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 After this presentation, you should be able to: › Know that E/M stands for › Know the 3 components of the E/M › Distinguish different categories of.

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Presentation on theme: " After this presentation, you should be able to: › Know that E/M stands for › Know the 3 components of the E/M › Distinguish different categories of."— Presentation transcript:

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2  After this presentation, you should be able to: › Know that E/M stands for › Know the 3 components of the E/M › Distinguish different categories of E/M › Understand levels of complexity › Level Medical Decision Making › Know when modifiers apply (and look them up) › Appropriately document according to E/M level

3  E/M › Professional face-to-face service between doctor and patient › Documentation to support the above › S: History › O: Physical › A: Decision Making › P: Decision Making

4  Categories of E/M Services  Elements of the E/M Visit  Modifiers

5 PPO patient seen by your partner last year, consult requested by the ED, you see the patient and document  Encounter type? A. Hospital/inpatient new B. Hospital/inpatient consultation C. Office/outpatient new D. Office/outpatient consultation E. Office/outpatient established

6 PPO patient seen by your partner last year, consult requested by the ED, you see the patient and document  Encounter type? A. Hospital/inpatient new B. Hospital/inpatient consultation C. Office/outpatient new D. Office/outpatient consultation E. Office/outpatient established

7 Medicare patient seen by your partner last year, consult requested by the ED, you see the patient and document  Encounter type? A. Hospital/inpatient new B. Hospital/inpatient consultation C. Office/outpatient new D. Office/outpatient consultation E. Office/outpatient established

8 Medicare patient seen by your partner last year, consult requested by the ED, you see the patient and document  Encounter type? A. Hospital/inpatient new B. Hospital/inpatient consultation C. Office/outpatient new D. Office/outpatient consultation E. Office/outpatient established

9 Medicare patient never seen by you or your partner, consult requested by the ED, you see the patient and document  Encounter type? A. Hospital/inpatient new B. Hospital/inpatient consultation C. Office/outpatient new D. Office/outpatient consultation E. Office/outpatient established

10 Medicare patient never seen by you or your partner, consult requested by the ED, you see the patient and document  Encounter type? A. Hospital/inpatient new B. Hospital/inpatient consultation C. Office/outpatient new D. Office/outpatient consultation E. Office/outpatient established

11  Office or other outpatient (includes ED) › New (requires all 3 key components) › Established (2 of 3 components)  Hospital inpatient › Initial hospital care (3 components) › Subsequent hospital care (2 of 3 components) › Hospital discharge  Consultations › Office or other outpatient › Initial inpatient

12  Office or other outpatient › New (requires all 3 key components of E/M)  Never seen by your group  Seen by you or group member more than 3 years ago › Established (2 of 3 components of E/M)  Not New visit  Not Consultation

13  Consultations › Definition  “A consultation is defined as a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.”

14  Consultations › Guidelines  The consultant’s opinion is requested by another physician  Documentation of verbal or written request  Documentation of consultant’s opinion  Consultant may initiate treatment  Communication of consultant’s opinion to the requesting physician

15  Consultations › Situations  Requests between physicians of the same group  Report consultation code if guidelines are met  Initiation of treatment  Usually stems from medical decision making portion of the E/M service  “Even though treatment is initiated, the initial service is still considered a consultative visit.”  If the consulting physician assumes care, the initial service should be reported as a consult.

16  Consultations › Medicare eliminated this whole category

17  Categories of E/M Services  Elements of the E/M Visit  Modifiers

18 Wrist pain, dull, constant, with numbness ROS Gen: weight gain, CV: none H/O DM  History type? A. Problem focused (level 1) B. Expanded problem focused (level 2) C. Detailed (level 3) D. Comprehensive (levels 4 and 5)

19 Wrist pain, dull, constant, with numbness ROS Gen: weight gain, CV: none H/O DM  History type? A. Problem focused (level 1) B. Expanded problem focused (level 2) C. Detailed (level 3) D. Comprehensive (levels 4 and 5)

20  Detailed level › HPI-ROS-PFS 4-2-1

21 Wrist pain, sharp, dull, throbbing, aching ROS 10+ PMH: none, PSH: none, Meds: none  History type? A. Problem focused (level 1) B. Expanded problem focused (level 2) C. Detailed (level 3) D. Comprehensive (levels 4 and 5)

22 Wrist pain, sharp, dull, throbbing, aching (2 elements) ROS 10+ PMH: none, PSH: none, Meds: none  History type? A. Problem focused (level 1) B. Expanded problem focused (level 2) C. Detailed (level 3) D. Comprehensive (levels 4 and 5)

23 Wrist pain, constant, worsening, with numbness ROS 10+ PMH: none, FHx: Heart disease, SocHx: +EtOH  History type? A. Problem focused (level 1) B. Expanded problem focused (level 2) C. Detailed (level 3) D. Comprehensive (levels 4 and 5)

24 Wrist pain, constant, worsening, with numbness ROS 10+ PMH: none, FHx: Heart disease, SocHx: +EtOH  History type? A. Problem focused (level 1) B. Expanded problem focused (level 2) C. Detailed (level 3) D. Comprehensive (levels 4 and 5)

25  History › CC (1 element)  Describe reason for visit  Every visit must have the CC stated

26  History › HPI (4 elements)  Location: site of the problem  Quality: sharp, dull, throbbing  Severity: minor, moderate, severe  Duration: intermittent, constant  Timing: with exercise, nightly, after meals  Context: worsening, recurrent  Modifying factors: rest, heat, cold, elevation  Associated symptoms: numbness, tingling

27  History › ROS (10 elements)  Constitutional  Eyes  Ear, nose, throat  Cardiovascular  Respiratory  Gastrointestinal  Genitourinary  Musculoskeletal  Integumentary  Neurologic  Psychiatric  Endocrine  Hematologic  Immunologic

28  History › PFSH (3 elements)  Past history  Illnesses  Operations  Allergies  Family history  Social history  Occupation  Tobacco and alcohol use

29 History CCHPIROSPFSH Problem focused Expanded problem Detailed Comprehensive14103

30 No distress, intact cap refill in all fingers B UE: nontender except over palpable dorsal wrist mass, functional ROM, no dislocations, no atrophy, no wounds  Exam type? A. Problem focused (level 1) B. Expanded problem focused (level 2) C. Detailed (level 3) D. Comprehensive (levels 4 and 5)

31 No distress, intact cap refill in all fingers B UE: nontender except over palpable dorsal wrist mass, functional ROM, no dislocations, no atrophy, no wounds  Exam type? A. Problem focused (level 1) B. Expanded problem focused (level 2) C. Detailed (level 3) D. Comprehensive (levels 4 and 5)

32  Physical examination—Musculoskeletal › Constitutional (2 elements) › Cardiovascular and/or lymphatic (1 element) › Musculoskeletal (17 elements) › Skin (4 elements) › Neuropsychiatric (5 elements)

33  Physical examination—Musculoskeletal › Constitutional (2 elements)  Vital signs (any 3 of the following items)  Temperature  Pulse  Respiration  Blood pressure  Height  Weight  General appearance

34  Physical examination—Musculoskeletal › Cardiovascular and/or lymphatic (1 element)  Pulse  Capillary refill  Skin perfusion  Edema  Lymph node palpation

35  Physical examination—Musculoskeletal › Musculoskeletal (17 elements)  Gait examination  In 4 of 6 body areas: (head/neck, trunk, 4 extremities)  Inspect/palpate  Assess ROM  Assess stability  Assess strength, tone, atrophy, or spasticity

36  Physical examination—Musculoskeletal › Skin (4 elements)  In 4 of 6 body areas: (head/neck, trunk, 4 extremities)  Inspection and/or palpation

37  Physical examination—Musculoskeletal › Neuropsychiatric (5 elements)  Coordination  Reflexes (deep tendon or pathologic)  Sensation  Orientation  Mood and affect

38 Physical examination Elements Problem focused1 Expanded problem6 Detailed12 ComprehensiveAll

39 Problem: New fracture, HTN, DM Risk: Major surgery with risk factors Data: Reviewed films  Decision type? A. Straightfoward (levels 1 and 2) B. Low (level 3) C. Moderate (level 4) D. High (level 5)

40 Problem: New fracture, HTN, DM (HIGH) Risk: Major surgery with risk factors (HIGH) Data: Reviewed films (LOW)  Decision type? A. Straightfoward (levels 1 and 2) B. Low (level 3) C. Moderate (level 4) D. High (level 5)

41 Problem: F/U fracture with displacement Risk: ORIF Data: Reviewed films  Decision type? A. Straightfoward (levels 1 and 2) B. Low (level 3) C. Moderate (level 4) D. High (level 5)

42 Problem: F/U fracture with displacement (LOW) Risk: ORIF (MOD) Data: Reviewed films (LOW)  Decision type? A. Straightfoward (levels 1 and 2) B. Low (level 3) C. Moderate (level 4) D. High (level 5)

43 Problem: New onset numbness, DM stable Risk: Major surgery Data: Read EMG report  Decision type? A. Straightfoward (levels 1 and 2) B. Low (level 3) C. Moderate (level 4) D. High (level 5)

44 Problem: New onset numbness, DM stable (HIGH) Risk: Major surgery (MODERATE) Data: Read EMG report (STRAIGHTFORWARD)  Decision type? A. Straightfoward (levels 1 and 2) B. Low (level 3) C. Moderate (level 4) D. High (level 5)

45  Decision making › Number of diagnosis/management options › Risk of complications › Amount/complexity of data reviewed

46  Decision making › Number of diagnosis/management options  Self-limited or minor problem1  Established problem1  Worsening problem2  New problem, no additional workup3  New problem, additional workup planned4  Add up points  Score = 1, 2, 3, 4+

47  Decision making › Risk of complications  Minimal  Suture removal, lab tests, rest  Low  Two minor problems, sprain, order PT/OT, minor surgery without risk factors  Moderate  Two chronic illness, CT, MRI, aspiration, Rx, fx management, major surgery without risk factors, minor surgery with risk factors  High  Illness with severe exacerbation, abrupt neurological change, major surgery with risk factors, emergency surgery

48  Decision making › Amount/complexity of data reviewed  Order test1  Review test result1  Discuss test with performing physician1  Decide to obtain records1  Review and summarize records2  Review x-ray or specimen2  Add up points  Score = 1, 2, 3, 4+

49 Decision making (2 of 3) OptionsRiskData Straightforward1Minimal1 Low complexity2Low2 Moderate complexity 3Moderate3 High complexity4High4

50  How do you decide level of service? › Components  History  Physical examination  Decision making › New patients and consultations  Need all 3 components  Code for lowest component › Established patients  Code for 2 out of 3 components

51 New or Consult Level 1Level 2Level 3Level 4Level 5 History Problem focused Expanded problem Detailed Compre- hensive Physical Exam Problem focused Expanded problem Detailed Compre- hensive Decision making Straight- forward Low complexity Moderate complexity High complexity

52 Return Level 1Level 2Level 3Level 4Level 5 History None Problem focused Expanded problem Detailed Compre- hensive Physical Exam None Problem focused Expanded problem Detailed Compre- hensive Decision making None Straight- forward Low complexity Moderate complexity High complexity

53  Categories of E/M Services  Elements of the E/M Visit  Modifiers

54  What are modifiers? › Modifiers indicate that a service or procedure has been altered by circumstance but not changed in definition  How are modifiers reported? › Two digits appended to CPT code  Example:

55 Patient presents with new finger triggering after carpal tunnel release  Codes? A. Postop-24 (unrelated E/M during postop) B. Return-24 C. Postop-25 (separate E/M on day of procedure) D. Return-25

56 Patient presents with new finger triggering after carpal tunnel release  Codes? A. Postop-24 (unrelated E/M during postop) B. Return-24 C. Postop-25 (separate E/M on day of procedure) D. Return-25

57 New patient seen in ED for radius fracture, and then taken to surgery the same day  Codes? A. Inpatient consult and surgical code (radius ORIF) B. Outpatient consult and surgical code C. Inpatient consult-57 (decision for major surgery) and surgical code D. Outpatient consult-57 and surgical code E. Surgical code only

58 New patient seen in ED for radius fracture, and then taken to surgery the same day  Codes? A. Inpatient consult and surgical code (radius ORIF) B. Outpatient consult and surgical code C. Inpatient consult-57 (decision for major surgery) and surgical code D. Outpatient consult-57 and surgical code E. Surgical code only

59 New patient seen in ED for radius fracture, and then decision to schedule surgery next week  Codes? A. Inpatient consult and surgical code (radius ORIF) B. Outpatient consult and surgical code C. Inpatient consult-57 (decision for major surgery) and surgical code D. Outpatient consult-57 and surgical code E. Surgical code only

60 New patient seen in ED for radius fracture, and then decision to schedule surgery next week  Codes? A. Inpatient consult and surgical code (radius ORIF) B. Outpatient consult and surgical code C. Inpatient consult-57 (decision for major surgery) and surgical code D. Outpatient consult-57 and surgical code E. Surgical code only

61  CPT modifiers -21: Prolonged E/M services -24: Unrelated E/M during postop period New problem, management of complication, etc. -25: Significant and separate E/M on the same day of procedure Note: chief complaint should be different than diagnosis, and procedure should be separately documented from the E/M note -57: Decision for surgery Appended to E & M code that resulted in the decision for surgery

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63  Leveling an E/M visit › 58 y/o RHD male › Motorcycle accident › Left wrist pain

64  Leveling an E/M visit › History (comprehensive)  CC (1)  Left wrist injury  HPI (4)  58 y/o RHD male sustains a motorcycle injury (context) this morning (timing), and has sharp pain (quality) in the left wrist (location).  ROS (10)  PFSH (3)  The patient has hypertension (past). Family history includes heart disease (family). He smokes 1 ppd x 23 yrs (social).

65  Leveling an E/M visit › Physical examination (comprehensive)  Constitutional (2)  T: 98.4, P 72, B/P 152/90 (3 vital signs)  The patient appears well developed and is in moderate distress (general appearance).  Cardiovascular (1)  He has good capillary refill in all fingertips of the left hand without lymphedema.

66  Leveling an E/M visit › Physical examination (comprehensive)  Musculoskeletal (17)  The patient is on bedrest, and gait cannot be examined (1).  Examination of the left upper extremity shows gross deformity at the wrist (1). ROM (1) and strength (1) is decreased due to pain. There is no joint laxity but definite motion across the fracture site (1) on examination.  Examination of the right upper and bilateral lower extremities reveals no tenderness (3), functional ROM (3), no dislocations (3), and no atrophy/weakness (3).

67  Leveling an E/M visit › Physical examination (comprehensive)  Skin (4)  No wounds are present on bilateral upper (2) and bilateral lower extremities (2).  Neuropsychiatric (5)  Patient has normal fine motor control (coordination). Babinski is symmetrically downgoing (reflex). He has intact sharp-dull differentiation to the radial, median, and ulnar nerve distributions of the left hand (sensation). He is oriented person, place, and time (orientation). His mood and affect are appropriate (mood and affect).

68  Leveling an E/M visit › Decision making (2 of 3 components)  Number of options  This patient presents with a new problem, and no further workup is necessary (3 points). He also has HTN, which is stable at this time (1 point). HIGH  Risk of complications  I recommend major surgery, with open treatment. His risk factors include HTN and tobacco use. HIGH  Complexity of data  I ordered x-ray films (1 point), and have personally reviewed them. The findings show a left distal radius fracture with intra- articular comminution (2 points). MODERATE

69  Leveling an E/M visit Decision making (2 of 3) OptionsRiskData Straightforward1Minimal1 Low complexity2Low2 Moderate complexity3Moderate3 High complexity4High4

70  Leveling an E/M visit New patient Level 1Level 2Level 3Level 4Level 5 History Problem focused Expanded problem Detailed Compre- hensive Physical Exam Problem focused Expanded problem Detailed Compre- hensive Decision making Straight- forward Low complexity Moderate complexity High complexity

71  Selecting the correct category  A 30 y/o patient presents to your office for redness and swelling in the forearm. You obtain the history, perform examination, and order blood tests. You admit the patient on the same day for treatment. After completion of your office hours that day, you see him in the hospital.

72  Selecting the correct category  A 30 y/o patient presents to your office for redness and swelling in the forearm. You obtain the history, perform examination, and order blood tests. You admit the patient on the same day for treatment. After completion of your office hours that day, you see him in the hospital. › You will not separately report the office visit and the initial hospital care. › Only the initial hospital care ( ) is reported.

73  Selecting the correct category  A 30 y/o patient presents to your office on Wednesday for redness and swelling in the forearm. You obtain the history, perform examination, and order blood tests. You admit the patient on the same day for treatment. On Thursday, you make rounds and see him as an inpatient. The patient is seen again on Friday.

74  Selecting the correct category  A 30 y/o patient presents to your office on Wednesday for redness and swelling in the forearm. You obtain the history, perform examination, and order blood tests. You admit the patient on the same day for treatment. On Thursday, you make rounds and see him as an inpatient. The patient is seen again on Friday. › You report the Wednesday office E/M code ( ). › You also report the appropriate initial hospital care code ( ) for Thursday, which is when you had his first inpatient encounter. › Rounds on Friday will be reported as subsequent hospital care ( ).

75  Selecting the correct category  Dr. A (ED physician) requests your opinion and advice regarding the patient’s displaced tibia fracture. The request and the need for the consultation are documented. You perform the consultation, document your opinion and advice, and communicate this opinion and advice to Dr. A. You then assumes responsibility for the management by taking her to the OR the same day.

76  Selecting the correct category  Dr. A (ED physician) requests your opinion and advice regarding the patient’s displaced tibia fracture. The request and the need for the consultation are documented. You perform the consultation, document your opinion and advice, and communicate this opinion and advice to Dr. A. You then assumes responsibility for the management by taking her to the OR the same day. › You report your E/M services as an office or other outpatient consultation ( ), with -57 modifier appended. › You also report the procedure code for treatment of tibial fracture using intramedullary device (27759).

77  Modifiers  Your patient presents for post-op visit after R carpal tunnel release. At the same visit, he brings up a new complaint of L long finger stiffness and triggering, worse in the morning.

78  Modifiers  Your patient presents for post-op visit after R carpal tunnel release. At the same visit, he brings up a new complaint of L long finger stiffness and triggering, worse in the morning. › For post-op visit, the E/M code is usually › But he has a new complaint, unrelated. › The E/M code for the L long finger trigger should be reported, with modifier:

79  Modifiers  Your patient presents for post-op visit after R carpal tunnel release. At the same visit, he brings up a new complaint of L long finger stiffness and triggering, worse in the morning. You decide to inject the L long finger with Kenalog, and you perform the procedure in your office.

80  Modifiers  Your patient presents for post-op visit after R carpal tunnel release. At the same visit, he brings up a new complaint of L long finger stiffness and triggering, worse in the morning. You decide to inject the L long finger with Kenalog, and you perform the procedure in your office. › The E/M code for the L long finger trigger should be reported (99213).  Because this is within the post-op period, add modifier -24.  For decision for minor office procedure, add modifier -25. › Report the injection of tendon sheath (20550).  Unrelated procedure during post-op period (-79). › Final code set: , and

81  History  CC  HPI (4)  ROS (10)  PFSH (3)  Examination  General, cardiovascular, gait, 4/6 extremities, skin, neuropsychiatric (29)  Decision (2/3)  Options  Risks  Data

82  After this presentation, you should be able to: › Know that E/M stands for › Know the 3 components of the E/M › Distinguish different categories of E/M › Understand levels of complexity › Level Medical Decision Making › Know when modifiers apply (and look them up) › Appropriately document according to E/M level

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