DOCUMENTATION REQUIREMENTS E/M Codes

Codes accounting for the errors What codes should have been used Targeted Codes 99214 : 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 errors What codes should have been used

Principles of Documentation: MR should be complete & legible 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

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

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

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? Outpatient : Level of Visit Codes

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

Expanded Problem Focused E & M Determination Level History Examination Med. Decision Making I Prob. Focused Problem Focused Straightforward II Expanded Prob. Focused Expanded Problem Focused III Detailed Low Complexity IV Comprehensive Moderate Complexity V High Complexity

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

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  review of systems, ROS  past, family and/or social history, PFSH

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 one 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

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

at least 4 or the status of at least 3 chronic or inactive conditions 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 4 or the status of at least 3 chronic or inactive conditions DG 4 & 5

ROS Elements musculoskeletal constitutional symptoms integumentary neurological psychiatric endocrine hematologic/lymphatic allergic/immunologic constitutional symptoms eyes ears, nose, mouth, throat cardiovascular respiratory gastrointestinal genitourinary

ROS Definitions PROBLEM PERTINENT - inquires about the system directly related to the problem in HPI EXTENDED - directly related system + 2 - 9 systems documented COMPLETE - directly related system + all additional body systems DG 6, 7 & 8

PFSH - Pertinent - 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) DG 9

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

Level of Service Determination History Problem Focused Expanded Prob. Focused Detailed Comprehensive HPI Brief Extended ROS N/A Problem Pertinent Complete PFSH Pertinent * Must have all 3 in column or choose lowest

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

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

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

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

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)

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

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

Complexity factors…. Pt’s # of diagnoses the 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)

DG for # of Diagnoses or Mgmt. Options…. Established 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 out initiation or changes in treatment to whom or where referrals or consults are made or from whom the advice is requested

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

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

Diagnostic Procedure Ordered Management Options Selected Table of Risk Level of Risk Presenting Problem Diagnostic Procedure Ordered Management Options Selected minimal one self limited or minor problem Lab tests w/ venipuncture Chest x-rays EKG/EEG Urinalysis Ultrasound KOH Prep rest Gargles Elastic bandages Superficial dressings low 2 or more self limited problems 1 stable chronic illness Acute complicated illness Physiologic tests not under stress Non-cardiovascular imaging studies w/ contrast Superficial needle biopsies Clinical lab test Skin biopsies over the counter drugs Minor surgery w/ no identified risk factors PT or OT IV fluids w/o additives

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

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

Medical Decision Making Determination Type of Decision Making Straight Forward Low Moderate High # of dx. or mgmt options Minimal Limited Multiple Extensive Data Reviewed Risks extensive * 2 of 3 elements must be met or exceeded

Initial Patients must have 3 of 3 E & M Determination Initial Patients must have 3 of 3 Level History Examination Med. Decision Making I 99201 Prob. Focused Problem Focused Straightforward II 99202 Expanded Prob. Focused Expanded Problem Focused III 99203 Detailed Low Complexity IV 99204 Comprehensive Moderate Complexity V 99205 High Complexity

Initial Patients must have 3 of 3 E & M Determination Initial Patients must have 3 of 3 Level History Examination Med. Decision Making I 99201 Prob. Focused Problem Focused Straightforward II 99202 Expanded Prob. Focused Expanded Problem Focused III 99203 Detailed Low Complexity IV 99204 Comprehensive Moderate Complexity V 99205 High Complexity

NEW PATIENTS 99201-99205 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.

Established Patients must have 2 of 3 E & M Determination Established Patients must have 2 of 3 Level History Examination Med. Decision Making I 99211 Prob. Focused Problem Focused Straightforward II 99212 Expanded Prob. Focused Expanded Problem Focused III 99213 Detailed Low Complexity IV 99214 Comprehensive Moderate Complexity V 99215 High Complexity

ESTABLISHED PATIENTS 99211-99215 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.

EST. PT Billing - 99211 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

Observation Care 99218-99220 Characteristics of Observation Pts: Report encounters by the supervising MD Characteristics of Observation Pts: not been admitted as an inpatient may be physically detained in ER clinical condition is being observed additional time needed to clarify condition to determine if hospitalization is needed

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

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

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

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