Physician Coding II Evaluation and Management Codes

Physician Coding II Evaluation and Management Codes
E. Douglas Norcross, MD FACS Professor of Surgery Medical University of South Carolina

For most surgeons, procedure codes provide the bulk of codes used for billing.

However, surgeons perform Evaluation and Management services as well.

What are E and M codes anyway?
Procedure codes are descriptors of specific procedures and activities Evaluation and Management Codes (E & M codes) are those used to describe patent encounters

E and M Service Types Commonly Used by Surgeons
Initial inpatient hospital visit Subsequent inpatient hospital visit New outpatient visit Established patient outpatient visit Observation/Inpatient visit: Admitted/Discharged on Same Date Inpatient Hospital Discharge Service Outpatient consultation Inpatient consultation Critical Care

What follows is going to seem almost unbelievably complicated!
That’s because it is! Unfortunately, these are the rules nonetheless

But there are easy tools available one can carry in one’s pocket to help figure out the appropriate level of coding.

Each coding category is associated with a number of “levels of care” An example
99221 Initial Hospital Care for the evaluation and management of a patient which requires these 3 components: A detailed or comprehensive history A detailed or comprehensive examination Medical decision making that is straightforward or of low complexity 99222 Initial Hospital Care for the evaluation and management of a patient which requires these 3 components: A comprehensive history A comprehensive examination Medical decision making of moderate complexity 99223 Initial Hospital Care for the evaluation and management of a patient which requires these 3 components: Medical decision making of high complexity

Another Example Subsequent Hospital Care
99231 Subsequent Hospital Care, per day, for the evaluation and management of a patient, which requires at least two of these three components A problem focused interval history A problem focused examination Medical decision making that is straightforward or of low complexity 99232 Subsequent Hospital Care, per day, for the evaluation and management of a patient, which requires at least two of these three components An expanded problem focused interval history A expanded problem focused examination Medical decision making of moderate complexity 99233 Subsequent Hospital Care, per day, for the evaluation and management of a patient, which requires at least two of these three components A detailed interval history A detailed examination Medical decision making of high complexity

So, to bill an Evaluation and Management Code, a physician must decide not only what type of service was provided, but also at what level.

So how does one decide which level to use?

Picking a Coding Level Level of E and M service depends primarily upon 4 components History Physical Examination Complexity of Decision Making Time (Applies only for certain codes and/or special circumstances)

This is important!! The ONLY thing that matters is how much you document in each of these areas. What you actually do is irrelevant if it isn’t documented!

History Level of history depends upon extent of documentation of:
History of Present Illness Past Medical History/Family History/Social History Review of Systems

A chief complaint must ALWAYS be documented or you can not send a bill!

Physical Examination Level of physical examination depends upon the extent of documentation of the completeness of a physical examination performed.

Complexity of Medical Decision Making
Level of history depends upon extent of documentation of: Number of Diagnoses Amount of information reviewed Risk of Morbidity and mortality

Medical Decision Making
Determining Level of Code Code level Physical Examination History Medical Decision Making # diagnoses Data reviewed M & M risk HPI PFSH ROS

Let’s talk about the patient history first

History Four recognized levels
Problem Focused History Expanded Problem Focused History Detailed History Comprehensive History

So how do we decide if this is a problem focused history, an expanded problem focused history, a detailed history, or a comprehensive History?

History Problem Focused Expanded Problem Focused Detailed
Chief Complaint Brief history of present illness or problem Expanded Problem Focused Problem pertinent system review Detailed Extended history of present illness or problem Problem pertinent system review extended to include a review of a limited number of additional systems Pertinent past, family, and/or social history directly related to the patient’s problems Comprehensive Review of systems that is directly related to the problem(s) identified in the history of present illness plus a review of all additional body systems Complete past, family, and social history

So there are levels for each component of the history
History of Present Illness Past medical Surgical History/Family History/Social History Review of Systems

Let’s start with the History of Present Illness

History Problem Focused Brief history of present illness or problem
Chief Complaint Brief history of present illness or problem Expanded Problem Focused Problem pertinent system review Detailed Extended history of present illness or problem Problem pertinent system review extended to include a review of a limited number of additional systems Pertinent past, family, and/or social history directly related to the patient’s problems Comprehensive Review of systems that is directly related to the problem(s) identified in the history of present illness plus a review of all additional body systems Complete past, family, and social history

So the HPI can be either brief or extended

So what the heck is the difference between a brief History of Present Illness and an extended History of Present Illness?

That depends on how many of the following components are documented.
Location Duration Timing Severity Quality Context Modifying Factors Associated Signs/symptoms

History of Present Illness Components
Location “Where does it hurt” Duration “How long has it hurt” Timing “How often does it hurt” Severity “How badly does it hurt” Quality “What does the pain feel like” Context “When does it hurt” Modifying factors “What makes the pain better or worse” Sign symptoms “What other things related to the pain are present”

History of Present Illness
HPI Level Needed components Brief HPI 1-3 components Extended HPI ≥4 components

Remember. You MUST have a chief complaint documented
Remember. You MUST have a chief complaint documented. It can be contained in the HPI or a narrative history but it has to be there.

Patient is a 25 yo F with abdominal pain.
An Example Chief Complaint Patient is a 25 yo F with abdominal pain. There is no HPI component. Therefore, according to the rules which require at least a brief HPI for any level of history, no billable history is documented for this patient encounter.

That may be OK for some E and M codes which require that only two of the three billing components (History, Physical Examination, and Complexity of Decision Making) are documented. For example, inpatient follow up visits only require two of the three components.

But any new patient encounter requires all three components
But any new patient encounter requires all three components! So, if this is all that is documented for a new patient you are seeing in the ER, you just provided an unbillable service no matter how extensive your documentation of physical examination, and no matter how complex the medical decision making!

You are now working for free!!!

An Example Let’s document a bit better!
Patient is a 25 yo F with 24 hr hx of worsening, continuous, moderately severe, dull, RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting.

Patient is a 25 yo F with 24 hr hx of worsening continuous moderately severe dull RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. Location Duration Timing Severity Quality Context Modifying factors Sign symptoms

Patient is a 25 yo F with 24 hr hx of worsening continuous moderately severe dull RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. Location RLQ Duration Timing Severity Quality Context Modifying factors Sign symptoms

Patient is a 25 yo F with 24 hr hx of worsening continuous moderately severe dull RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. Location RLQ Duration 24 hr hx Timing Severity Quality Context Modifying factors Sign symptoms

Patient is a 25 yo F with 24 hr hx of worsening continuous moderately severe dull RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. Location RLQ Duration 24 hr hx Timing Continuous Severity Quality Context Modifying factors Sign symptoms

Patient is a 25 yo F with 24 hr hx of worsening continuous moderately severe dull RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. Location RLQ Duration 24 hr hx Timing Continuous Severity Moderately severe Quality Context Modifying factors Sign symptoms

Patient is a 25 yo F with 24 hr hx of worsening continuous moderately severe dull RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. Location RLQ Duration 24 hr hx Timing Continuous Severity Moderately severe Quality Dull Context Modifying factors Sign symptoms

Patient is a 25 yo F with 24 hr hx of worsening continuous moderately severe dull RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. Location RLQ Duration 24 hr hx Timing Continuous Severity Moderately severe Quality Dull Context Awoke patient from sleep Modifying factors Sign symptoms

Patient is a 25 yo F with 24 hr hx of worsening continuous moderately severe dull RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. Location RLQ Duration 24 hr hx Timing Continuous Severity Moderately severe Quality Dull Context Awoke patient from sleep Modifying factors Worsened with movement Sign symptoms

Patient is a 25 yo F with 24 hr hx of worsening continuous moderately severe dull RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. Location RLQ Duration 24 hr hx Timing Continuous Severity Moderately severe Quality Dull Context Awoke patient from sleep Modifying factors Worsened with movement Sign symptoms No reported nausea or vomiting

Seriously… how hard is that?
This is an extended HPI with all 8 components and is only two sentences long! Seriously… how hard is that?

So, on the sample coding tool……

Now let’s talk about the Past Medical History, Social History and Family History Components of the overall History

There are three components (And this one is easy!)
Past Medical/Surgical History Family History Social History

Past Medical History, Family History, Social History
Overall History level Needed components Problem Focused Expanded problem focused Detailed 1 of the 3 PFSH components Comprehensive (est. pt.) 2 of the 3 PFSH components Comprehensive (new. pt.) All 3 PFSH components

Adding To Our Example How many components of the PFSH are documented in this note?
Patient is a 25 yo insulin dependent diabetic F with 24 hr hx of worsening, continuous, moderately severe, dull, RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. We have one component (PMH) documented

Adding To Our Example Some More How many components of the PFSH are documented in this note now?
Past Medical History Patient is a 25 yo insulin dependent diabetic F with 24 hr hx of worsening, continuous, moderately severe, dull, RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. The patient is a social drinker. No history of recent febrile illness in the family. Social History Family History

This is adequate for a comprehensive PFSH history!
Isn’t that easy?

So, adding to our example

If this were for an established patient, we would only need two components to achieve the highest level.

Which of these has the higher coding level?
75 year old female with a history of Insulin dependent Diabetes Mellitus, Coronary Artery Disease including having had a Coronary Artery Bypass Graft five years ago. She had a CVA after that surgery and was recently diagnosed with Chronic Obstructive Pulmonary Disease. She takes NSAIDS for arthritis and was recently diagnosed with ALS. Pt is a 25 yo F S/P Lap appy. No smoking. Parents healthy.

Which of these has the higher coding level?
75 year old female with a history of Insulin dependent Diabetes Mellitus, Coronary Artery Disease including having had a Coronary Artery Bypass Graft five years ago. She had a CVA after that surgery and was recently diagnosed with Chronic Obstructive Pulmonary Disease. She takes NSAIDS for arthritis and was recently diagnosed with ALS. (Contains only PMH) Pt is a 25 yo F S/P Lap appy. No smoking. Parents healthy. (Contains PMH, SH and FH) So the second has the higher level of coding!

No one said this all made sense!

And now, the Review of Systems!

The level of coding is based, simply on how many systems you ask about.

Review of Systems Recognized Systems
Constitutional Eyes Ears, Nose, Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin/Integumentary Neurologic Psychiatric Endocrine Hematologic/lymph Allergy/Immunologic

Review of Systems ROS Requirement Needed components None
Problem pertinent 1 Limited 2-9 Complete ROS ≥10

Continuing Our Example How many components of the ROS are documented in this note?
Patient is a 25 yo insulin dependent diabetic F with 24 hr hx of worsening, continuous, moderately severe, dull, RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. The patient is a social drinker. No history of recent febrile illness in the family. Patient reports no chest pain, no dyspnea, no bleeding disorders. No urinary frequency. Wears contact lenses. Occasional sinus problems.

Patient is a 25 yo insulin dependent diabetic F with 24 hr hx of worsening, continuous, moderately severe, dull, RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. The patient is a social drinker. No history of recent febrile illness in the family. Patient reports no chest pain, no dyspnea, no bleeding disorders. No urinary frequency. Wears contact lenses. Occasional sinus problems. Constitutional Cardiovascular Respiratory Gastrointestinal Genitourinary Hematologic/lymph Eyes Ears, Nose, Throat Musculoskeletal Skin/Integumentary Neurologic Psychiatric Endocrine Allergy/Immunologic

Patient is a 25 yo insulin dependent diabetic F with 24 hr hx of worsening, continuous, moderately severe, dull, RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. The patient is a social drinker. No history of recent febrile illness in the family. Patient reports no chest pain, no dyspnea, no bleeding disorders. No urinary frequency. Wears contact lenses. Occasional sinus problems. Constitutional Cardiovascular No Chest Pain Respiratory Gastrointestinal Genitourinary Hematologic/lymph Eyes Ears, Nose, Throat Musculoskeletal Skin/Integumentary Neurologic Psychiatric Endocrine Allergy/Immunologic

Patient is a 25 yo insulin dependent diabetic F with 24 hr hx of worsening, continuous, moderately severe, dull, RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. The patient is a social drinker. No history of recent febrile illness in the family. Patient reports no chest pain, no dyspnea, no bleeding disorders. No urinary frequency. Wears contact lenses. Occasional sinus problems. Constitutional Cardiovascular No Chest Pain Respiratory No Dyspnea Gastrointestinal Genitourinary Hematologic/lymph Eyes Ears, Nose, Throat Musculoskeletal Skin/Integumentary Neurologic Psychiatric Endocrine Allergy/Immunologic

Patient is a 25 yo insulin dependent diabetic F with 24 hr hx of worsening, continuous, moderately severe, dull, RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. The patient is a social drinker. No history of recent febrile illness in the family. Patient reports no chest pain, no dyspnea, no bleeding disorders. No urinary frequency. Wears contact lenses. Occasional sinus problems. Constitutional Cardiovascular No Chest Pain Respiratory No Dyspnea Gastrointestinal Genitourinary Hematologic/lymph No Bleeding Disorders Eyes Ears, Nose, Throat Musculoskeletal Skin/Integumentary Neurologic Psychiatric Endocrine Allergy/Immunologic

Patient is a 25 yo insulin dependent diabetic F with 24 hr hx of worsening, continuous, moderately severe, dull, RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. The patient is a social drinker. No history of recent febrile illness in the family. Patient reports no chest pain, no dyspnea, no bleeding disorders. No urinary frequency. Wears contact lenses. Occasional sinus problems. Constitutional Cardiovascular No Chest Pain Respiratory No Dyspnea Gastrointestinal Genitourinary No Urinary Frequency Hematologic/lymph No Bleeding Disorders Eyes Ears, Nose, Throat Musculoskeletal Skin/Integumentary Neurologic Psychiatric Endocrine Allergy/Immunologic

Patient is a 25 yo insulin dependent diabetic F with 24 hr hx of worsening, continuous, moderately severe, dull, RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. The patient is a social drinker. No history of recent febrile illness in the family. Patient reports no chest pain, no dyspnea, no bleeding disorders. No urinary frequency. Wears contact lenses. Occasional sinus problems. Constitutional Cardiovascular No Chest Pain Respiratory No Dyspnea Gastrointestinal Genitourinary No Urinary Frequency Hematologic/lymph No Bleeding Disorders Eyes Wears Contact Lenses Ears, Nose, Throat Musculoskeletal Skin/Integumentary Neurologic Psychiatric Endocrine Allergy/Immunologic

Patient is a 25 yo insulin dependent diabetic F with 24 hr hx of worsening, continuous, moderately severe, dull, RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. The patient is a social drinker. No history of recent febrile illness in the family. Patient reports no chest pain, no dyspnea, no bleeding disorders. No urinary frequency. Wears contact lenses. Occasional sinus problems. Constitutional Cardiovascular No Chest Pain Respiratory No Dyspnea Gastrointestinal Genitourinary No Urinary Frequency Hematologic/lymph No Bleeding Disorders Eyes Wears Contact Lenses Ears, Nose, Throat Occasional Sinus Problems Musculoskeletal Skin/Integumentary Neurologic Psychiatric Endocrine Allergy/Immunologic

So we have commented on 6 different systems.
ROS Requirement Needed components None Problem pertinent 1 Limited 2-9 Complete ROS ≥10 So this is a limited review of systems

Can we make this a complete review of systems?

Continuing Our Example How many components of the ROS are documented in this note?
Patient is a 25 yo insulin dependent diabetic F with 24 hr hx of worsening, continuous, moderately severe, dull, RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. The patient is a social drinker. No history of recent febrile illness in the family. Patient reports no chest pain, no dyspnea, no bleeding disorders. No urinary frequency. Wears contact lenses. Occasional sinus problems. All other systems negative.

Patient is a 25 yo insulin dependent diabetic F with 24 hr hx of worsening, continuous, moderately severe, dull, RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. The patient is a social drinker. No history of recent febrile illness in the family. Patient reports no chest pain, no dyspnea, no bleeding disorders. No urinary frequency. Wears contact lenses. Occasional sinus problems. All other systems negative. Constitutional All other systems negative. Cardiovascular No Chest Pain Respiratory No Dyspnea Gastrointestinal Genitourinary No Urinary Frequency Hematologic/lymph No Bleeding Disorders Eyes Wears Contact Lenses Ears, Nose, Throat Occasional Sinus Problems Musculoskeletal Skin/Integumentary Neurologic Psychiatric Endocrine Allergy/Immunologic

This is a complete review of systems with all 14 components documented!
That’s not so bad is it!

Review of Systems You can include questions asked in the HPI as part of the review of systems unless you count them as part of the HPI! It is perfectly fine to document “all other systems negative” but, you have to have asked about them all.

You do NOT want to have documented “all other systems negative” and a few days later document that the patient has had auditory hallucinations for five years! The OIG (Office of the Inspector General) would wonder about your initial coding and that is never a good thing.

So let’s go back to our example without the risky “all other systems negative” comment
Patient is a 25 yo insulin dependent diabetic F with 24 hr hx of worsening, continuous, moderately severe, dull, RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. The patient is a social drinker. No history of recent febrile illness in the family. Patient reports no chest pain, no dyspnea, no bleeding disorders. No urinary frequency. Wears contact lenses. Occasional sinus problems.

So, adding ROS to our example

So, is this a detailed history or a comprehensive history?

The level for coding depends upon the lowest component

So this is a detailed history

Can I improve the documentation to get to a comprehensive history?
Patient is a 25 yo insulin dependent diabetic F with 24 hr hx of worsening, continuous, moderately severe, dull, RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. The patient is a social drinker. No history of recent febrile illness in the family. Patient reports no chest pain, no dyspnea, no bleeding disorders. No urinary frequency. Wears contact lenses. Occasional sinus problems. No psychiatric history, joint pain, seizures. Patient is allergic to Penicillin (rash)

Patient is a 25 yo insulin dependent diabetic F with 24 hr hx of worsening, continuous, moderately severe, dull, RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. The patient is a social drinker. No history of recent febrile illness in the family. Patient reports no chest pain, no dyspnea, no bleeding disorders. No urinary frequency. Wears contact lenses. Occasional sinus problems. No psychiatric history, joint pain, seizures. Patient is allergic to Penicillin (rash) Constitutional Cardiovascular No Chest Pain Respiratory No Dyspnea Gastrointestinal Genitourinary No Urinary Frequency Hematologic/lymph No Bleeding Disorders Eyes Wears Contact Lenses Ears, Nose, Throat Occasional Sinus Problems Musculoskeletal Skin/Integumentary Neurologic Psychiatric No Psychiatric History Endocrine Allergy/Immunologic

Patient is a 25 yo insulin dependent diabetic F with 24 hr hx of worsening, continuous, moderately severe, dull, RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. The patient is a social drinker. No history of recent febrile illness in the family. Patient reports no chest pain, no dyspnea, no bleeding disorders. No urinary frequency. Wears contact lenses. Occasional sinus problems. No psychiatric history, joint pain, seizures. Patient is allergic to Penicillin (rash) Constitutional Cardiovascular No Chest Pain Respiratory No Dyspnea Gastrointestinal Genitourinary No Urinary Frequency Hematologic/lymph No Bleeding Disorders Eyes Wears Contact Lenses Ears, Nose, Throat Occasional Sinus Problems Musculoskeletal No Joint Pain Skin/Integumentary Neurologic Psychiatric No Psychiatric History Endocrine Allergy/Immunologic

Patient is a 25 yo insulin dependent diabetic F with 24 hr hx of worsening, continuous, moderately severe, dull, RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. The patient is a social drinker. No history of recent febrile illness in the family. Patient reports no chest pain, no dyspnea, no bleeding disorders. No urinary frequency. Wears contact lenses. Occasional sinus problems. No psychiatric history, joint pain, seizures. Patient is allergic to Penicillin (rash) Constitutional Cardiovascular No Chest Pain Respiratory No Dyspnea Gastrointestinal Genitourinary No Urinary Frequency Hematologic/lymph No Bleeding Disorders Eyes Wears Contact Lenses Ears, Nose, Throat Occasional Sinus Problems Musculoskeletal No Joint Pain Skin/Integumentary Neurologic No seizures Psychiatric No Psychiatric History Endocrine Allergy/Immunologic

Patient is a 25 yo insulin dependent diabetic F with 24 hr hx of worsening, continuous, moderately severe, dull, RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. The patient is a social drinker. No history of recent febrile illness in the family. Patient reports no chest pain, no dyspnea, no bleeding disorders. No urinary frequency. Wears contact lenses. Occasional sinus problems. No psychiatric history, joint pain, seizures. Patient is allergic to Penicillin (rash) Constitutional Cardiovascular No Chest Pain Respiratory No Dyspnea Gastrointestinal Genitourinary No Urinary Frequency Hematologic/lymph No Bleeding Disorders Eyes Wears Contact Lenses Ears, Nose, Throat Occasional Sinus Problems Musculoskeletal No Joint Pain Skin/Integumentary Neurologic No seizures Psychiatric No Psychiatric History Endocrine Allergy/Immunologic Allergic to Penicillin

We now have ten systems covered on our review of systems

Since all three components of the history are at the highest level, we now have a comprehensive history.

What do I do if the patient received a little too much morphine in the emergency department and is barely arousable? How can I obtain a history?

This is a comprehensive history!
HPI: Patient is a 25 yo F who, per Dr Smith, has a 24 hr hx of worsening abdominal pain . No other history is obtainable due to patients altered mental status. This is a comprehensive history!

One can bill as if a history item was completed if you document that it was unable to be completed and why.

Examples Further history unobtainable due to patients altered mental status Social History, Family History and Review of Systems not obtained due to emergent need for evaluation and treatment History obtained from family as above. Further history unobtainable due to patient confusion

So what is the bottom line for history
Always document a chief complaint You only need to document the answer to four HPI questions to get the highest HPI level PMH, FH and SH are important in choosing a coding level No matter what you document for everything else, if you leave out a review of systems, you have the lowest level of history.

Physical Examination

Physical Examination also has levels
Problem Focused Expanded Problem Focused Detailed Comprehensive

Physical Examination 1995 Rules
Level of code based on number of body areas examined and extent of exam in each area

Physical Examination Body Areas
Head Including the face Neck Chest including breast and axilla Abdomen Genitalia, groin, and buttocks Back Each extremity

Problem focused: A limited Examination of the affected body area or organ system Expanded problem focused: A limited examination of the affected body area or organ system and other symptomatic or related organ system(s) Detailed: An extended examination of the affected body area(s) and other symptomatic or related organ system(s) Comprehensive: A general multisystem examination or a complete examination of a single organ system

However, 1995 rules were considered too vague and were “clarified” in 1997.

Level of code based on number of organ systems examined and extent of exam in each area based on a designated series of “bullets” assigned to each organ system.

Do not even think about trying to memorize the next six slides!!!!

Physical Examination Organ Systems
Eyes Ears, nose, mouth, and throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic/lymphatic/immunologic

Physical Examination “Bullets”
Constitutional Three vital signs (NOTE: MUST HAVE THREE VITAL SIGNS LISTED, AF/VSS does NOT count!) General appearance Eyes Inspection of conjunctivae and lids Examination of pupils and irises (PERRLA) Ophthalmoscopic discs and posterior segments Ears, Nose, Mouth, and Throat External appearance of the ears and nose (overall appearance, scars, lesions, masses) Otoscopic examination of the external auditory canals and tympanic membranes Assessment of hearing Inspection of nasal mucosa, septum and turbinates Inspection of lips, teeth and gums Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx Neck Examination of neck (e.g., masses, overall appearance, symmetry, tracheal position, crepitus) Examination of thyroid

Physical Examination “Bullets” 1997 rules
Respiratory (Four possible “bullets”) Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic movement) Percussion of chest (e.g., dullness, flatness, hyperresonance) Palpation of chest (e.g., tactile fremitus) Auscultation of the lungs Cardiovascular (Seven possible “bullets”) Palpation of the heart (location, size, thrills) Auscultation of the heart with notation of abnormal sounds and murmurs Assessment of lower extremities for edema and/or varicosities Examination of the carotid arteries (e.g., pulse amplitude, bruits) Examination of abdominal aorta (e.g., size, bruits) Examination of the femoral arteries (e.g., pulse amplitude, bruits) Examination of the pedal pulses (e.g., pulse amplitude) Chest (Breasts) (Two possible “bullets”) Inspection of the breasts (e.g., symmetry, nipple discharge) Palpation of the breasts and axillae (e.g., masses, lumps, tenderness)

Gastrointestinal (Abdomen) (Five possible “bullets”) Examination of the abdomen with notation of presence of masses or tenderness Examination of the liver and spleen Examination for the presence or absence of hernias Examination (when indicated) of anus, perineum, and rectum, including sphincter tone, presence of hemorrhoids, rectal masses Obtain stool for occult blood testing when indicated Genitourinary (Male) (Three possible “bullets”) Examination of the scrotal contents (e.g., hydrocoele, spermatocoele, tenderness of cord, testicular mass) Examination of the penis Digital rectal examination of the prostate gland (e.g., size, symmetry, nodularity, tenderness) Genitourinary (Female) Pelvic examination (with or without specimen collection for smears and cultures, which may include: (Six possible “bullets”) Examination of the external genitalia (e.g., general appearance, hair distribution, lesions) Examination of the urethra (e.g., masses, tenderness, scarring) Examination of the bladder (e.g., fullness, masses, tenderness) Examination of the cervix (e.g., general appearance, discharge, lesions) Examination of the uterus (e.g., size, contour, position, mobility, tenderness, consistency, descent or support) Examination of the adnexa/parametria (e.g., masses, tenderness, organomegaly, nodularity)

Lymphatic : Palpation of lymph nodes two or more areas: (Four possible “bullets”) Neck Axillae Groin Other (NOTE: MUST DOCUMENT EXAMINATION OF TWO NODAL BASINS TO EARN A BULLET!) Skin (Two possible “bullets”) Inspection of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers) Palpation of the skin and subcutaneous tissue (e.g., induration, subcutaneous nodules, tightening) Neurologic (Three possible “bullets”) Test cranial nerves with notation of any deficits Examination of DTRs with notation of any pathologic reflexes (e.g., Babinksi) Examination of sensation (e.g., by touch, pin, vibration, proprioception Psychiatric (Two possible “bullets”) Description of patient’s judgment and insight Brief assessment of mental status which may include orientation to time, place, and person recent and remote memory mood and affect

Musculoskeletal (Three possible “bullets”) Examination of gait and station Inspection and/or palpation of digits and nails (e.g., clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes) Examination of the joints, bones, and muscles of one or more of the following six areas: head and neck spine, ribs, and pelvis right upper extremity left upper extremity right lower extremity left lower extremity The examination of a given area may include: Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses or effusions Assessment of range of motion with notation of any pain, crepitation or contracture Assessment of stability with notation of any dislocation, subluxation, or laxity Assessment of muscle strength and tone (e.g., flaccid, cogwheel, spastic) with notation of any atrophy or abnormal movements

Physical Examination Level 1997 rules
Needed components Problem Focused 1 to 5 bullets from one or more organ systems Expanded problem focused At least six bullets from any organ systems Detailed At least two bullets from 6 organ systems OR 12 bullets from 2 or more organ systems Comprehensive 2 bullets from each of 9 organ systems

But I’m a vascular surgeon. No one comes to me look in their ears
But I’m a vascular surgeon. No one comes to me look in their ears! Can I ever achieve a comprehensive examination?

The 1997 revision included descriptions of specialty examinations

11 recognized specialty examinations
Cardiovascular Ear, nose, and throat Eye Genitourinary (Male) Genitourinary (Female) Hematologic, Lymphatic, Immunologic Musculoskeletal Neurologic Psychiatric Respiratory Skin

An example The Cardiovascular Specialty Examination

Cardiovascular Specialty Examination
The Chest (Breasts), Head/Face, Lymphatic and Genitourinary body systems/body areas are not considered integral parts of the cardiovascular specialty exam

Cardiovascular Specialty Examination
Level of Exam Bullets Problem Focused 1-5 specialty exam bullets Expanded Problem Focused 6-11 specialty exam bullets Detailed ≥ 12 specialty exam bullets Comprehensive At least 1 specialty examination bullet from each box within box “A” AND Every bullet from each box within box “B”

Cardiovascular Specialty Examination Box “A”
Organ System Bullets Eyes Inspection of conjunctivae and lids Ears, Nose, Mouth and Throat Inspection of teeth, gums and palate Inspection of oral mucosa with notation of presence of pallor or cyanosis Neck Examination of jugular veins (e.g., distension; a, v or cannon a waves) Examination of thyroid (e.g., enlargement, tenderness, mass) Musculoskeletal Examination of the back with notation of kyphosis or scoliosis Examination of gait with notation of ability to undergo exercise testing and/or participation in exercise programs Assessment of muscle strength and tone (e.g., flaccid, cog wheel, spastic) with notation of any atrophy and abnormal movements Extremities Inspection and palpation of digits and nails (e.g., clubbing, cyanosis, inflammation, petechiae, ischemia, infections, Osler's nodes) Skin Inspection and/or palpation of skin and subcutaneous tissue (e.g., stasis, dermatitis, ulcers, scars, xanthomas)

Cardiovascular Specialty Examination Box “B”
Organ System Bullets Cardiovascular Palpation of heart (e.g., location, size and forcefulness of the point of maximal impact; thrills; lifts; palpable S3 or S4) Auscultation of heart including sounds, abnormal sounds and murmurs Measurement of blood pressure in two or more extremities when indicated (e.g., aortic dissection, coarctation) Examination of: Carotid arteries (e.g., waveform, pulse amplitude, bruits, apical-carotid delay) Abdominal aorta (e.g., size, bruits) Femoral arteries (e.g., pulse amplitude, bruits) Pedal pulses (e.g., pulse amplitude) Extremities for peripheral edema and/or varicosities Constitutional Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff) General appearance of patient (e.g., development, nutrition, body habitus, deformities, attention to grooming) Gastrointestinal (Abdomen) Examination of abdomen with notation of presence of masses or tenderness Examination of liver and spleen Obtain stool sample for occult blood from patients who are being considered for thrombolytic or anticoagulant therapy Neurological/Psychiatric Brief assessment of mental status including: Orientation to time, place and person Mood and affect (e.g., depression, anxiety, agitation) Respiratory Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic movement) Auscultation of lungs (e.g., breath sounds, adventitious sounds, rubs)

Confused yet? So was every physician in the country!

Physical Examination 1997 rules
The 1997 rules were so complicated that even congress recognized that they were absurdly complex and unworkable.

So you can apply either the 1995 or the 1997 set of rules as you see fit!

Physical Examination 1997 rules
Although 1995 rules are recognized, following the 1997 rules may avoid any unfortunate disagreements in the event of a CMS audit due to the ambiguity of the 1995 rules.

Many available coding tools list both methods

Back to our Example Patient is a 25 yo insulin dependent diabetic F with 24 hr hx of worsening, continuous, moderately severe, dull, RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. The patient is a social drinker. No history of recent febrile illness in the family. Patient reports no chest pain, no dyspnea, no bleeding disorders. No urinary frequency. Wears contact lenses. Occasional sinus problems. No psychiatric history, joint pain, seizures. Patient is allergic to Penicillin (rash) On exam, pts. abdomen is tender at McBurney’s point. Pt has rebound tenderness referred to RLQ. This is probably best described as a limited examination of an affected body area by 1995 rules

1997 Rules On exam, pts. abdomen is tender at McBurney’s point
1997 Rules On exam, pts. abdomen is tender at McBurney’s point. Pt has rebound tenderness referred to RLQ. Gastrointestinal (Abdomen) (Five possible “bullets”) Examination of the abdomen with notation of presence of masses or tenderness Examination of the liver and spleen Examination for the presence or absence of hernias Examination (when indicated) of anus, perineum, and rectum, including sphincter tone, presence of hemorrhoids, rectal masses Obtain stool for occult blood testing when indicated So we only have one “bullet” documented.

On exam, pts. abdomen is tender at McBurney’s point
On exam, pts. abdomen is tender at McBurney’s point. Pt has rebound tenderness referred to RLQ. This would be a problem focused examination by 1995 rules And also by 1997 rules

Can we do better? The importance of documenting negative findings!
On exam, the patient is a well developed, well nourished, awake, alert & oriented female. Temp: 98.8F Pulse: 78, BP: 120/75. Heart regular rate and rhythm. Lungs clear. Abdomen is tender at McBurney’s point. Pt has rebound tenderness referred to RLQ. No hepatosplenomegaly. No hernias noted. No previous abdominal incisions. Normal rectal exam. Stool hemoccult negative. No cervical tenderness on pelvic examination. No leg edema. No lymphadenopathy noted.

On exam, the patient is a well developed, well nourished, awake, alert & oriented female. Temp: 98.8F Pulse: 78, BP: 120/75. Heart regular rate and rhythm. Lungs clear. Abdomen is tender at McBurney’s point. Pt has rebound tenderness referred to RLQ. No hepatosplenomegaly. No hernias noted. No previous abdominal incisions. Normal rectal exam. Stool hemoccult negative. No cervical tenderness on pelvic examination. No leg edema. No lymphadenopathy noted. By the 1995 rules this is probably best described as an “extended examination of the affected area and other symptomatic or related systems”

1997 Rules On exam, the patient is a well developed, well nourished, awake, alert & oriented female. Temp: 98.8F Pulse: 78, BP: 120/75. Heart regular rate and rhythm. Lungs clear. Abdomen is tender at McBurney’s point. Pt has rebound tenderness referred to RLQ. No hepatosplenomegaly. No hernias noted. No previous abdominal incisions. Normal rectal exam. Stool hemoccult negative. No cervical tenderness on pelvic examination. No leg edema. No lymphadenopathy noted. Organ System Physical Exam Findings Bullets Constitutional WD/WN F, P 78, BP 120/75, Temp 98.8 2 bullets Eyes Ears, Nose, Mouth, and Throat Neck Respiratory Cardiovascular Chest (Breasts) Gastrointestinal (Abdomen) Genitourinary (Male) Genitourinary (Female) Lymphatic Musculoskeletal Skin Neurologic Psychiatric

1997 Rules On exam, the patient is a well developed, well nourished, awake, alert & oriented female. Temp: 98.8F Pulse: 78, BP: 120/75. Heart regular rate and rhythm. Lungs clear. Abdomen is tender at McBurney’s point. Pt has rebound tenderness referred to RLQ. No hepatosplenomegaly. No hernias noted. No previous abdominal incisions. Normal rectal exam. Stool hemoccult negative. No cervical tenderness on pelvic examination. No leg edema. No lymphadenopathy noted. Organ System Physical Exam Findings Bullets Constitutional WD/WN F, P 78, BP 120/75, Temp 98.8 2 bullets Eyes Ears, Nose, Mouth, and Throat Neck Respiratory Lungs clear 1 bullet Cardiovascular Chest (Breasts) Gastrointestinal (Abdomen) Genitourinary (Male) Genitourinary (Female) Lymphatic Musculoskeletal Skin Neurologic Psychiatric

1997 Rules On exam, the patient is a well developed, well nourished, awake, alert & oriented female. Temp: 98.8F Pulse: 78, BP: 120/75. Heart regular rate and rhythm. Lungs clear. Abdomen is tender at McBurney’s point. Pt has rebound tenderness referred to RLQ. No hepatosplenomegaly. No hernias noted. No previous abdominal incisions. Normal rectal exam. Stool hemoccult negative. No cervical tenderness on pelvic examination. No leg edema. No lymphadenopathy noted. Organ System Physical Exam Findings Bullets Constitutional WD/WN F, P 78, BP 120/75, Temp 98.8 2 bullets Eyes Ears, Nose, Mouth, and Throat Neck Respiratory Lungs clear 1 bullet Cardiovascular Heart regular rate and rhythm Chest (Breasts) Gastrointestinal (Abdomen) Genitourinary (Male) Genitourinary (Female) Lymphatic Musculoskeletal Skin Neurologic Psychiatric

1997 Rules On exam, the patient is a well developed, well nourished, awake, alert & oriented female. Temp: 98.8F Pulse: 78, BP: 120/75. Heart regular rate and rhythm. Lungs clear. Abdomen is tender at McBurney’s point. Pt has rebound tenderness referred to RLQ. No hepatosplenomegaly. No hernias noted. No previous abdominal incisions. Normal rectal exam. Stool hemoccult negative. No cervical tenderness on pelvic examination. No leg edema. No lymphadenopathy noted. Organ System Physical Exam Findings Bullets Constitutional WD/WN F, P 78, BP 120/75, Temp 98.8 2 bullets Eyes Ears, Nose, Mouth, and Throat Neck Respiratory Lungs clear 1 bullet Cardiovascular Heart regular rate and rhythm Chest (Breasts) Gastrointestinal (Abdomen) Abdomen is tender at McBurney’s point. Pt has rebound tenderness referred to RLQ. No hepatosplenomegaly. No hernias noted, Normal rectal exam. Stool hemoccult negative. 5 bullets Genitourinary (Male) Genitourinary (Female) Lymphatic Musculoskeletal Skin Neurologic Psychiatric

1997 Rules On exam, the patient is a well developed, well nourished, awake, alert & oriented female. Temp: 98.8F Pulse: 78, BP: 120/75. Heart regular rate and rhythm. Lungs clear. Abdomen is tender at McBurney’s point. Pt has rebound tenderness referred to RLQ. No hepatosplenomegaly. No hernias noted. No previous abdominal incisions. Normal rectal exam. Stool hemoccult negative. No cervical tenderness on pelvic examination. No leg edema. No lymphadenopathy noted. Organ System Physical Exam Findings Bullets Constitutional WD/WN F, P 78, BP 120/75, Temp 98.8 2 bullets Eyes Ears, Nose, Mouth, and Throat Neck Respiratory Lungs clear 1 bullet Cardiovascular Heart regular rate and rhythm Chest (Breasts) Gastrointestinal (Abdomen) Abdomen is tender at McBurney’s point. Pt has rebound tenderness referred to RLQ. No hepatosplenomegaly. No hernias noted, Normal rectal exam. Stool hemoccult negative. 5 bullets Genitourinary (Male) Genitourinary (Female) No cervical tenderness on pelvic examination. Lymphatic Musculoskeletal Skin Neurologic Psychiatric

1997 Rules On exam, the patient is a well developed, well nourished, awake, alert & oriented female. Temp: 98.8F Pulse: 78, BP: 120/75. Heart regular rate and rhythm. Lungs clear. Abdomen is tender at McBurney’s point. Pt has rebound tenderness referred to RLQ. No hepatosplenomegaly. No hernias noted. No previous abdominal incisions. Normal rectal exam. Stool hemoccult negative. No cervical tenderness on pelvic examination. No leg edema. No lymphadenopathy noted. Organ System Physical Exam Findings Bullets Constitutional WD/WN F, P 78, BP 120/75, Temp 98.8 2 bullets Eyes Ears, Nose, Mouth, and Throat Neck Respiratory Lungs clear 1 bullet Cardiovascular Heart regular rate and rhythm Chest (Breasts) Gastrointestinal (Abdomen) Abdomen is tender at McBurney’s point. Pt has rebound tenderness referred to RLQ. No hepatosplenomegaly. No hernias noted, Normal rectal exam. Stool hemoccult negative. 5 bullets Genitourinary (Male) Genitourinary (Female) No cervical tenderness on pelvic examination. Lymphatic Musculoskeletal Skin No previous abdominal incisions. Neurologic Psychiatric

1997 Rules On exam, the patient is a well developed, well nourished, awake, alert & oriented female. Temp: 98.8F Pulse: 78, BP: 120/75. Heart regular rate and rhythm. Lungs clear. Abdomen is tender at McBurney’s point. Pt has rebound tenderness referred to RLQ. No hepatosplenomegaly. No hernias noted. No previous abdominal incisions. Normal rectal exam. Stool hemoccult negative. No cervical tenderness on pelvic examination. No leg edema. No lymphadenopathy noted. Organ System Physical Exam Findings Bullets Constitutional WD/WN F, P 78, BP 120/75, Temp 98.8 2 bullets Eyes Ears, Nose, Mouth, and Throat Neck Respiratory Lungs clear 1 bullet Cardiovascular Heart regular rate and rhythm Chest (Breasts) Gastrointestinal (Abdomen) Abdomen is tender at McBurney’s point. Pt has rebound tenderness referred to RLQ. No hepatosplenomegaly. No hernias noted, Normal rectal exam. Stool hemoccult negative. 5 bullets Genitourinary (Male) Genitourinary (Female) No cervical tenderness on pelvic examination. Lymphatic Musculoskeletal Skin No previous abdominal incisions. Neurologic awake, alert & oriented Psychiatric

1997 Rules On exam, the patient is a well developed, well nourished, awake, alert & oriented female. Temp: 98.8F Pulse: 78, BP: 120/75. Heart regular rate and rhythm. Lungs clear. Abdomen is tender at McBurney’s point. Pt has rebound tenderness referred to RLQ. No hepatosplenomegaly. No hernias noted. No previous abdominal incisions. Normal rectal exam. Stool hemoccult negative. No cervical tenderness on pelvic examination. No leg edema. No lymphadenopathy noted. Organ System Physical Exam Findings Bullets Constitutional WD/WN F, P 78, BP 120/75, Temp 98.8 2 bullets Eyes Ears, Nose, Mouth, and Throat Neck Respiratory Lungs clear 1 bullet Cardiovascular Heart regular rate and rhythm Chest (Breasts) Gastrointestinal (Abdomen) Abdomen is tender at McBurney’s point. Pt has rebound tenderness referred to RLQ. No hepatosplenomegaly. No hernias noted, Normal rectal exam. Stool hemoccult negative. 5 bullets Genitourinary (Male) Genitourinary (Female) No cervical tenderness on pelvic examination. Lymphatic Musculoskeletal No leg edema Skin No previous abdominal incisions. Neurologic awake, alert & oriented Psychiatric

1997 Rules On exam, the patient is a well developed, well nourished, awake, alert & oriented female. Temp: 98.8F Pulse: 78, BP: 120/75. Heart regular rate and rhythm. Lungs clear. Abdomen is tender at McBurney’s point. Pt has rebound tenderness referred to RLQ. No hepatosplenomegaly. No hernias noted. No previous abdominal incisions. Normal rectal exam. Stool hemoccult negative. No cervical tenderness on pelvic examination. No leg edema. No lymphadenopathy noted. Organ System Physical Exam Findings Bullets Constitutional WD/WN F, P 78, BP 120/75, Temp 98.8 2 bullets Eyes Ears, Nose, Mouth, and Throat Neck Respiratory Lungs clear 1 bullet Cardiovascular Heart regular rate and rhythm Chest (Breasts) Gastrointestinal (Abdomen) Abdomen is tender at McBurney’s point. Pt has rebound tenderness referred to RLQ. No hepatosplenomegaly. No hernias noted, Normal rectal exam. Stool hemoccult negative. 5 bullets Genitourinary (Male) Genitourinary (Female) No cervical tenderness on pelvic examination. Lymphatic No lymphadenopathy noted Musculoskeletal No leg edema Skin No previous abdominal incisions. Neurologic awake, alert & oriented Psychiatric

1997 Rules So we now have 14 bullets in 9 different systems just by documenting negative findings!
Organ System Physical Exam Findings Bullets Constitutional WD/WN F, P 78, BP 120/75, Temp 98.8 2 bullets Eyes Ears, Nose, Mouth, and Throat Neck Respiratory Lungs clear 1 bullet Cardiovascular Heart regular rate and rhythm Chest (Breasts) Gastrointestinal (Abdomen) Abdomen is tender at McBurney’s point. Pt has rebound tenderness referred to RLQ. No hepatosplenomegaly. No hernias noted, Normal rectal exam. Stool hemoccult negative. 5 bullets Genitourinary (Male) Genitourinary (Female) No cervical tenderness on pelvic examination. Lymphatic No lymphadenopathy noted Musculoskeletal No leg edema Skin No previous abdominal incisions. Neurologic awake, alert & oriented Psychiatric

On exam, the patient is a well developed, well nourished, awake, alert & oriented female. Temp: 98.8F Pulse: 78, BP: 120/75. Heart regular rate and rhythm. Lungs clear. Abdomen is tender at McBurney’s point. Pt has rebound tenderness referred to RLQ. No hepatosplenomegaly. No hernias noted. No previous abdominal incisions. Normal rectal exam. Stool hemoccult negative. No cervical tenderness on pelvic examination. No leg edema. No lymphadenopathy noted. This would be a comprehensive examination by 1995 rules And also by 1997 rules

The bottom line on physical examination
Perform a thorough physical examination appropriate to the problem. (Just another way of saying be a good doctor!) Document all positive AND negative findings. Use the available tools to figure out what level examination you have performed

Unlike history, and physical examination, medical decision making is not divided into problem focused, expanded problem focused, detailed, and comprehensive levels

Instead, medical decision making is divided into straightforward, low, moderate, and high complexity levels

Level of complexity of medical decision making is based on three factors Problem Points: The nature and number of clinical problems for which the patient is being evaluated or managed. Data Points: The amount of patient related data reviewed Risk: Risk of patient complications, morbidity and/or mortality

Problem Points Data Points Risk Straightforward Complexity 1 Minimal Low Complexity 2 Low Moderate Complexity 3 Moderate High Complexity 4 High

Problem Points Data Points Risk Straightforward Complexity 1 Minimal Low Complexity 2 Low Moderate Complexity 3 Moderate High Complexity 4 High Level of medical decision making depends upon highest two out of the three above!

Problem Points Data Points Risk Straightforward Complexity 1 Minimal Low Complexity 2 Low Moderate Complexity 3 Moderate High Complexity 4 High So, for a patient scored as above, this would be a “moderate complexity” level of medical decision making.

Problem Points Data Points Risk Straightforward Complexity 1 Minimal Low Complexity 2 Low Moderate Complexity 3 Moderate High Complexity 4 High So, would this! You only need two of the three!

It’s a matter of “points” earned for each of the three areas

Problem Points Each problem listed in your documentation gets assigned a certain number of points
Self-limited or minor (maximum of 2 self limited problems can be assigned points) 1 Established problem, stable or improving Established problem, worsening 2 New problem (to you!), with no additional work-up planned (maximum of 1) 3 New problem (to you!), with additional work-up planned 4 So it is important to list, not just each problem, but also whether the problem is stable, worsening, or improving and whether any additional workup is planned

So, back to our example Patient is a 25 yo insulin dependent diabetic F with 24 hr hx of worsening, continuous, moderately severe, dull, RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. The patient is a social drinker. No history of recent febrile illness in the family. Patient reports no chest pain, no dyspnea, no bleeding disorders. No urinary frequency. Wears contact lenses. Occasional sinus problems. No psychiatric history, joint pain, seizures. Patient is allergic to Penicillin (rash) On exam, the patient is a well developed, well nourished, awake, alert & oriented female. Temp: 98.8F Pulse: 78, BP: 120/75. Heart regular rate and rhythm. Lungs clear. Abdomen is tender at McBurney’s point. Pt has rebound tenderness referred to RLQ. No hepatosplenomegaly. No hernias noted. No previous abdominal incisions. Normal rectal exam. Stool hemoccult negative. No cervical tenderness on pelvic examination. No leg edema. No lymphadenopathy noted. Assessment: Acute Appendicitis (New), Insulin Dependent Diabetes Mellitus (Stable) Plan: OR for laparoscopic appendectomy

Calculating Problem Points
Assessment: Acute Appendicitis (New), Insulin Dependent Diabetes Mellitus (Stable) Plan: OR for laparoscopic appendectomy Problem Points Self-limited or minor (maximum of 2 self limited problems can be assigned points) 1 Established problem, stable or improving Established problem, worsening 2 New problem (to you!), with no additional work-up planned (maximum of 1) 3 New problem (to you!), with additional work-up planned 4 So we have a total of four problem points documented Adding Diabetes to the problem list increased the documentation to the maximum level

Data Points Data Reviewed Points Review or order clinical lab tests 1
Review or order radiology test (except heart catheterization or Echo) Review or order medicine test (PFTs, EKG, cardiac echo or catheterization, etc.) Discuss test with performing physician Independent review of image, tracing, or specimen 2 Decision to obtain old records Review and summation of old records

Data Points One can only use any one category of data review once for any single encounter. For example, if you order a CBC as well as a Chem 7, you only get 1 point, not 1 point for each test ordered. No “double dipping” is allowed. For example, if you order labs and then review those results during the same visit, you only get one point, not one point for ordering and one point for reviewing.

Data Points You can claim points for reviewing an image or tracing, even if the image, tracing or specimen has been reviewed by another physician (as when a radiologist provides an official interpretation for an X-ray). However, you must include your own interpretation in the chart in order to claim these points.

Back to our example Patient is a 25 yo insulin dependent diabetic F with 24 hr hx of worsening, continuous, moderately severe, dull, RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. The patient is a social drinker. No history of recent febrile illness in the family. Patient reports no chest pain, no dyspnea, no bleeding disorders. No urinary frequency. Wears contact lenses. Occasional sinus problems. No psychiatric history, joint pain, seizures. Patient is allergic to Penicillin (rash) On exam, the patient is a well developed, well nourished, awake, alert & oriented female. Temp: 98.8F Pulse: 78, BP: 120/75. Heart regular rate and rhythm. Lungs clear. Abdomen is tender at McBurney’s point. Pt has rebound tenderness referred to RLQ. No hepatosplenomegaly. No hernias noted. No previous abdominal incisions. Normal rectal exam. Stool hemoccult negative. No cervical tenderness on pelvic examination. No leg edema. No lymphadenopathy noted. CBC shows increased WBC count to CT scan reviewed which shows inflammatory changes in RLQ of abdomen. Assessment: Acute Appendicitis (New), Insulin Dependent Diabetes Mellitus (Stable) Plan: OR for laparoscopic appendectomy

Calculating Data Points
CBC shows increased WBC count to CT scan reviewed which shows inflammatory changes in RLQ of abdomen. Data Reviewed Points Review or order clinical lab tests 1 Review or order radiology test (except heart catheterization or Echo) Review or order medicine test (PFTs, EKG, cardiac echo or catheterization, etc.) Discuss test with performing physician Independent review of image, tracing, or specimen 2 Decision to obtain old records Review and summation of old records So we have a total of three data points.

Risk Assessment Risk assessment is basically a measure of how sick the patient is and how much risk their work up and treatment places upon them

Risk assessment Level of risk is determined by examining three separate dimensions of the encounter
Presenting problems Diagnostic procedures Management options selected

Diagnostic Procedures Management Options Selected
Risk Assessment Risk Level Presenting Problems Diagnostic Procedures Management Options Selected Minimal Risk (Requires ONE of these elements in ANY of the three categories listed) One self-limited or minor problem, e.g., cold, insect bite, tinea corporis (Why did this patient even come to see me?) Laboratory tests Chest X-rays EKG/EEG Urinalysis Ultrasound/Echocardiogram KOH prep Rest Gargles Elastic bandages Superficial dressings Low Risk (Requires ONE of these elements in ANY of the three categories listed) Two or more self-limited or minor problems One stable chronic illness, e.g., well controlled , DM2, cataract Acute uncomplicated injury or illness, e.g., cystitis, allergic rhinitis, sprain Physiologic tests not under stress, e.g., PFTs Non-cardiovascular imaging studies with contrast, e.g., barium enema Superficial needle biopsy ABG Skin biopsies Over the counter drugs Minor surgery, with no identified risk factors Physical therapy Occupational therapy IV fluids, without additives

Risk Assessment Risk Level Presenting Problems Diagnostic Procedures Management Options Selected Moderate Risk (Requires ONE of these elements in ANY of the three categories listed) Two stable chronic illnesses One chronic illness with mild exacerbation or progression Undiagnosed new problem with uncertain prognosis (e.g., lump in breast) Acute illness with systemic symptoms (e.g., pyelonephritis, pneumonitis, colitis Acute complicated injury (e.g., head injury with brief loss of consciousness) Physiologic tests under stress, e.g., cardiac stress test, fetal contraction stress test Diagnostic endoscopies, with no identified risk factors Deep needle, or incisional biopsies Cardiovascular imaging studies, with contrast, with no identified risk factors, e.g., arteriogram, cardiac catheterization Obtain fluid from body cavity, e.g., LP/thoracentesis Minor surgery, with identified risk factors Elective major surgery (open, percutaneous, or endoscopic), with no identified risk factors Prescription drug management Therapeutic nuclear medicine IV fluids, with additives Closed treatment of fracture or dislocation, without manipulation

Risk Assessment Risk Level Presenting Problems Diagnostic Procedures Management Options Selected High Risk (Requires ONE of these elements in ANY of the three categories listed) One or more chronic illness, with severe exacerbation or progression Acute or chronic illness or injury, which poses a threat to life or bodily function, e.g., multiple trauma, acute MI, pulmonary embolism, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness, with potential threat to self or others, peritonitis, ARF An abrupt change in neurological status, e.g., seizure, TIA, weakness, sensory loss Cardiovascular imaging, with contrast, with identified risk factors Cardiac EP studies Diagnostic endoscopies, with identified risk factors Discography Elective major surgery (open, percutaneous, endoscopic), with identified risk factors Emergency major surgery (open, percutaneous, endoscopic) Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Decision not to resuscitate, or to de-escalate care because of poor prognosis

Back to our example Patient is a 25 yo insulin dependent diabetic F with 24 hr hx of worsening, continuous, moderately severe, dull, RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. The patient is a social drinker. No history of recent febrile illness in the family. Patient reports no chest pain, no dyspnea, no bleeding disorders. No urinary frequency. Wears contact lenses. Occasional sinus problems. No psychiatric history, joint pain, seizures. Patient is allergic to Penicillin (rash) On exam, the patient is a well developed, well nourished, awake, alert & oriented female. Temp: 98.8F Pulse: 78, BP: 120/75. Heart regular rate and rhythm. Lungs clear. Abdomen is tender at McBurney’s point. Pt has rebound tenderness referred to RLQ. No hepatosplenomegaly. No hernias noted. No previous abdominal incisions. Normal rectal exam. Stool hemoccult negative. No cervical tenderness on pelvic examination. No leg edema. No lymphadenopathy noted. CBC shows increased WBC count to CT scan reviewed which shows inflammatory changes in RLQ of abdomen. Assessment: Acute Appendicitis (New), Insulin Dependent Diabetes Mellitus (Stable) Plan: OR for laparoscopic appendectomy

What is the risk? Risk Level Presenting Problems Diagnostic Procedures Management Options Selected Minimal Risk (Requires ONE of these elements in ANY of the three categories listed) One self-limited or minor problem, e.g., cold, insect bite, tinea corporis (Why did this patient even come to see me?) Laboratory tests Chest X-rays EKG/EEG Urinalysis Ultrasound/Echocardiogram KOH prep Rest Gargles Elastic bandages Superficial dressings Low Risk (Requires ONE of these elements in ANY of the three categories listed) Two or more self-limited or minor problems One stable chronic illness, e.g., well controlled , DM2, cataract Acute uncomplicated injury or illness, e.g., cystitis, allergic rhinitis, sprain Physiologic tests not under stress, e.g., PFTs Non-cardiovascular imaging studies with contrast, e.g., barium enema Superficial needle biopsy ABG Skin biopsies Over the counter drugs Minor surgery, with no identified risk factors Physical therapy Occupational therapy IV fluids, without additives

What is the risk? Risk Level Presenting Problems Diagnostic Procedures Management Options Selected Moderate Risk (Requires ONE of these elements in ANY of the three categories listed) Two stable chronic illnesses One chronic illness with mild exacerbation or progression Undiagnosed new problem with uncertain prognosis (e.g., lump in breast) Acute illness with systemic symptoms (e.g., pyelonephritis, pneumonitis, colitis Acute complicated injury (e.g., head injury with brief loss of consciousness) Physiologic tests under stress, e.g., cardiac stress test, fetal contraction stress test Diagnostic endoscopies, with no identified risk factors Deep needle, or incisional biopsies Cardiovascular imaging studies, with contrast, with no identified risk factors, e.g., arteriogram, cardiac catheterization Obtain fluid from body cavity, e.g., LP/thoracentesis Minor surgery, with identified risk factors Elective major surgery (open, percutaneous, or endoscopic), with no identified risk factors Prescription drug management Therapeutic nuclear medicine IV fluids, with additives Closed treatment of fracture or dislocation, without manipulation

What is the risk? Risk Level Presenting Problems Diagnostic Procedures Management Options Selected High Risk (Requires ONE of these elements in ANY of the three categories listed) One or more chronic illness, with severe exacerbation or progression Acute or chronic illness or injury, which poses a threat to life or bodily function, e.g., multiple trauma, acute MI, pulmonary embolism, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness, with potential threat to self or others, peritonitis, ARF An abrupt change in neurological status, e.g., seizure, TIA, weakness, sensory loss Cardiovascular imaging, with contrast, with identified risk factors Cardiac EP studies Diagnostic endoscopies, with identified risk factors Discography Elective major surgery (open, percutaneous, endoscopic), with identified risk factors Emergency major surgery (open, percutaneous, endoscopic) Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Decision not to resuscitate, or to de-escalate care because of poor prognosis

What is the risk? Therefore, this is a high risk patient

So what is the level of medical decision making for this encounter?
Problem Points Data Points Risk Straightforward Complexity 1 Minimal Low Complexity 2 Low Moderate Complexity 3 Moderate High Complexity 4 High Remember, we determine the level of medical decision making based on the lower of the two highest scoring components. Therefore, this is a high complexity level of medical decision making.

Can we send a bill for this encounter?
This visit is not covered under the global fee for the operative procedure even though the encounter is occurring within 24 hours of that procedure because the decision to operate was made during this encounter. So we can, and should, bill for this encounter

So what E and M code do we use to bill for this patient encounter?
This is a new patient The patient will be admitted to the hospital Thus an initial inpatient hospital visit code is appropriate.

For our example We documented a comprehensive history
We documented a detailed physical examination We documented high complexity medical decision making.

So which level do we choose?
99221 Initial Hospital Care for the evaluation and management of a patient which requires these 3 components: A detailed or comprehensive history A detailed or comprehensive examination Medical decision making that is straightforward or of low complexity 99222 Initial Hospital Care for the evaluation and management of a patient which requires these 3 components: A comprehensive history A comprehensive examination Medical decision making of moderate complexity 99223 Initial Hospital Care for the evaluation and management of a patient which requires these 3 components: Medical decision making of high complexity So this is properly coded as a encounter since all three components have to be met at the minimum level for that level of care code.

Yes, this looks absurdly complicated
Yes, this looks absurdly complicated. What do you expect from a government bureaucracy!

This is important! One’s history, physical examination and decision making drives ones documentation which drives one’s coding NOT the other way around!

This is important too! One’s chosen code should be appropriate to the chief complaint if one is to avoid scrutiny and potential compliance violations

So documenting the highest level visit for a patient with a simple minor laceration is likely to be questioned!

So what’s the bottom line?
If you asked the question, document the answer. If you examined it, document the findings, even if negative. Document your entire problem list, not just your final diagnosis. Document the studies you ordered and reviewed, and document it. If you talk to another physician, document it. If you ask for or review old records, document it. Use the tools that exist to figure out the level of coding.

And Use the Tools!!

Are there special rules for teaching hospitals?

Of course there are! This is the government after all!

Rules for Teaching Physicians General Concepts
Services furnished in teaching settings are paid under the Medicare Physician Fee Schedule (MPFS) if the services are: Personally furnished by a physician who is not a resident or Furnished by a resident when a teaching physician is physically present during the critical or key portions of the service

So the attending must perform their own history and physical examination to confirm the findings of the resident or be physically present when a resident performs a history and physical examination.

Rules for Teaching Physicians Residents
Both residents and teaching physicians may document physician services in the patient’s medical record. The documentation must be dated and contain a legible signature or identity On medical review, the combined entries into the medical record by the teaching physician and resident constitute the documentation for the service. Documentation by only the resident of the presence and participation of the teaching physician is not sufficient to establish the presence and participation of the teaching physician.

Rules for Teaching Physicians Residents
Attending physicians must attest that they have reviewed a residents history and physical examination, assessment, and plan, and, if they concur with those findings based on their own history and physical examination, document their agreement. An attending physician can add additional history and physical findings as appropriate. An attending physician can document their own findings where they disagree with what was documented by the resident.

Rules for Teaching Physicians Students
Any contribution and participation of a student must be performed in the physical presence of a teaching physician or resident except for the review of systems, past medical history, family, and/or social history. The teaching physician may only refer to a student’s documentation of ROS and/or PFSH. The teaching physician may not refer to a student’s documentation of physical examination findings or medical decision making in his or her personal note. If a student documents other aspects of an E and M service, the teaching physician must verify and redocument the history of present illness perform and redocument the physical examination Redocument the medical decision making activities of the service

Short Version What residents document counts.
What students document doesn’t count (except for the Past Medical History, Social History, Family History, and Review of Systems)

Are there modifiers used for E and M codes?

Commonly used modifiers applied to for E and M codes by surgeons
24 Modifier: Unrelated evaluation and management service by the same physician during a postoperative period. 25 Modifier: Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other services 57 Modifier: Decision for Surgery

Summary E and M coding is complex but can be deciphered using simple, readily available tools. Document all of your findings, both positive and negative. Special rules apply to documentation performed by residents and students. There are modifiers that can be employed to clarify coding.

Why should you care about this?
Surgeons deserve to be paid for the work they do, including the work that is not procedural. E and M codes can provide a significant source of revenue when you enter practice. As residents, the attendings are asked to evaluate you on your knowledge of billing and coding every time an evaluation is completed in e value.

Physician Coding II Evaluation and Management Codes

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Physician Coding II Evaluation and Management Codes

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