1. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. 4-1 Chapter 4 Evaluation and Management Codes, Part 1

2. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw- Hill Education. Learning Objectives 4.1 Abstract documentation to identify the location of the encounter. 4.2 Distinguish between new and established patients. 4.3 Calculate the appropriate level of service. 4-2

3. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw- Hill Education. Learning Objectives (cont.) 4.4 Determine when to report prolonged services. 4.5 Ascertain the appropriate way to report a consultation. 4.6 Determine the appropriate level of medical decision making provided by the physician. 4-3

4. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw- Hill Education. Key Terms Consultation Established patient Evaluation and Management (E/M) Level of patient history Level of physical examination 4-4

5. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw- Hill Education. Key Terms (cont.) Medical decision making (MDM) New patient PFSH Relationship Transfer of care 4-5

6. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw- Hill Education. E/M Codes Evaluation and Management (E/M) codes –First section in the CPT book. –Codes numbered 99201–99499. –Used to compensate the provider for meeting face-to-face with the patient and his or her family. 4-6

7. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw- Hill Education. Location Location of the encounter –Outpatient facility –Physician’s office –Hospital –Nursing Home –…etc. 4-7

8. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw- Hill Education. Levels of Key Components Information necessary to classify visit –Level of history taken –Level of examination performed –Complexity of medical decision making (MDM) 1-8

9. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw- Hill Education. Level of Service Level of Patient History –Problem-focused –Expanded problem-focused –Detailed –Comprehensive 4-9

10. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw- Hill Education. Level of Service (cont.) Level of Physical Exam –Problem-focused –Expanded problem-focused –Detailed –Comprehensive 4-10

11. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw- Hill Education. Level of Service (cont.) Level of MDM –Straightforward –Low complexity –Moderate complexity –High complexity 4-11

12. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw- Hill Education. Level of Service (cont.) Determine –level of history taken –level of physician exam performed –level of MDM was …put together into one E/M code Use list of body areas and organ systems with other descriptors shown in the E/M Guidelines directly in front of section. 4-12

13. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw- Hill Education. Time An E/M code may be determined by time spent with the patient… only when counseling takes 51% or more of the total time spent during the encounter. -discussing diagnosis and treatment -not psychological counseling - 90804-90857 4-13

14. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw- Hill Education. Relationship Identify relationship between physician and patient –New patient, established patient, and consultation –Initial visit, subsequent visit 4-14

15. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw- Hill Education. Unit/Floor Time (Hospital and Other Inpatient Visits) Time spent attending to a patient in a facility –Hospital or nursing home Includes time with patient, patient’s family, nursing staff, and time spent reviewing patient’s chart. 4-15

16. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw- Hill Education. Prolonged Services: 99354–99359 Report E/M services that are at least 30 minutes longer than the amount of time represented by the standard E/M codes. 4-16

17. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw- Hill Education. Consultations –A consultation is when a physician requests an opinion of another physician. Referral –A physician transfers care of a patient to another physician. –This patient is a new patient, not a consultation. 4-17

18. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw- Hill Education. Reading the Physician’s Notes Get to know how the physician writes his or her notes. Use key words to identify the correct E/M code. 4-18

19. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw- Hill Education. Chapter Summary Evaluation and Management (E/M) codes report the energy and knowledge a healthcare professional puts into gathering information, reviewing data, and determining the patient’s current condition and the best course of treatment. 4-19