allergies Social History – age appropriate review of past and current activities Social History – age appropriate review of past and current activities May include marital status, living situation, employment and occupational hx, use of drugs/alcohol/tobacco, ed May include marital status, living situation, employment and occupational hx, use of drugs/alcohol/tobacco, ed Family History – review of medical events in family Family History – review of medical events in family

18 History PFSH PFSH Pertinent – review of history area directly related to problem identified in HPI – at least one item from any of P, F, S Pertinent – review of history area directly related to problem identified in HPI – at least one item from any of P, F, S Complete – review of 2-3 PFSH areas if f/u visit, 3/3 areas if new patient Complete – review of 2-3 PFSH areas if f/u visit, 3/3 areas if new patient

19 History – E/M levels Problem Focused Problem Focused CC, 1-3 HPI elements CC, 1-3 HPI elements Expanded Problem Focused Expanded Problem Focused CC, 1-3 HPI, problem pertinent system review (>1) CC, 1-3 HPI, problem pertinent system review (>1) Detailed Detailed CC, 4+ HPI, problem pertinent ROS additional ROS, pertinent PFSH (1 element) CC, 4+ HPI, problem pertinent ROS additional ROS, pertinent PFSH (1 element) Comprehensive Comprehensive CC, 4+ HPI, complete ROS (10+), complete PFSH CC, 4+ HPI, complete ROS (10+), complete PFSH

20 History Type of History HPIROSPFSH Problem Focused Brief 1-3 N/AN/A Expanded Problem Focused Brief 1-3 Problem Pertinent >1 N/A Detailed Extended 4+ Extended 2-9 Pertinent 1 Comprehensive Extended 4+ Compete (10+) Complete 2/3 or 3/3*

21 Exam Organ systems Organ systems For a general multi-system exam For a general multi-system exam Body areas Body areas

22 Exam – Organ Systems Vital Signs, General Symptoms Vital Signs, General Symptoms Eyes Eyes ENT ENT CV CV Respiratory Respiratory GI GI GU Musculoskeletal Skin Neurological Psychiatric Heme/Lymph/Immuno

23 Exam – Body Areas Head/face Head/face Neck Neck Breast/Axillary Breast/Axillary Abdomen Abdomen Genitalia Genitalia Back/spine Back/spine Extremity Extremity

24 Exam Document specific abnormal and relevant negative findings of affected or symptomatic area Document specific abnormal and relevant negative findings of affected or symptomatic area Document abnormal or unexpected findings of unaffected or asymptomatic areas Document abnormal or unexpected findings of unaffected or asymptomatic areas abnormal is insufficient abnormal is insufficient Templates ok Templates ok Reference cards, review sheets Reference cards, review sheets

25 Exam – levels (see p81 guide) Problem focused Problem focused Limited to affected body area or organ system (1-6 elements) Limited to affected body area or organ system (1-6 elements) Expanded Problem Focused Expanded Problem Focused Affected system plus other symptomatic or related (6) Affected system plus other symptomatic or related (6) Detailed Detailed Extended exam of affected area and other symptomatic or related organ system Extended exam of affected area and other symptomatic or related organ system Comprehensive Comprehensive Multisystem exam (8-12) or complete single system Multisystem exam (8-12) or complete single system

26 Medical Decision Making

27 Medical Decision Making - tips TELL THE STORY TELL THE STORY The medical record must clearly support all diagnoses reported on the claim The medical record must clearly support all diagnoses reported on the claim Document impressions, diagnoses, tests ordered and/or reviewed AND the plan of care Document impressions, diagnoses, tests ordered and/or reviewed AND the plan of care What is the complexity of care for this patient AT THIS TIME? What is the complexity of care for this patient AT THIS TIME? Is the patient improved, resolved, unresponding? Is the patient improved, resolved, unresponding?

28 Medical Decision Making Complexity of establishing a diagnosis Complexity of establishing a diagnosis Four types/levels – guided by … Four types/levels – guided by … The number of diagnoses or management options The number of diagnoses or management options The amount or complexity of data ordered or reviewed The amount or complexity of data ordered or reviewed The risk of complications and morbidity/mortality The risk of complications and morbidity/mortality

29 Medical Decision Making 4 levels 4 levels Straightforward Straightforward Low Complexity Low Complexity Moderate Complexity Moderate Complexity High Complexity High Complexity 3 subcomponents 3 subcomponents Diagnoses and Management Options Diagnoses and Management Options Amount and Complexity of Data Amount and Complexity of Data Risk of Complications Risk of Complications

30 Decision Making To qualify for a specific level of Decision Making, 2 of the 3 elements listed for that specific category must be met or exceeded To qualify for a specific level of Decision Making, 2 of the 3 elements listed for that specific category must be met or exceeded Diagnosed problems less complex than undiagnosed Diagnosed problems less complex than undiagnosed Consider Consider How many diagnostic tests ordered How many diagnostic tests ordered Did you request a consult Did you request a consult

31 Diagnoses and Management Options For established diagnosis For established diagnosis Improved, resolved, unresponding Improved, resolved, unresponding If diagnosis not established If diagnosis not established Possible, probable, rule out Possible, probable, rule out Document treatment plan Document treatment plan Include medication changes Include medication changes Therapies Therapies Patient instructions, nursing instructions Patient instructions, nursing instructions

32 Amount and complexity of data Review and/or order of clinical lab and XR tests Review and/or order of clinical lab and XR tests Review and/or order of diagnostic tests Review and/or order of diagnostic tests XR, scans, nuclear med, cardiac cath, echo, ekg, eeg, non-invasive vasc, PFTs XR, scans, nuclear med, cardiac cath, echo, ekg, eeg, non-invasive vasc, PFTs Document review of old records Document review of old records Document information from family or caretaker Document information from family or caretaker Summarize relevant findings, if any Summarize relevant findings, if any If not, document fact that reviews done If not, document fact that reviews done

33 Risk of complication Minimal Minimal Low Low Moderate Moderate High High

34 Documenting Risk See tables on risk See tables on risk Make sure to document Make sure to document Co-morbidities Co-morbidities Underlying diseases Underlying diseases Other factors increasing risk Other factors increasing risk

35 Medical Decision Making MDM - Level Dx/MgmtDataRisk Straight- forward Minimal < 2 elements Minimal/none < 1 elementMinimal Low Limited 3-4 elements Limited 2 elements Low Moderate Multiple 5-6 elements Multiple 3 elements Moderate High Extensive > Extensive > 7 elements Extensive > Extensive > 4 elementsHigh

36 What code do I choose? Step 1: Is the patient New or Established, Inpatient or Outpatient? Step 1: Is the patient New or Established, Inpatient or Outpatient? New = 3 key components New = 3 key components Established = 2 of 3 key components Established = 2 of 3 key components Step 2: What level of History and Exam was performed? Step 2: What level of History and Exam was performed? Use reference card for definitions Use reference card for definitions Step 3: Review the 3 subcomponents for Medical Decision Making Step 3: Review the 3 subcomponents for Medical Decision Making meets or exceeds is issue meets or exceeds is issue

37 What code do I choose? Step 4: Compare your assessments against the requirements for a given level of service Step 4: Compare your assessments against the requirements for a given level of service May not match exactly May not match exactly meets or exceeds is key phrase meets or exceeds is key phrase

38 New and Established Patients 3 of 3 Key Components 3 of 3 Key Components New patient office New patient office Initial Inpatient Admission Initial Inpatient Admission Initial Consultation Initial Consultation 2 of 3 Key Components 2 of 3 Key Components Established Office Established Office Subsequent Inpatient care Subsequent Inpatient care

39 Time Choose code based on face-to-face time with the patient when OVER 50% of the visit was spent in counseling Choose code based on face-to-face time with the patient when OVER 50% of the visit was spent in counseling Document the total time spent with the patient Document the total time spent with the patient Document the total time spent in counseling Document the total time spent in counseling Document the content of the counseling, and Document the content of the counseling, and Choose the level of E/M by the total amount of time Choose the level of E/M by the total amount of time

40 Other E&M Issues Consultations Consultations Incident to Incident to NPs, PAs, midwives, Clinical Nurse Specialists NPs, PAs, midwives, Clinical Nurse Specialists Shared visits Shared visits Involves physician and non-physician practitioner Involves physician and non-physician practitioner Prolonged services Prolonged services Critical Care Critical Care Teaching Physicians (including GE exemption codes) Teaching Physicians (including GE exemption codes)

41 Learning Objectives At the end of this session, residents will At the end of this session, residents will Be able to describe what medical documentation facilitates Be able to describe what medical documentation facilitates Be able to identify three key components in selecting the levels of E/M services Be able to identify three key components in selecting the levels of E/M services Be able to select the appropriate level of an E&M service for a new and established patient in either the outpatient or inpatient setting Be able to select the appropriate level of an E&M service for a new and established patient in either the outpatient or inpatient setting Be able to identify resources for compliance Be able to identify resources for compliance


Download ppt "Evaluation & Management Coding and Documentation 101 – the basics Stephanie Ann Call, MD MSPH VCU Internal Medicine Training Program The Practice of Medicine."

Similar presentations


Ads by Google