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1 Evaluation & Management Services. 2 What is documentation and why is it important?  Medical record documentation is required pertinent findings, facts.

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Presentation on theme: "1 Evaluation & Management Services. 2 What is documentation and why is it important?  Medical record documentation is required pertinent findings, facts."— Presentation transcript:

1 1 Evaluation & Management Services

2 2 What is documentation and why is it important?  Medical record documentation is required pertinent findings, facts and observations about a patients health history. for reporting pertinent findings, facts and observations about a patients health history. patient care quality of care,  The medical record documents patient care showing the chronology of treatment, communication between physicians, quality of care, and collection of data.

3 3 General principles of documentation  Medical record should be complete and legible.  Documentation should include: Chief complaint Exam and Diagnostic Test results Assessment Plan

4 4 E/M Coding  Key Components History Physical Examination Medical Decision Making  Contributory Factors Nature of the presenting problem Medical Necessity drives code selection Extent of counseling Coordination of care Time

5 5 E/M Guidelines  Medicare and Commercial Insurance CMS 1995 and 1997 E/M guidelines Use either set 1997 approved by AMA  Medicaid Does not use ‘95 or ‘97 guidelines Uses AMA guidelines found in the CPT book “Instructions for selecting a Level of E/M Service”E/M Service Guidelines section list “Instructions for selecting a Level of E/M Service”

6 6 Medical Necessity diagnosis treatment  A service that is reasonable and necessary for the diagnosis and treatment of illness or injury, or to improve the functioning of a malformed body member. Government definition

7 7 STEP ONE - HISTORY

8 8 History  Definitions (CC) Chief complaint (CC) Reason for the visit (HPI) History of present illness (HPI) chronological description of the development of the patient’s illness from the 1 st sign and/or symptom to the present. (ROS) 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 experienced (PFSH) Past, Family, Social, History (PFSH)

9 9 History  Definitions - Cont (PFSH)  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: (P)Past History (P) (F)Family History (F) (S)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

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

11 11 CPT History Guidelines (Medicaid)  Problem focused:  Problem focused: CC; brief HPI  Expanded problem focused:  Expanded problem focused: CC; brief HPI, problem pertinent ROS  Detailed:  Detailed: 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 problems  Comprehensive:  Comprehensive: CC; extended HPI, ROS which is directly related to the problem(s) identified in the HPI plus a review of all additional body systems; complete PFSH

12 12 Elements of History HPI  Location  Quality  Severity  Duration  Timing  Context  Modifying factors  Associated signs and symptoms

13 13 Elements of History - HPI  Location (e.g., pain in groin)  Location – place, whereabouts, site, position. Where on the body is the patient experiencing signs or symptoms? (e.g., pain in groin)  Quality – (e.g., burning pain in groin)  Quality – A description, characteristics, or statement to identify the type of sign or symptom. (e.g., burning pain in groin)  Severity – (e.g., History of mild burning pain in groin that has become more intense)  Severity – Degree, intensity, ability to endure. (e.g., History of mild burning pain in groin that has become more intense)

14 14 Elements of History - HPI  Duration (e.g., History of intermittent mild burning pain in groin that has become more intense and frequent for the last two weeks)  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 (e.g., history of intermittent mild burning 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).

15 15 Elements of History - HPI  Context – (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).  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).

16 16 Elements of History - HPI  Modifying Factors (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)  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 – (e.g., Shortness of breath, light- headedness, nausea/vomiting)  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)

17 17 Elements of History - ROS  Constitutional (e.g., fever, weight loss/gain, lack of appetite)  Eyes  Ears, nose, throat, mouth  Respiratory  Gastrointestinal  Genitourinary  Musculoskeletal  Integumentary (skin and/or breast)  Neurological  Psychiatric  Endocrine  Hematologic/Lymphatic  Allergic/Immunologic

18 18 Example ROS Documentation Example of ROS  Patient denies loss of consciousness. He has not had any bowel or bladder problems. All other systems are negative.

19 19 Evaluation ofROS Evaluation of Sample ROS  Patient denies loss of consciousness or bowel/bladder problem. All other systems are negative.  Neurological  Neurological = loss of consciousness  Gastrointestinal  Gastrointestinal = no bowel Program  Genitourinary  Genitourinary = no bladder problems  All other neg

20 20 Element of History - Past/Family/Social History - (PFSH)  Past History:  Past History: the patient’s history of illnesses, operations, injuries, treatments, medications.  Family History:  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:  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.

21 21 Body Areas vs. Organ Systems  BODY AREAS Head, incl. Face Neck Chest, incl. Breasts & axillae Abdomen Genitalia, groin, buttocks Back, incl. Spine Each extremity  ORGAN SYSTEMS Constitutional (vitals & general appearance) Eyes ENT, mouth Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic/Lymphatic/Immunologic exam components body areas organ systems The exam components are divided up between body areas and organ systems. These can be combined when counting elements for exam.

22 22 History CASE STUDY New 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

23 23 History CASE STUDY CC ?  What is the patient’s CC ? Vaginal Discharge Elements of HPI?  What are the patient’s Elements of HPI? 1. Location - 1. Location - vaginal 2. Duration - 2. Duration - past 2 days 3. Timing - 3. Timing - a heavier flow in the morning 4. Modifying factor - 4. Modifying factor - There is no change with Monistat  What is the Level of HPI? Ans: Detailed Ans: Detailed CASE STUDY New 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

24 24 History CASE STUDY ROS?  What is/are the ROS? Integumentary - itching Genitourinary - burning with urination Constitutional - fever  What is the Level of ROS? Ans: Detailed PFSH  What is/are the patient’s PFSH PH (past history) – N/A FH (family History) - N/A SH – (social history) - Patient has had 2 sexual partners in the past 60 days  What is the Level of PFSH? Ans: Detailed CASE STUDY New 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

25 25 History CASE STUDY ANSWER/EXPLANATION  History Level = Detailed (3 of 3) CC CC HPI HPI = Extended (4+ elements) ROS ROS = Extended (3 elements) PFSH PFSH = Pertinent (1 element) EXAMPLE  CC - Vaginal discharge  HPI - New patient is complaining of a white vaginal (location) discharge for the past 2 days (duration) with a heavier flow in the morning (timing). There is no change with Monistat (modifying factor).  ROS - Patient denies itching (integumentary), burning with urination (genitourinary) or fever (constitutional).  PFSH - Patient has had 2 sexual partners in the past 60 days (social) EXAMPLE  CC - Vaginal discharge  HPI - New patient is complaining of a white vaginal (location) discharge for the past 2 days (duration) with a heavier flow in the morning (timing). There is no change with Monistat (modifying factor).  ROS - Patient denies itching (integumentary), burning with urination (genitourinary) or fever (constitutional).  PFSH - Patient has had 2 sexual partners in the past 60 days (social)

26 26 STEP TWO – EXAMINATION Performed by Physician STEP TWO – EXAMINATION Performed by Physician

27 27 Physical Exam  Problem Focused (95)<1 body area/ organ system (97) 1-5 elements  Expanded Problem Focused (95) 2-4 body areas/ organ systems (97) elements  Detailed (95) 5-7 body areas/organ systems (97) 12 elements in 2+areas/systems  Comprehensive (95) 8 organ systems (97) General exam: Perform all elements document at least 2 elements in each of 9 areas/systems

28 28 CPT Physical Exam Guidelines (Medicaid)  Problem focused: limited exam  Problem focused: limited exam of the affected body area or organ system  Expanded problem focused:limited exam  Expanded problem focused: limited exam of the affected body area or organ system and other symptomatic or related organ system(s)  Detailed:extended exam  Detailed: extended exam of the affected body area(s) and other symptomatic or related organ system(s)  Comprehensive:multi-system exam complete exam  Comprehensive: general multi-system exam or a complete exam of a single organ system

29 29 Physical Exam Example  Vaginal Discharge Exam Constitutional BP, temp, pulse Genitourinary Examination of external genitalia Examination of cervix  What is the Level of the Physical Exam? Problem Focused = ANS: Problem Focused = (At least two body areas/organ systems) CASE STUDY New 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

30 30 STEP THREE MEDICAL DECISION-MAKING

31 31 MEDICAL DECISION-MAKING  MDMcomplexity of establishing a diagnosis and/or selecting a management option.  MDM refers to the complexity of establishing a diagnosis and/or selecting a management option.  MDM  MDM is the function of 3 variables 1.Number of diagnoses and/or management options 2.Amount &/or complexity of data that must be obtained, reviewed &/or analyzed 3.Risk of significant complications, morbidity &/or mortality

32 32 Self Limited or Minor; stable, improving, worsening x1 Established Problem*; stable, improvedx1 Established Problem*; worseningX2 New Problem*; no workup plannedX3 New Problem*; addl. workup plannedx4 Total Diagnosis or management options Number of Diagnosis Management Options Number of Diagnosis and/or Management Options

33 33  Documentation should include: Diagnostic service: Ordered, planned, scheduled or performed Review of tests results Simple notation or initialing & dating Decision to obtain old records or additional History Relevant findings from review of old records Discussion of results with performing physician Direct visualization and interpretation Amount and/or Complexity of Data

34 34 risk  Refers to patient’s level of risk at the visit  Sources of risk Presenting problem Diagnostic procedures ordered Management options selected “Table of Risk”  Illustrated by clinical examples in “Table of Risk” Risk of Complications, Morbidity and/or Mortality

35 35 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. Documented Example of MDM

36 36 Evaluation of MDM herniated disk MRI Motrin 800 Vicodin A/P: By history, suspect possible herniated disk. Patient will be referred for MRI scan. Prescribe Motrin 800 mg, tid with food, Vicodin for pain.  Number of dx/tx  Number of dx/tx options = new problem with addl workup  Amt/complexity of data  Amt/complexity of data = ordered MRI  Risk  Risk = prescription management

37 37 Decision Making  Straightforward (0 -1) #Diagnostic/treatment options (0 -1) Amt./complexity of data (0 -1) Risk (minimal)  Low Complexity #Diagnostic/treatment (2) options (2) Amt./complexity of data(2) Risk (low)  Moderate Complexity #Diagnostic/treatment (3) options (3) (3) Amt./complexity of data (3) Risk (moderate)  High Complexity (4) #Diagnoses/mgmt options (4) (4) Amt./complexity of data (4) Risk (high)

38 38 Straightforward  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 Complexity  limited 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. Decision Making

39 39 Decision Making Moderate Complexity  multiple number of diagnoses or management options considered.  moderate amount and complexity of data reviewed.  moderate risk of complications or morbidity or mortality (uncertain outcome or increased probability of prolonged functional impairment or high probability of severe prolonged functional impairment). High Complexity  extensive number of diagnoses or management options considered  extensive amount and complexity of data reviewed  high risk of complications or morbidity or mortality (uncertain outcome or increased probability of prolonged functional impairment or high probability of severe prolonged functional impairment).

40 40 CPT MDM Guidelines (Medicaid)  Complexity measured by: the number of management options # of possible diagnoses and/or the number of management options that must be considered. tests, other information Amount/complexity of records, tests, other information that must be obtained, reviewed, and analyzed. morbidity, mortality, as well as co-morbidities, associated with the patient’s presenting problem(s),the diagnostic procedure(s) and/or the possible management options. Risk of significant complications, morbidity, mortality, as well as co-morbidities, associated with the patient’s presenting problem(s), the diagnostic procedure(s) and/or the possible management options.

41 41 Table 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 injury  High – Chronic illness with severe exacerbation, acute or chronic illness that poses threat to life, abrupt change in neurologic status.

42 42 Decision Making Example  Vaginal Discharge Exam New problem, additional workup planned (4)Lab is ordered (4) (1) Review/order tests in 8xxxx series (1)  What is the Level of Medical Decision Making? ANS: Moderate (2 0f 3) Moderate decision making Undiagnosed new problem with uncertain prognosis Prescription drug management –Prescription written Extensive # Diagnosis/treatment options Extensive # Diagnosis/treatment options Minimal amount of data to be reviewed Minimal amount of data to be reviewed Table of Risk - Moderate

43 43 Level Assignment EXAMPLE/CASE STUDY CPT BOOK  History  History = Detailed  Physical Exam  Physical Exam = Problem Focused  Decision Making  Decision Making = Moderate  What is the code for a New & Established Patient? ANSWER  Level = 99203, new patient  If Established Patient = ANSWER  Level = 99203, new patient  If Established Patient = 99214

44 44 Contributing Factors  Presenting Problem Minimal Self-Limited/Minor Low Severity Moderate Severity High Severity  Time FACE-TO-FACE Time is a key factor ONLY when: Counseling or coordination of care takes up OVER 50% of the total visit timeCounseling or coordination of care takes up OVER 50% of the total visit time

45 45 Consultation Code Selection

46 46 Definition 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

47 47 Consultation vs. Referral Consultation:  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.

48 48 Four Elements That Distinguish A Consultation whose opinion or advice regarding unknown or uncertain problem 1.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. request must be documented 2.The written or verbal request for a consultation must be documented in the medical record. may initiate diagnostic or therapeutic services  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: Documented a)Documented in the medical record; and Communicated by written report b)Communicated by written report to the requesting physician or other appropriate source.

49 49 Types of Inpatient Consultations  Initial Inpatient No difference in new or established Reported one time during hospital stay Requires 3 of 3 key components be documented  Follow-up Inpatient Used to complete an initial consultation Complete initial consult, initiated by consulting physician Subsequent consult, initiated by attending physician Requires 2 of 3 key components be documented

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

51 51 Counseling Examples  Established patient, 20 minute visit to follow- up on oral contraceptive use NP NP RN MA RN (MA 99213)  15 minutes of a 20 minute visit spent counseling the patient on alcohol and cigarette use during pregnancy NP NP RNMA RN (MA 99213)

52 52 Definitions  New Patient Has not received face-to-face services from ANY provider in the agency Within past 3 years (AMA)  Established Patient Has received face-to-face services from ANY provider in the agency Within past 3 years (AMA)

53 53 Selecting a Level of E/M  Identify (POS) Place of service (POS) = where (office) (TOS) Type of service (TOS) = what (Problem/Preventive) Status of Patient = who (New/Established) history - physical exam - decision making - counseling  Determine the extent of history - physical exam - decision making - counseling DOCUMENTATION Must consider all factors, and make sure adequate DOCUMENTATION in chart to justify code.

54 54 Office  Report Problem visit (vs. Preventive visit)  ,  , performed by MD, NP, PA,CNS   Ancillary staff i.e. RN, LPN, CNA MD/NP must be in the clinic MD/NP must be in the clinic  Report only 1 E/M per day  Report diagnostic tests, studies, procedures separately

55 55 Office (Medicaid)  ,  , may be performed by any staff of a “certified family planning clinic”. Staff may be MD, NP, PA, RN, CMA or unlicensed personnel acting in a coordinated manner to provide the service(s).  Other reporting requirements are the same as other providers

56 56 Preventive Medicine Services

57 57 Preventive Medicine i.e. annual, routine, well child exams  Routine management of patients without presenting problems, i.e. annual, routine, well child exams  Performed by (MD,NP,PA,CNS) Includes other clinic staff if Medicaid  Codes New/established patients Age  Not usedfollow-up visits for specified problems  Not used for scheduled follow-up visits for specified problems

58 58 CASE STUDY  Susan 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

59 59 CASE STUDY  Michael, 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 - Identify (POS)  Place of service (POS) = where (office) (TOS)  Type of service (TOS) = what (Problem/Preventive)  Status of Patient = who (New/Established) history - physical exam - decision making - counseling  Determine the extent of history - physical exam - decision making - counseling

60 60 CASE STUDY A 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


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