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DOCUMENTATION REQUIREMENTS E/M Codes. Targeted Codes 99214 : established patient, outpt. visit – presenting problems are usually moderate to high severity.

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Presentation on theme: "DOCUMENTATION REQUIREMENTS E/M Codes. Targeted Codes 99214 : established patient, outpt. visit – presenting problems are usually moderate to high severity."— Presentation transcript:

1 DOCUMENTATION REQUIREMENTS E/M Codes

2 Targeted Codes : established patient, outpt. visit – presenting problems are usually moderate to high severity 99212: established patient, outpt. Visit – presenting problems usually self limited or minor 99233: subsequent hospital care – usually patient is unstable, developed a significant complication or a significant new problem 99231: subsequent hospital care – usually a stable, recovering, or improving patient Codes accounting for the errorsWhat codes should have been used

3 Principles of Documentation: MR should be complete & legibleMR should be complete & legible Documentation for each patient encounter should include:Documentation for each patient encounter should include: –Reason for encounter & relevant history –Physical exam & findings –Prior diagnostic test results –Assessment –Clinical impression or diagnosis –Plan for care –Date –Legible identity of the observer

4 Principles of Documentation Cont. If not documented, the rationale for ordering diagnostic & ancillary services should be easily inferredIf not documented, the rationale for ordering diagnostic & ancillary services should be easily inferred Past & present diagnosis should be accessible to the treating/consulting physicianPast & present diagnosis should be accessible to the treating/consulting physician Appropriate risk factors should be identifiedAppropriate risk factors should be identified Pt’s progress, response to & changes in treatment & diagnosis revision should be documentedPt’s progress, response to & changes in treatment & diagnosis revision should be documented CPT & ICD-9 codes on claim must be supported by MR documentationCPT & ICD-9 codes on claim must be supported by MR documentation

5 Evaluation and Management Codes - Developed jointly by HCFA & the AMA How to stay on the good side of HCFA

6 MEDICAL NECESSITY –Inpatient : Does the diagnosis code support the medical need for the service performed? If not, does the documentation in the record support the necessity? If not, does the documentation in the record support the necessity? –Outpatient : Level of Visit Codes

7 The 7 Components: 1) History 2) Examination 3) Medical Decision Making 4) Counseling 5) Coordination of Care 6) Nature of Presenting Problem 7) Time KEY

8 E & M Determination LevelHistoryExamination Med. Decision Making I Prob. Focused Problem Focused Straightforward II Expanded Prob. Focused Expanded Problem Focused Straightforward IIIDetailedDetailed Low Complexity IVComprehensiveComprehensive Moderate Complexity VComprehensiveComprehensive High Complexity

9 The 7 Components: 1) History 2) Examination 3) Medical Decision Making 4) Counseling 5) Coordination of Care 6) Nature of Presenting Problem 7) Time KEY

10 Documentation of History: Level of service is based on 4 types: 1) problem focused 2) expanded problem focused 3) detailed 4) comprehensive History elements (some or all):  chief complaint, CC  history of present illness, HPI  chief complaint, CC  history of present illness, HPI  review of systems, ROS  past, family and/or social history, PFSH  review of systems, ROS  past, family and/or social history, PFSH

11 ROS & PFSH obtained Earlier w/o any change: Do not have to re-record if there is evidence that a physician had reviewed & updated the previous oneDo not have to re-record if there is evidence that a physician had reviewed & updated the previous one How to documented the review:How to documented the review: –Describe any new information, –not that there has been no change, or –note the date & location of the earlier entry DG 1

12 If not able to obtain information - note in chart the patient’s condition & the circumstances that preclude obtaining a historyIf not able to obtain information - note in chart the patient’s condition & the circumstances that preclude obtaining a history DG 2 & 3 ROS & PFSH may be recorded by ancillary staff or by the patient - physician must supplement or confirm the information received for documentationROS & PFSH may be recorded by ancillary staff or by the patient - physician must supplement or confirm the information received for documentation

13 HPI Elements 1) location 2) quality 3) severity 4) duration 5) timing 6) context 7) modifying factors 8) associated signs & symptoms Brief:1-3 Extended: at least 4or the status of at least 3 chronic or inactive conditions at least 4 or the status of at least 3 chronic or inactive conditions DG 4 & 5

14 ROS Elements constitutional symptomsconstitutional symptoms eyeseyes ears, nose, mouth, throatears, nose, mouth, throat cardiovascularcardiovascular respiratoryrespiratory gastrointestinalgastrointestinal genitourinarygenitourinary musculoskeletalmusculoskeletal integumentaryintegumentary neurologicalneurological psychiatricpsychiatric endocrineendocrine hematologic/lymphatichematologic/lymphatic allergic/immunologicallergic/immunologic

15 ROS Definitions PROBLEM PERTINENT - inquires about the system directly related to the problem in HPIPROBLEM PERTINENT - inquires about the system directly related to the problem in HPI EXTENDED - directly related system systems documentedEXTENDED - directly related system systems documented COMPLETE - directly related system + all additional body systemsCOMPLETE - directly related system + all additional body systems DG 6, 7 & 8

16 PFSH - Pertinent - review of history areas directly related to problem in HPIPertinent - review of history areas directly related to problem in HPI Complete - review of 2 or all 3, depending on the category on E&M code (required for comprehensive assessments)Complete - review of 2 or all 3, depending on the category on E&M code (required for comprehensive assessments) DG 9

17 PFSH requirements for: Initial Patients requires 1 item from the 3 areasrequires 1 item from the 3 areas applies to outpt/office, consults, observation pts, nursing home assessments, domiciliary care, home careapplies to outpt/office, consults, observation pts, nursing home assessments, domiciliary care, home care Est. Patients requires 1 item from the 2 areasrequires 1 item from the 2 areas applies to outpt/office, ER services, domiciliary care, home careapplies to outpt/office, ER services, domiciliary care, home care DG 10 & 11

18 Level of Service Determination * Must have all 3 in column or choose lowest History Problem Focused Expanded Prob. Focused DetailedComprehensive HPIBriefBriefExtendedExtended ROSN/A Problem Pertinent ExtendedComplete PFSHN/ADetailedPertinentComplete

19 The 7 Components: 1) History 2) Examination 3) Medical Decision Making 4) Counseling 5) Coordination of Care 6) Nature of Presenting Problem 7) Time KEY

20 Documentation of Examination: Level of service is based on 4 types: 1) problem focused 2) expanded problem focused 3) detailed 4) comprehensive Exam Types:  cardiovascular, ENT & mouth, eyes, male & female genitourinary, hematological/lymphatic/immunologic, musculoskeletal, neurological, psychiatric, respiratory, skin  cardiovascular, ENT & mouth, eyes, male & female genitourinary, hematological/lymphatic/immunologic, musculoskeletal, neurological, psychiatric, respiratory, skin

21 Documentation Guidelines: Elements w/ mult. components require documentation of at least 1 componentElements w/ mult. components require documentation of at least 1 component “abnormal” can be used for exams of the affected or symptomatic body area“abnormal” can be used for exams of the affected or symptomatic body area abnormal/unexpected finding in asymptomatic areas should be describedabnormal/unexpected finding in asymptomatic areas should be described “negative” or “normal” is sufficient for unaffected or asymptomatic areas“negative” or “normal” is sufficient for unaffected or asymptomatic areas

22 General Multi-System Exams: PROBLEM FOCUSED: 1-5  elements in  1 body areas/systems EXPANDED PROBLEM FOCUSED:  6  elements in  1 body areas/systems DETAILED:  2  elements in  6 ore more body areas/systems (or  12 elements in  2 areas) COMPREHENSIVE: all  elements in selected areas,  9 body areas/systems

23 Single Organ Exams: PROBLEM FOCUSED: 1-5  elements in any box EXPANDED PROBLEM FOCUSED:  6  elements in any box DETAILED:  12  elements in any box (eye & psychiatric  9 elements) COMPREHENSIVE: all  elements ( document every element in bold boxes & at least 1 in normal boxes)

24 The 7 Components: 1) History 2) Examination 3) Medical Decision Making 4) Counseling 5) Coordination of Care 6) Nature of Presenting Problem 7) Time KEY

25 Documentation of Medical Decision Making: Level of service is based on 4 types: 1) straight - forward 2) low complexity 3) moderate complexity 4) high complexity -complexity of establishing a diagnosis and/or selecting a management option

26 Complexity factors…. Pt’s # of diagnosesPt’s # of diagnoses the amount and/or complexity of MR, tests, & other information that must be obtained, reviewed, & analyzedthe amount and/or complexity of MR, tests, & other information that must be obtained, reviewed, & analyzed risk of significant complications, morbidity/mortality as well as co- morbidities associated with the presenting problem(s)risk of significant complications, morbidity/mortality as well as co- morbidities associated with the presenting problem(s)

27 DG for # of Diagnoses or Mgmt. Options…. Established dx. - state if improved/well controlled/ resolving or worsening/failing to change as expectedEstablished dx. - state if improved/well controlled/ resolving or worsening/failing to change as expected new diagnosis - stated in form of differential dx. possible/probable/rule outnew diagnosis - stated in form of differential dx. possible/probable/rule out initiation or changes in treatmentinitiation or changes in treatment to whom or where referrals or consults are made or from whom the advice is requestedto whom or where referrals or consults are made or from whom the advice is requested

28 DG for amount & complexity of data to review…. Types of service ordered at the time of encounterTypes of service ordered at the time of encounter reviewed results, initial & date report w/ the resultsreviewed results, initial & date report w/ the results any further history or information obtained from MR, patient, etc.any further history or information obtained from MR, patient, etc. relevant findings from aboverelevant findings from above results of discussions w/ physiciansresults of discussions w/ physicians associated w/ reviewed results direct visualization or independent interpretation of tests/films interpreted by another physiciandirect visualization or independent interpretation of tests/films interpreted by another physician

29 Risk DG... Any factor that would increase the risk of complications, morbidity, mortalityAny factor that would increase the risk of complications, morbidity, mortality procedures planned at that timeprocedures planned at that time specific procedure performed at time of encounterspecific procedure performed at time of encounter need for an urgent procedure to be doneneed for an urgent procedure to be done

30 Table of Risk Level of Risk Presenting Problem Diagnostic Procedure Ordered Management Options Selected minimal one self limited or minor problem one self limited or minor problem Lab tests w/ venipunctureLab tests w/ venipuncture Chest x-raysChest x-rays EKG/EEGEKG/EEG UrinalysisUrinalysis UltrasoundUltrasound KOH PrepKOH Prep rest rest GarglesGargles Elastic bandagesElastic bandages Superficial dressingsSuperficial dressings low 2 or more self limited problems 2 or more self limited problems 1 stable chronic illness 1 stable chronic illness Acute complicated illnessAcute complicated illness Physiologic tests not under stressPhysiologic tests not under stress Non-cardiovascular imaging studies w/ contrastNon-cardiovascular imaging studies w/ contrast Superficial needle biopsiesSuperficial needle biopsies Clinical lab testClinical lab test Skin biopsiesSkin biopsies over the counter drugs over the counter drugs Minor surgery w/ no identified risk factorsMinor surgery w/ no identified risk factors PT or OTPT or OT IV fluids w/o additivesIV fluids w/o additives

31 Table of Risk Level of Risk Presenting Problem Diagnostic Procedure Ordered Management Options Selected Moderate one or more chronic illness w/ mild exacerbation one or more chronic illness w/ mild exacerbation 2 or more stable chronic illnesses 2 or more stable chronic illnesses undiagnosed new problem w/ uncertain prognosis undiagnosed new problem w/ uncertain prognosis Acute illness w/ systemic symptomsAcute illness w/ systemic symptoms Acute complicated injuryAcute complicated injury Physiologic test under stressPhysiologic test under stress Diagnostic endoscopies w/ no identified risk factorsDiagnostic endoscopies w/ no identified risk factors Deep needle or incisional biopsyDeep needle or incisional biopsy Cardiovascular imaging studies w/ contrast & no identified risk factorsCardiovascular imaging studies w/ contrast & no identified risk factors Obtain fluid from body cavityObtain fluid from body cavity minor surgery w/ identified risk factors minor surgery w/ identified risk factors Elective major surgery w/ no identified risk factorsElective major surgery w/ no identified risk factors Prescription drug managementPrescription drug management Therapeutic Nuclear Med. Therapeutic Nuclear Med. IV fluids w/ additivesIV fluids w/ additives Closed treatment of fracture or dislocation w/o manipulationClosed treatment of fracture or dislocation w/o manipulation

32 Table of Risk Level of Risk Presenting Problem Diagnostic Procedure Ordered Management Options Selected High one or more chronic illness w/ severe exacerbation one or more chronic illness w/ severe exacerbation acute/chronic illness/injury that pose a threat to life or bodily function acute/chronic illness/injury that pose a threat to life or bodily function Diagnostic endoscopies w/ identified risk factors Diagnostic endoscopies w/ identified risk factors Cardiovascular imaging studies w/ contrast & identified risk factorsCardiovascular imaging studies w/ contrast & identified risk factors Cardiac electrophysiological testsCardiac electrophysiological tests DiscographyDiscography Emergency major surgery Emergency major surgery Elective major surgery w/ identified risk factorsElective major surgery w/ identified risk factors Parental controlled substancesParental controlled substances Drug therapy requiring intensive monitoring for toxicityDrug therapy requiring intensive monitoring for toxicity Decision not to resuscitateDecision not to resuscitate

33 Medical Decision Making Determination * 2 of 3 elements must be met or exceeded Type of Decision Making Straight Forward LowModerateHigh # of dx. or mgmt options MinimalLimitedMultipleExtensive Data Reviewed MinimalLimitedModerateExtensive RisksMinimalLowextensiveHigh

34 E & M Determination Initial Patients must have 3 of 3 LevelHistoryExamination Med. Decision Making I99201 Prob. Focused Problem Focused Straightforward II99202 Expanded Prob. Focused Expanded Problem Focused Straightforward III99203DetailedDetailed Low Complexity IV99204ComprehensiveComprehensive Moderate Complexity V99205ComprehensiveComprehensive High Complexity

35 E & M Determination Initial Patients must have 3 of 3 LevelHistoryExamination Med. Decision Making I99201 Prob. Focused Problem Focused Straightforward II99202 Expanded Prob. Focused Expanded Problem Focused Straightforward III99203DetailedDetailed Low Complexity IV99204ComprehensiveComprehensive Moderate Complexity V99205ComprehensiveComprehensive High Complexity

36 36 NEW PATIENTS One who has NOT received any professional services from the physician or any other physician of the same specialty who belongs to the same group practice within the past 3 years.

37 E & M Determination Established Patients must have 2 of 3 LevelHistoryExamination Med. Decision Making I99211 Prob. Focused Problem Focused Straightforward II99212 Expanded Prob. Focused Expanded Problem Focused Straightforward III99213DetailedDetailed Low Complexity IV99214ComprehensiveComprehensive Moderate Complexity V99215ComprehensiveComprehensive High Complexity

38 38 ESTABLISHED PATIENTS One who HAS received professional services from the physician of the same specilaity who belongs to the same group practice within the last 3 years.

39 39 EST. PT Billing Can be billed by the nursing staff when a chief complaint exists. Normally Required Care: Blood pressure, weight, reactions to current meds, additional services not usually provided by a physician NOT: finger sticks & injections *physician must be on the premises

40 40 Observation Care Report encounters by the supervising MD Characteristics of Observation Pts: not been admitted as an inpatient not been admitted as an inpatient may be physically detained in ER may be physically detained in ER clinical condition is being observed clinical condition is being observed additional time needed to clarify condition additional time needed to clarify condition to determine if hospitalization is needed to determine if hospitalization is needed

41 41 Observation to Inpatient- MD admits pt to both w/in 24 hours – bill as initial hospital visitMD admits pt to both w/in 24 hours – bill as initial hospital visit Do NOT bill for an initial hospital visit & initial obs. codeDo NOT bill for an initial hospital visit & initial obs. code Can NOT bill for an obs. discharge mgmt when admitting to inpt.Can NOT bill for an obs. discharge mgmt when admitting to inpt.

42 42 Global Surgical Period Fee includes obs paymentFee includes obs payment Must use modifiers with the CPT code to receive paymentMust use modifiers with the CPT code to receive payment –57 indicates that the decision for surgery was made while the patient was in obs. –57 indicates that the decision for surgery was made while the patient was in obs. -24 denotes observation services are unrelated to the surgery-24 denotes observation services are unrelated to the surgery -79 subsequent surgical procedure-79 subsequent surgical procedure -25 separately identifiable service -25 separately identifiable service

43 43 MODIFIER -25 Indicates that E/M codes reported on the same bill are for significant and separately identifiable services Indicates that E/M codes reported on the same bill are for significant and separately identifiable services

44 One last thing… If using a template to dictate your note DON’T FORGET to state that it was “normal” or “negative”


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