2What is documentation and why is it important? Medical record documentation is requiredfor reporting pertinent findings, facts and observations about a patients health history.The medical record documents patient care showing the chronology of treatment, communication between physicians, quality of care, and collection of data.
3General principles of documentation Medical record should be complete and legible.Documentation should include:Chief complaintExam and Diagnostic Test resultsAssessmentPlan
4E/M Coding Key Components Contributory Factors History Physical ExaminationMedical Decision MakingContributory FactorsNature of the presenting problemMedical Necessity drives code selectionExtent of counselingCoordination of careTime
5E/M Guidelines Medicare and Commercial Insurance Medicaid CMS 1995 and 1997 E/M guidelinesUse either set1997 approved by AMAMedicaidDoes not use ‘95 or ‘97 guidelinesUses AMA guidelines found in the CPT bookE/M Service Guidelines section list “Instructions for selecting a Level of E/M Service”
6Medical NecessityA service that is reasonable and necessary for the diagnosis and treatment of illness or injury, or to improve the functioning of a malformed body member.Government definition
8History Definitions Chief complaint (CC) Reason for the visitHistory of present illness (HPI)chronological description of the development of the patient’s illness from the 1st sign and/or symptom to the present.Review of systems (ROS)is an inventory of body systems obtained through a series of questions asked by the physician seeking to identify signs and/or symptoms that the patient may be experiencing or has experiencedPast, Family, Social, History (PFSH)
9History Definitions - Cont Past, Family, Social, History (PFSH) The PFSH consists of a review of one or more of the following three areas of the patient’s history:Past History (P)Family History (F)Social History (S)The PFSH is considered to be interval history for subsequent inpatient visits.Interval history - any new history information obtained since the last “physician-patient” encounter
10History Problem Focused Detailed Chief Complaint Chief ComplaintBrief HPI (1-3) Extended HPI (4 or status ofNo ROS chronic/inactive)No PFSH Extended ROS (2-9)Expanded Problem Pertinent PFSH (1)Focused ComprehensiveProblem pertinent ROS (1) chronic/inactive)No PFSH Complete ROS (10)ALL 3 elements must be Complete PFSH (2 or 3met: HPI,ROS,PFSH, based on category of E/M)FOR A NEW PATIENT.
11CPT History Guidelines (Medicaid) Problem focused: CC; brief HPIExpanded problem focused: CC; brief HPI, problem pertinent ROSDetailed: CC; extended HPI, problem pertinent ROS extended to include a review of limited number of additional systems; pertinent PFSH directly related to the patient’s problemsComprehensive: CC; extended HPI, ROS which is directly related to the problem(s) identified in the HPI plus a review of all additional body systems; complete PFSH
12Elements of History HPI LocationQualitySeverityDurationTimingContextModifying factorsAssociated signs and symptoms
13Elements of History - HPI Location – place, whereabouts, site, position. Where on the body is the patient experiencing signs or symptoms? (e.g., pain in groin)Quality – A description, characteristics, or statement to identify the type of sign or symptom. (e.g., burning pain in groin)Severity – Degree, intensity, ability to endure. (e.g., History of mild burning pain in groin that has become more intense)
14Elements of History - HPI Duration – Length of time. How long has patient been experiencing the signs or symptoms? (e.g., History of intermittent mild burning pain in groin that has become more intense and frequent for the last two weeks)Timing – Regulation of occurrence. A description of when the patient experiences signs or symptoms (e.g., history of intermittent mild burning in groin that has become more intense and frequent for the last two weeks).
15Elements of History - HPI Context – Circumstances, cause, precursor, outside factors. A description of where the patient is or what the patient does when the signs or symptoms are experienced (e.g., history of intermitted mild burning pain in groin that has become more intense and frequent for the last two weeks since the patient bent down to pick up son and continues to feel intense pain when bending).
16Elements of History - HPI Modifying Factors – Elements that change, alter or have some effect on the complaint or symptoms (e.g., history of intermittent mild burning pain in the groin that has become more intense and frequent for last two weeks since the patient bent down to pick up son; continues to feel intense pain when bending. Patient currently on Motrin 800 mg BID for past 3 weeks without relief)Associated Signs and Symptoms – Factors or symptoms that accompany the main symptoms. What other factors does patient experience in addition to this discomfort/pain? (e.g., Shortness of breath, light-headedness, nausea/vomiting)
17Elements of History - ROS Constitutional (e.g., fever, weight loss/gain, lack of appetite)EyesEars, nose, throat, mouthRespiratoryGastrointestinalGenitourinaryMusculoskeletalIntegumentary (skin and/or breast)NeurologicalPsychiatricEndocrineHematologic/LymphaticAllergic/Immunologic
18Documentation Example of ROS Patient denies loss of consciousness. He has not had any bowel or bladder problems. All other systems are negative.
19Evaluation of Sample ROS Patient denies loss of consciousness or bowel/bladder problem. All other systems are negative.Neurological = loss of consciousnessGastrointestinal = no bowel ProgramGenitourinary = no bladder problemsAll other neg
20Element of History - Past/Family/Social History - (PFSH) Past History: the patient’s history of illnesses, operations, injuries, treatments, medications.Family History: a review of medical events in the patient’s family, including diseases which may be hereditary or place the patient at risk.”Social History: Contains marital status and/or living arrangements; current employment; occupational history; use of drugs, alcohol and tobacco; level of education, sexual history; or other relevant social factors.
21Body Areas vs. Organ Systems The exam components are divided up between body areas and organ systems. These can be combined when counting elements for exam.ORGAN SYSTEMSConstitutional (vitals & generalappearance)EyesENT, mouthCardiovascularRespiratoryGastrointestinalGenitourinaryMusculoskeletalSkinNeurologicPsychiatricHematologic/Lymphatic/ImmunologicBODY AREASHead, incl. FaceNeckChest, incl. Breasts &axillaeAbdomenGenitalia, groin, buttocksBack, incl. SpineEach extremity
22History CASE STUDYNew patient is complaining of a white vaginal discharge for the past 2 days with a heavier flow in the morning. There is no change with Monistat. Patient denies itching burning with urination or fever. Patient has had 2 sexual partners in the past 60 days
23History CASE STUDY What is the patient’s CC ? Vaginal DischargeWhat are the patient’s Elements of HPI?Location - vaginalDuration - past 2 daysTiming - a heavier flow in the morningModifying factor - There is no change with MonistatWhat is the Level of HPI?Ans: DetailedCASE STUDYNew patient is complaining of a white vaginal discharge for the past 2 days with a heavier flow in the morning. There is no change with Monistat. Patient denies itching burning with urination or fever. Patient has had 2 sexual partners in the past 60 days
24History CASE STUDY What is/are the ROS? What is the Level of ROS? Integumentary - itchingGenitourinary - burning with urinationConstitutional - feverWhat is the Level of ROS?Ans: DetailedWhat is/are the patient’s PFSHPH (past history) – N/AFH (family History) - N/ASH – (social history) - Patient has had 2 sexual partners in the past 60 daysWhat is the Level of PFSH?CASE STUDYNew patient is complaining of a white vaginal discharge for the past 2 days with a heavier flow in the morning. There is no change with Monistat. Patient denies itching burning with urination or fever. Patient has had 2 sexual partners in the past 60 days
25History CASE STUDY ANSWER/EXPLANATION History Level = Detailed (3 of 3)CCHPI = Extended (4+ elements)ROS = Extended (3 elements)PFSH = Pertinent (1 element)EXAMPLECC - Vaginal dischargeHPI - New patient is complaining of a white vaginal (location) discharge for the past 2 days (duration) with a heavier flow in the morning (timing). There is no change with Monistat (modifying factor).ROS - Patient denies itching (integumentary), burning with urination (genitourinary) or fever (constitutional).PFSH - Patient has had 2 sexual partners in the past 60 days (social)
27Physical Exam Problem Focused Expanded Problem Focused Detailed (95)<1 body area/organ system(97) 1-5 elementsExpanded Problem Focused(95) 2-4 body areas/ organ systems(97) elementsDetailed(95) 5-7 body areas/organ systems(97) 12 elements in 2+areas/systemsComprehensive(95) 8 organ systems(97) General exam: Perform all elements document at least 2 elements in each of 9 areas/systems
28CPT Physical Exam Guidelines (Medicaid) Problem focused: limited exam of the affected body area or organ systemExpanded problem focused: limited exam of the affected body area or organ system and other symptomatic or related organ system(s)Detailed: extended exam of the affected body area(s) and other symptomatic or related organ system(s)Comprehensive: general multi-system exam or a complete exam of a single organ system
29Physical Exam Example Vaginal Discharge Exam ConstitutionalBP, temp, pulseGenitourinaryExamination of external genitaliaExamination of cervixWhat is the Level of the Physical Exam?ANS: Problem Focused = (At least two body areas/organ systems)CASE STUDYNew patient is complaining of a white vaginal discharge for the past 2 days with a heavier flow in the morning. There is no change with Monistat. Patient denies itching burning with urination or fever. Patient has had 2 sexual partners in the past 60 days
31MEDICAL DECISION-MAKING MDM refers to the complexity of establishing a diagnosis and/or selecting a management option.MDM is the function of 3 variablesNumber of diagnoses and/or management optionsAmount &/or complexity of data that must be obtained, reviewed &/or analyzedRisk of significant complications, morbidity &/or mortality
32Number of Diagnosis and/or Management Options Self Limited or Minor; stable, improving, worseningx1Established Problem*; stable, improvedEstablished Problem*; worseningX2New Problem*; no workup plannedX3New Problem*; addl. workup plannedx4Total Diagnosis or management options
33Amount and/or Complexity of Data Documentation should include:Diagnostic service:Ordered, planned, scheduled or performedReview of tests resultsSimple notation or initialing & datingDecision to obtain old records or additional HistoryRelevant findings from review of old recordsDiscussion of results with performing physicianDirect visualization and interpretation
34Risk of Complications, Morbidity and/or Mortality Refers to patient’s level of risk at the visitSources of riskPresenting problemDiagnostic procedures orderedManagement options selectedIllustrated by clinical examples in “Table of Risk”
35Documented Example of MDM A/P (assessment/plan): By history, suspect possible herniated disk. Patient will be referred for MRI scan. Prescribe Motrin 800 mg, tid with food, Vicodin for pain.
36Evaluation of MDMNumber of dx/tx options = new problem with addl workupAmt/complexity of data = ordered MRIRisk = prescription managementA/P: By history, suspect possible herniated disk. Patient will be referred for MRI scan. Prescribe Motrin 800 mg, tid with food, Vicodin for pain.
37Decision Making Straightforward Low Complexity Moderate Complexity #Diagnostic/treatment options (0 -1)Amt./complexity of data(0 -1)Risk (minimal)Low Complexity#Diagnostic/treatmentoptions (2)(2)Risk (low)Moderate Complexity#Diagnostic/treatmentoptions (3)Amt./complexity of data (3)Risk (moderate)High Complexity#Diagnoses/mgmt options (4)Amt./complexity of data (4)Risk (high)
38Decision Making Straightforward Low Complexity minimal number of diagnoses or management options considered.little, if any, amount or complexity of data reviewed.minimal risk of complications or morbidity or mortality (expectation of full recovery without functional impairment).Low Complexitylimited number of diagnoses or management options considered.limited amount and complexity of data reviewed.low risk of complications or morbidity or mortality (uncertain outcome or increased probability of prolonged functional impairment.
39Decision Making Moderate Complexity High Complexity multiple number of diagnoses or management options considered.moderate amount and complexity of data reviewed.moderate risk of complications or morbidity or mortality (uncertainoutcome or increased probability of prolonged functional impairment orhigh probability of severe prolonged functional impairment).High Complexityextensive number of diagnoses or management options consideredextensive amount and complexity of data reviewedhigh risk of complications or morbidity or mortality (uncertainoutcome or increased probability of prolonged functional impairmentor high probability of severe prolonged functional impairment) .
40CPT MDM Guidelines (Medicaid) Complexity measured by:# of possible diagnoses and/or the number of management options that must be considered.Amount/complexity of records, tests, other information that must be obtained, reviewed, and analyzed.Risk of significant complications, morbidity, mortality, as well as co-morbidities, associated with the patient’s presenting problem(s), the diagnostic procedure(s) and/or the possible management options.
41Table of Risk Examples Presenting Problem Minimal – One self-limited or minor problem.Low – Two or more minor problems, one stable chronic illness, acute uncomplicated illness.Moderate – Chronic illness with exacerbation, two of more stable chronic illnesses, undiagnosed new problem with uncertain prognosis, acute illness with systemic pneumonitis, acute complicated injuryHigh – Chronic illness with severe exacerbation, acute or chronic illness that poses threat to life, abrupt change in neurologic status.
42Decision Making Example Vaginal Discharge ExamNew problem, additional workup plannedLab is ordered (4)Review/order tests in 8xxxx series (1)What is the Level of Medical Decision Making?ANS: Moderate (2 0f 3)Moderate decision makingUndiagnosed new problem with uncertain prognosisPrescription drug managementPrescription writtenExtensive # Diagnosis/treatment optionsMinimal amount of data to be reviewedTable of Risk - Moderate
43Level Assignment EXAMPLE/CASE STUDY CPT BOOK History = DetailedPhysical Exam = Problem FocusedDecision Making = ModerateWhat is the code for a New & Established Patient?ANSWERLevel = 99203, new patientIf Established Patient = 99214
44Contributing Factors Presenting Problem Time Minimal Self-Limited/MinorLow SeverityModerate SeverityHigh SeverityTimeFACE-TO-FACETime is a key factor ONLY when:Counseling or coordination of care takes up OVER 50% of the total visit time
46Definition of Consultation “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.”Payment for consultation is often significantly higher than other E/M service
47Consultation vs. Referral Requires a physician request for an opinion or advice.Request and reason for consult must be documented.Evidence of opinion and/or advice communicated back to requesting physician.UPIN is required.Referral:Is a transfer of care for treatment of a specified problem.Is for a known problem.Physician plans to manage the patient’s care and treatment.No report to referring physician is required.
48Four Elements That Distinguish A Consultation A type of service provided by a physician whose opinion or advice regarding evaluation and/or management of an unknown or uncertain problem is requested by another physician or appropriate source.The written or verbal request for a consultation must be documented in the medical record.The consulting physician may initiate diagnostic or therapeutic services at the consultation or subsequent visit.The consulting physician’s opinion and any services ordered or performed must be:a) Documented in the medical record; andb) Communicated by written report to the requesting physician or other appropriate source.
49Types of Inpatient Consultations Initial InpatientNo difference in new or establishedReported one time during hospital stayRequires 3 of 3 key components be documentedFollow-up InpatientUsed to complete an initial consultationComplete initial consult, initiated by consulting physicianSubsequent consult, initiated by attending physicianRequires 2 of 3 key components be documented
50Counseling/Coordination of Care Main factor determining code when takes up MORE than 50% of the total visit timeDocumentation:Total visit timeTime spent in Counseling/Coordination of CareFace to faceSubject/ contentCode level is based on the total visit timenot just the time spent in counseling
51Counseling ExamplesEstablished patient, 20 minute visit to follow-up on oral contraceptive useNP 99213RN (MA 99213)15 minutes of a 20 minute visit spent counseling the patient on alcohol and cigarette use during pregnancy
52Definitions New Patient Established Patient Has not received face-to-face services fromANY provider in the agencyWithin past 3 years (AMA)Established PatientHas received face-to-face services from
53Selecting a Level of E/M IdentifyPlace of service (POS) = where (office)Type of service (TOS) = what (Problem/Preventive)Status of Patient = who (New/Established)Determine the extent of history - physical exam - decision making - counselingMust consider all factors, and make sure adequate DOCUMENTATION in chart to justify code.
54Office 99201-99215 Report Problem visit (vs. Preventive visit) , performed by MD, NP, PA,CNSAncillary staff i.e. RN, LPN, CNAMD/NP must be in the clinicReport only 1 E/M per dayReport diagnostic tests, studies, procedures separately
55Office (Medicaid), may be performed by any staff of a “certified family planning clinic”. Staff may be MD, NP, PA, RN, CMA or unlicensed personnel acting in a coordinated manner to provide the service(s).Other reporting requirements are the same as other providers
57Preventive MedicineRoutine management of patients without presenting problems, i.e. annual, routine, well child examsPerformed by (MD,NP,PA,CNS)Includes other clinic staff if MedicaidCodesNew/established patientsAgeNot used for scheduled follow-up visits for specified problems
58CASE STUDYSusan Johnson was referred to Dr. Jones’ office for her opinion of Susan’s chronic low back pain radiating to the leg. Dr. Jones took a detail history, performed a detailed examination, and medical decision making was of low complexity.99243
59CASE STUDYMichael, age 38, scheduled an annual physical exam with Dr. Graves. He has been Dr. Graves’ patient for 15 years and had his last annual physical 2 years ago.First - IdentifyPlace of service (POS) = where (office)Type of service (TOS) = what (Problem/Preventive)Status of Patient = who (New/Established)Determine the extent of history - physical exam - decision making - counseling99395
60CASE STUDYA 2-year-old boy with bacterial pneumonia is hospitalized and has had 5 days of antibiotic therapy. Today the child developed a fever of F with a mild rash on his torso. In a subsequent hospital visit, the attending physician performed a problem-focused history and examination. The MDM complexity was low.99231