Chapter 19

  How to select the evaluation and management level of service Objective

  Professional services  Evaluation and management services  Levels of service  Key components  Contributory factors  History  Exam  Decision making Key Concepts

  Face-to-face time spent with a patient obtaining his/her history, performing examinations, evaluating, determining and providing treatments, conferring with him/her, suggesting preventive health measures all = professional services  Physicians charge for these professional services called Evaluation and Management using specific Current Procedural Terminology (CPT) codes Evaluation and Management

  E/M codes differ depending on the following:  Place of service  Type of service  Content of the service  Nature of presenting problem  Time typically required to provide the service E/M Codes

  For primary and urgent care services there are up to 5 levels of codes defined by 6 different key components:  History  Examination  Medical decision making  These next 3 are contributory factors and are not required to be provided during each patient encounter:  Counseling  Coordination of care  Nature of presenting problem Key Components

  These vary depending on type of visit. Primary care, urgent care, workers’ compensation visits to a primary care physician use the same series of CPT codes. Orthopedic medicine and rehab services have their own sets of CPT codes.  Do This! Pg. 241  Place cursor in Level of Service field on Visit Documentation screen(Figure 19-1) to access Level of Service screen Level of Service

  Figure 19-2  Click following checkboxes for key components of the E/M level of service code:  History: CC-this component means that physician reviewed chief complaint(CC) with patient,asked patient about history of present illness/injury(HPI), reviewed patient’s past history of similar injuries(P) and reviewed history of patient’s problem system (Prob Sys)and multiple other systems (Mult Other Sys)  Exam: this component means physician examined affected body area and other related systems  Decision-Making: This component means physician selected one diagnosis for the patient’s condition and reviewed the area and accessed the risk of long term complications  After clicking checkboxes click Submit button to accept choices Level of Service Screen

  Figure 19-3  Many physicians know the level of CPT service codes without checking the boxes for history, exam, and decision making.  Type the level of service CPT code directly in the Level of Service field on Visit Documentation screen and press ENTER  MedTrak will automatically check the appropriate boxes for history, exam and decision making based on CPT code entered  After reviewing Level of Service screen click Submit button to accept code. Level of Service screen refreshes with message :Level of Service updated to ….(Code)” at top of screen  The physician clicks Exit screen button to return to Visit Documentation screen  e/M level of service CPT code appears next to Level of Service field  Visit Documentation screen should look similar to Figure 19-4 with information about each of sections selected displayed to right of field for that section  Do This! Pg. 245 Level of Services Screen

  Click Done button to notify MedTrak that you are finished with Out the Door process(Visit Documentation)  Figure 19-5  Do This! Pg. 246

  You will need to print and turn in Mr. Baker’s evaluation and management level of service code, in addition to all other sections of Out the Door process that you completed in the electronic health record  Do This! Pg. 247 Printing The Patient’s Chart