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1 Evaluation & Management Services. 2 E/M Coding Key components History Physical examination Medical Decision making Contributory factors Nature of the.

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Presentation on theme: "1 Evaluation & Management Services. 2 E/M Coding Key components History Physical examination Medical Decision making Contributory factors Nature of the."— Presentation transcript:

1 1 Evaluation & Management Services

2 2 E/M Coding Key components History Physical examination Medical Decision making Contributory factors Nature of the presenting problem Medical Necessity drives code selection Extent of counseling Coordination of care Time

3 3 E/M Guidelines Medicare and Commercial Insurance CMS 1995 and 1997 E/M guidelines Use either set 1997 approved by AMA Medicaid Does not use 95 or 97 guidelines Uses AMA guidelines found in the CPT book E/M Service Guidelines section in Instructions for selecting a Level of E/M Service

4 4 Medical Necessity A service that is reasonable and necessary for the diagnosis and treatment of illness or injury, or to improve the functioning of a malformed body member Government definition

5 5 History Definitions (CC) Chief complaint (CC) Reason for the visit (HPI) History of present illness (HPI) Chronological review of condition/complaint (ROS) Review of systems (ROS) Inventory of systems through questions (PFSH) Past, Family, Social, History (PFSH)

6 6 History Problem Focused Detailed Chief Complaint Chief Complaint Brief HPI (1-3) Extended HPI (4 or status of No ROS 3 chronic/inactive) No PFSH Extended ROS (2-9) Expanded Problem Pertinent PFSH (1) Focused Comprehensive Chief Complaint Chief Complaint Brief HPI (1-3) Extended HPI (4 or status of Problem pertinent ROS (1) 3 chronic/inactive) No PFSH Complete ROS (10) ALL 3 elements must be Complete PFSH (2 or 3 met: HPI,ROS,PFSH based on category of E/M)

7 7 CPT History Guidelines (Medicaid) Problem focused: CC; brief HPI Expanded problem focused: CC; brief HPI, problem pertinent ROS Detailed: CC; extended HPI, problem pertinent ROS extended to include a review of limited number of additional systems; pertinent PFSH directly related to the patients problems Comprehensive: CC; extended HPI, ROS which is directly related to the problem(s) identified in the HPI plus a review of all additional body systems; complete PFSH

8 8 History Example CC - Vaginal discharge HPI - New patient is complaining of a white vaginal (location) discharge for the past 2 days (duration) with a heavier flow in the morning (timing). There is no change with Monistat (modifying factor). ROS - Patient denies itching (integumentary), burning with urination (genitourinary) or fever (constitutional). PFSH - Patient has had 2 sexual partners in the past 60 days (social)

9 9 History Example History Level = Detailed (3 of 3) CC CC HPI HPI = Extended (4+ elements) ROS ROS = Extended (3 elements) PFSH PFSH = Pertinent (1 element)

10 10 Physical Exam Problem Focused (95)<1 body area/ organ system (97) 1-5 elements Expanded Problem Focused (95) 2-4 body areas/ organ systems (97) elements Detailed (95) 5-7 body areas/organ systems (97) 12 elements in 2+areas/systems Comprehensive (95) 8 organ systems (97) General exam: Perform all elements document at least 2 elements in each of 9 areas/systems

11 11 CPT Physical Exam Guidelines (Medicaid) Problem focused: limited exam of the affected body area or organ system Expanded problem focused: limited exam of the affected body area or organ system and other symptomatic or related organ system(s) Detailed: extended exam of the affected body area(s) and other symptomatic or related organ system(s) Comprehensive: general multi-system exam or a complete exam of a single organ system

12 12 Physical Exam Example Vaginal Discharge Exam Constitutional BP, temp, pulse Genitourinary Examination of external genitalia Examination of cervix Physical Exam level = Expanded Problem Focused At least two body areas/organ systems

13 13 Decision Making Straightforward (0 -1) #Diagnostic/treatment options (0 -1) Amt./complexity of data (0 -1) Risk (minimal) Low Complexity #Diagnostic/treatment (2) options (2) Amt./complexity of data(2) Risk (low) Moderate Complexity #Diagnostic/treatment (3) options (3) (3) Amt./complexity of data (3) Risk (moderate) High Complexity (4) #Diagnoses/mgmt options (4) (4) Amt./complexity of data (4) Risk (high)

14 14 CPT MDM Guidelines (Medicaid) Complexity measured by: the number of management options # of possible diagnoses and/or the number of management options that must be considered. tests, other information Amount/complexity of records, tests, other information that must be obtained, reviewed, and analyzed. morbidity, mortality, as well as co-morbidities, associated with the patients presenting problem(s),the diagnostic procedure(s) and/or the possible management options. Risk of significant complications, morbidity, mortality, as well as co-morbidities, associated with the patients presenting problem(s), the diagnostic procedure(s) and/or the possible management options.

15 15 Decision Making Example Vaginal Discharge Exam New problem, additional workup planned (4)Lab is ordered (4) (1) Review/order tests in 8xxxx series (1) Moderate decision making Undiagnosed new problem with uncertain prognosis Prescription drug management –Prescription written (2 0f 3) Decision Making level = Moderate (2 0f 3) Extensive # Diagnosis/treatment options Minimal amount of data to be reviewed Table of risk - Moderate

16 16 Level Assignment Example History = Detailed Physical exam = Expanded Problem Focused Decision Making = Moderate Level = 99202, new patient If established patient = 99214

17 17 Contributing Factors Presenting Problem Minimal Self-Limited/Minor Low Severity Moderate Severity High Severity Time FACE-TO-FACE Time is a key factor ONLY when: Counseling or coordination of care takes up OVER 50% of the total visit time

18 18 Counseling/Coordination of Care Main factor determining code when takes up MORE than 50% of the total visit time Documentation: Total visit time Time spent in Counseling/Coordination of Care –Face to face Subject/ content Code level is based on the total visit time not just the time spent in counseling

19 19 Counseling Examples Established patient, 20 minute visit to follow- up on oral contraceptive use NP RN (MA 99213) 15 minutes of a 20 minute visit spent counseling the patient on alcohol and cigarette use during pregnancy NP RN (MA 99213)

20 20 Definitions New patient Has not received face-to-face services from ANY provider in the agency Within past 3 years (AMA) Established patient Has received face-to-face services from ANY provider in the agency Within past 3 years (AMA)

21 21 Selecting a Level of E/M Identify (POS) Place of service (POS) = where (office) (TOS) Type of service (TOS) = what (Problem/Preventive) Status of Patient = who (New/Established) history - physical exam - decision making - counseling Determine the extent of history - physical exam - decision making - counseling DOCUMENTATION Must consider all factors, and make sure adequate DOCUMENTATION in chart to justify code.

22 22 Office Report Problem visit (vs. Preventive visit) , performed by MD,DO,NP,PA,CNS Ancillary staff i.e. RN, LPN, CNA MD/NP must be in the clinic Report only 1 E/M per day Report diagnostic tests, studies, procedures separately

23 23 Office (Medicaid) , , may be performed by any staff of a certified family planning clinic. Staff may be MD, NP, PA, RN, CMA or unlicensed personnel acting in a coordinated manner to provide the service(s). Other reporting requirements are the same as other providers

24 24 Preventive Medicine Services

25 25 Preventive Medicine Routine management of patients without presenting problems, i.e. annual, routine, well child exams Performed by MD, DO,NP,PA,CNS Includes other clinic staff if Medicaid Codes New/established patients Age Not used for scheduled follow-up visits for specified problems


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