1. Making notes “authentic” and retaining quality Nancy M. Enos, FACMPE, CPC-I, CEMC, CPMA October 7, 2013 MGMA Annual Conference San Diego, CA

2. Agenda Hot topics in E/M coding – the OIG is watching high levels of service Electronic Health Records and Physician Documentation- Risk of copied and cloned notes The Chart Audit Process

3. 2012 OIG Work List E/M Trends in Coding of Claims OIG reviewed evaluation and management (E/M) claims to identify trends in the coding of E/M services from 2000-2009. Medicare paid $32 BILLION for E/M services in 2009, representing 19% of ALL Medicare part B payments. Providers are responsible for ensuring that the codes they submit accurately reflect the services they provide. E/M codes represent the type, setting, and complexity of services provided and the patient status, such as new or established.

4. 2012 OIG Work List E/M improper documentation due to cloned notes, identical documentation OIG will assess the extent to which CMS made potentially inappropriate payments for E/M services due to the consistency of E/M medical review determinations multiple E/M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments.

5. OIG Report released in May 2012 OIG released a report on Coding Trends of Medicare Evaluation and Management Services The report reflects OIG’s and CMS’ continuing suspicions about the increase in higher level billing indicating a need for physicians to audit their E/M coding “ I hereby direct executive departments and agencies to expand their use of Payment Recapture Audits, to the extent permitted by law and where cost-effective.” –Daniel R. Levinson, Inspector General

6. OIG Report From 2001 to 2010 Level 1 to 3 dropped 17% while Level 4 and 5 increased 17% The OIG identified 1,700 providers who billed level 4 or level 5 at least 95% of all E/M claims in 2010 OIG has sent the names of these “high billing” doctors to CMS, along with a recommendation for review and possible recoupment. http://oig.hhs.gov/oei/reports/oei-04-10-00180.pdf

7. OIG Report From 2001 to 2010 Level 1 to 3 dropped 17% while Level 4 and 5 increased 17% The OIG identified 1,700 providers who billed level 4 or level 5 at least 95% of all E/M claims in 2010 OIG has sent the names of these “high billing” doctors to CMS, along with a recommendation for review and possible recoupment http://oig.hhs.gov/oei/reports/oei-04-10-00180.pdf

8. Who are the 1,700? States  California 17.1%  New York 11.3%  Florida 9.6%  Texas 6.7%  Arizona 4.3%  Michigan 3.8%  Illinois 3.5%  Maryland 3.3%  New Jersey 3.2%  Pennsylvania 3.2% Specialties  Internal Medicine 19.8%  Family Practice 12.2%  Emergency Med. 9.9%  Nurse Practitioner 4.4%  Ob-Gyn 4.3%  Cardiovascular 4.0%  Orthopedic Surgery 3.9%  Psychiatry 3.8%  General Surgery 3.2%  Ophthalmology 3.2%

9. Is the Increase Justified? Electronic Medical Records provide a better way to capture patient acuity (more diagnosis codes) and template guided E/M notes may document and support a higher level of E/M Service Medical necessity is the key Completion of a Comprehensive History, and a Comprehensive Examination, does not justify a level 5 service if it is not medically reasonable and necessary.

10. Correcting “Undercoding” The uptick may be a correction of undercoding-many primary care doctors were overusing 99213 for complex patients with multiple chronic diseases, because handwriting a SOAP note for their follow up visits was time consuming Ancillary staff can complete the Chief Complaint, Review of Systems, Past, Family and Social History The provider MUST validate these entries

11. Risks of Electronic Health Records Templates can assist Coder’s adage…If it wasn’t documented, it wasn’t done Auditors adage…if it wasn’t necessary, don’t bill for it Auto-complete - check Review of Systems (ROS)  Were they all really reviewed?  Was it necessary? Physician training

12. Cloned Notes- History Does your EMR have templates that create a Complete 14-point Review of Systems (ROS) automatically? Issues and risks  Each element of the ROS must be supported by the History of Present Illness for medical necessity  For instance, a patient comes in to the Emergency Department for a hand injury  Review of systems includes Genitourinary system  “patient denies pregnancy, dysmenorrhea and has a normal menstrual cycle”

13. Cloned Notes- History Does your EMR have templates that create a Complete 14-point Review of Systems (ROS) automatically? Issues and risks  Each element of the ROS must be supported by the History of Present Illness for medical necessity  For instance, a patient comes in to the Emergency Department for a hand injury  Review of systems includes Genitourinary system  “patient denies pregnancy, dysmennorhea and has a normal menstrual cycle”  Patient is an 87 year old male

14. Validity of Data Systems that are documented in the HPI (patient presents with a rash on the left arm) contradict the systems documented in the ROS “list” (skin negative) Systems that are documented in the ROS that make no sense for the patient (female denies any erectile dysfunction) Systems that are documented in the HPI and conflict with personal or family history (HPI pt is here for full skin check, mother has malignant melanoma) and the Family history is “noncontributory”.

15. Cloned notes-Physical Exam Automated Text for a “Female exam” or “Male exam” Includes Organ systems and Body areas that are unrelated to the reason for the visit Findings such as “HEENT negative” do not indicate why the exam was done Neck-negative- what does this mean?  Musculoskeletal- neck, full range of motion  Cardiovascular- neck, no jugular venous distention  Lymphatic- neck, no adenopathy  Neurological- neck, no stiffness or pain (meningitis)

16. Coding based on documentation or risk? According to the OIG, if a visit is documented with a physical exam that is more extensive than the problem described in the HPI- If the code level agrees with the level of risk, the superfluous items in the PE are not a problem If the code level is based on the extent of the documentation in the physical exam, the visit may be overcoded Example: Detailed History, Detailed Exam, Low MDM  This should be billed as 99213 based on risk

17. Risk Based Coding The most important element of the 3 key components of History, Exam and Medical Decision Making is the MDM A comprehensive history and comprehensive exam cannot be billed at 99215 if the MDM is at Low or Moderate Risk Unless, time is the controlling factor and is documented  “greater than 50% of the face-to-face encounter was spent in counseling and coordination of care”  “Total time of the visit was 45 minutes”

18. Cloning and Fraud Providers who use EMR templates that create identical records for multiple patients on the same date of service will be reviewed for CLONING Using the same template for the same ROS and Physical Exam, for every patient, regardless of the reason for the visit, is considered CLONING Each entry should be AUTHENTIC to the patient visit, on that date Copying/pasting from a previous note is not allowed.

19. Medical Necessity Acuity is a good indicator of medical necessity. The more diagnosis codes (as long as the problems were addressed) the higher the severity Do you run reports by Diagnosis code and view your E/M levels?

20. Auditing Processes- validating the authenticity of Documentation

21. What to Audit Baseline Audit Identify areas in need of increased documentation to maintain compliance Recommended 10-15 records per provider Random records but should reflect trends of provider specific problem areas triggers or areas of concerns Include Evaluation and Management and surgical encounters Use reports to help decipher what types of services to review for your physicians

22. Auditing the Records Audit based on information provided to auditor Evaluated on information specific to the date of service Records must be “fused” Evaluate documentation content and medical necessity of visit Three notations of each performed audit:  Services billed  Documentation level  Medical necessity level

23. SOAP Notes Subjective (History) Describes the patients symptoms and reason for visit Questions  Presently experiencing  Have experienced  Other signs/symptoms  PFSH can be asked to help identify possible risk factors APSO Exam HistoryMDM

24. SOAP Notes Objective (Examination) Hands on examination of the patient by provider Includes: Vital signs, Eyes, Ears, Nose, Throat, Neck, Cardiovascular, Chest, Respiratory, GI, GU, Lymphatic, Musculoskeletal, Skin, Neurologic, Psychiatric APSO Exam HistoryMDM

25. SOAP Notes Assessment (MDM) Patient diagnosis Other information important to the diagnostic assessment APSO Exam HistoryMDM

26. SOAP Notes Plan (MDM) What the provider has developed for plan of treatment, referrals, consultations, medications and re-evaluations APSO Exam HistoryMDM

27. Counseling Documentation Counseling The physician spends a majority of the visit talking with the patient, and due to this is unable to fulfill all of the necessary components needed in order to meet documentation guidelines. Test results consume the visit Risks and benefits of a treatment are discussed Patient education Multiple treatment options are discussed

28. Time Documentation Provider spends more than 50% of the visit counseling the patient  Example: I spent more then 50% of the visit or a total of 45 minutes counseling the patient about their depression.  Document in patient medical record Time can not be used with Emergency Department codes

29. Components E/M services are scored based on the documentation of necessary components History - 1st component Examination - 2nd component Medical Decision Making (MDM) – 3rd component Contributing factors Counseling, coordination of care, nature of presenting problem, and time

30. History History of the medical record documentation should include four areas:  Chief Complaint  History of Present Illness  Review of Systems  Past, Family and Social History This area is scored on the area of history documented with the least amount of information.

31. Chief Complaint Chief Complaint is recommended of every medical record. Concise statement that describes the problem/condition for the patient encounter. Usually in the patient’s own words  This is usually documented by the nurse or medical assistant  Beware of “routine reasons”

32. Routine Reasons for visit Here to establish care Here for lab results Here for MRI or radiology results Here for annual exam (and an E/M code is reported) Here for “routine” recheck  Ugh! Actually used a word that says the visit is unnecessary! Share this list with your Medical Assistants!

33. History of Present Illness - HPI HISTORY COMPONENT Must be personally documented by the provider History of Present Illness Patient symptoms and Chief Complaint – What they are presently experiencing □ Location □ Severity □ Timing □ Modifying Factors □ Quality □ Context □ Duration □ Associated Signs & Symptom Brief 1-3 HPI Elements OR status of 2>chronic or inactive conditions Extended 4< HPI elements OR status of 3< chronic or inactive conditions

34. History of Present Illness (HPI) Location Severity Timing Modifying Factors Quality Duration Context Associated Signs and Symptoms HPI must be documented personally by the clinician.

35. First Component of HPI Brief History 1-3 Elements Extended History 4 or more elements for 95/97 guidelines 3 or more chronic/inactive for 97 guidelines □ Location □ Severity □ Timing □ Modifying Factors □ Quality □ Context □ Duration □ Associated Signs & Symptom Brief 1-3 HPI Elements OR status of 2>chronic or inactive conditions Extended 4< HPI elements OR status of 3< chronic or inactive conditions

36. Review of Systems HISTORY COMPONENT Review of Systems -ROS Inventory of body systems obtained by questions from provider to identify signs/and symptoms the patient may be experiencing or has experienced. □ Constitutional □ ENT □ Eyes □ Cardiovascular □ Respiratory □ GI □ GU □ Neurology □ Musculoskeletal □ Psychiatric □ Integumentary □ Endocrine □ Hem/Lymph □ Allergy/Immunology □ All Others Negative NonePertinent to 1 system Extended 2-9 Systems Complete 10 systems or all neg

37. Review of Systems - ROS Constitutional – Weight, fever, sweating ENT – Ears, Nose, Throat Eyes – Glasses, vision problems, Cardiovascular – Heart, palpitations, chest pain GI – Diarrhea, vomiting GU – Urinary, Male/Female problems Respiratory – SOB, coughing Musculoskeletal – Joint pains, backaches, stiffness Psychiatric – Depression, anxiety, mood swings Integumentary – Rashes, dryness, hair, nails, lesions Endocrine – Thyroid, excessive sweating Hem/Lymph – Easy bruising or bleeding, swollen glands Allergy/Immunology – Allergies to food, hepatitis. HIV Neurologic – Blackouts, seizures, memory loss, speech

38. No Double Dipping If you use a symptom or system in the History of Present Illness, you can’t use it in Review of Systems Example: The patient woke up with a headache today  Using headache as location (HPI) and Neurologic (ROS) is not permitted

39. Past, Family, Social History - PFSH HISTORY COMPONENT PFSH – Past Medical, Family & Social History The provider asks the patient information about past history of illnesses and diseases, social history, and, family history of diseases and illness. □ Past Medical History □ Family History □ Social History Established Patient None None 1 History Area 2 or 3 History Area □ Past Medical History □ Family History □ Social History New Patient None None 1 or 2 History Area 3 History Areas

40. Past- prior illnesses, surgery, hospitalizations, allergies, medications Family- age and cause of death of immediate family members, or family members with diseases that are related to the patient’s visit Social- lifestyle such a marital status, alcohol or tobacco use, occupation, education, living situation, sexual activity Past, Family, Social History - PFSH

41. History in Children Past History  Specifics regarding birth Family History  Pregnancy of mother  History of birth mother/father Social History  Parents alcohol or smoking habits  Child care settings

42. Unobtainable History Sometimes it is impossible to obtain a history due to the status of the patient. Document why the history was unobtainable How to score 1st view – Omit the history as scorable component 2nd view – Allow a complete history Recommendation: Let doctor’s decide and documented in your compliance manual

43. Examination An examination based on either the 1995 or 1997 documentation guidelines. 1995 examinations are based on the organ systems and body areas. 1997 examinations are based on bullets outlined through specific system examinations.

44. Examination Examination is the “hands on” examination performed by the provider Unremarkable and non-contributory do not meet the necessary requirements (Think “no comment”) Negative or normal meets documentation guidelines If abnormal – reason it is abnormal must be documented

45. Template Risks for Physical Exam The biggest risk in EMR documentation is the exam Using the same exam for every patient, every visit, may lead to ‘over- documentation’ of the exam Examples: Patient is seen for a sore throat Comprehensive exam is documented, mostly negative other than ears, nose, throat, respiratory and constitutional Why is an exam done of unrelated systems?

46. 95 Examination Body areas and systems can be acceptable for all levels of examination with the exception of the comprehensive level Body areas: Head, neck, chest, abdomen, genitalia, back, each extremity Body systems: Constitutional, eyes, ears, nose, throat, mouth, cardiovascular, respiratory, GI, GU, musculoskeletal, skin, neurologic, psychiatric, lymphatic

47. 95 Examination Body Areas BAHead, including the face BANeck: neck (masses, symmetry, etc), thyroid BAChest (Breasts): inspection breast, palpation breast/axillae BAAbdomen BAGenitalia, groin, buttocks BABack, including spine BALeft upper extremity BARight upper extremity BALeft lower extremity BARight lower extremity

48. 95 Examination Organ Systems=OS OSConstitutional 3 of the following: sit/stand BP, sup BP, temp, pulse rate, respiratory, height, weight or general appearance OSEyes conjunctivae/lids, pupils/irises, optic discs OS Ears, Nose, Mouth/Throat External exam ears/ nose, external auditory canal/tympanic membrane, hearing assessment, nasal mucosa/septum/turbinates, lips/teeth/gums, oropharynx OSRespiratory: Respiratory effort, chest percussion, chest palpation, auscultation of lungs OSCardiovascular Palpation heart, auscultation, exam of: carotid, femoral arteries, abdominal aorta, pedal pulses, extremities OSGastrointestinalAbdominal, lever/spleen, hernia, stool sample taken, anus, perineum, rectum OSGenitourinary Male: scrotum, penis, DRE/prostate Female: pelvic, ext genitalia, urethra, bladder, cervix, uterus, adnexa/parametria OSMusculoskeletal Gait/station, digits/nails, examination of jointst, bone, muscles, inspect & palpate, stability, ROM, strength & tone OSSkin Inspection skin/ subcutaneous tissue, palpation skin/ subcutaneous tissue OSNeurologic Crainal nerves, deep tendon reflexes, sensation OSPsychiatric Judgment/ insight, MSE: orientation, remote & recent memory, mood & affect OS Hematologic/ lymphatic Neck, axillae, groin, other/immunologic

49. 95 Examination Problem Focused1 body area or 1 body system Exp Problem Focused 2 - 7 body systems, no detail of any system required Detailed 2 - 7 body systems with affected system in detail Comprehensive 8 or more body system (not body areas) OR Problem Focused1 body area or 1 body system Exp Problem Focused 2 - 4 body systems or body areas Detailed 5 - 7 body systems or body areas Comprehensive 8 or more body systems (not body areas)

50. 97 Examination General Multisystem Constitutional Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3} pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (may be measured and recorded by ancillary staff) General appearance of patient e.g. development, nutrition, body habitus, deformities, attention to grooming Neck Examination of neck e.g. masses, overall appearance, symmetry, tracheal position, crepitus Examination of thyroid e.g. enlargement, tenderness, mass Eyes Inspection of conjunctivae and lids Examination of pupils and irises e.g. reaction to light and accommodation, size, symmetry Ophthalmoscopic examination of optic discs e.g. size, C/D ratio, appearance and posterior segments e.g. vessel changes, exudates, hemorrhages Ears, nose, External inspection of ears and nose mouth & Otoscopic examination of external auditory canals and tympanic membranes throat Assessment of hearing e.g. whispered voice, finger rub, tuning fork Inspection of nasal mucosa, septum and turbinates Inspection of lips, teeth and gums Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx

51. 97 Examination General Multisystem Respiratory Assessment of respiratory effect e.g. intercostal retractions, use of accessory muscles, diaphragmatic movement Percussion of chest e.g. dullness, flatness, hyperresonance Palpation of chest e.g. tactile fremitus Auscultation of lungs e.g. breath sounds, adventitious sounds, rubs Cardiovascular Palpation of heart e.g. location, size, thrills Auscultation of heart with notation of abnormal sounds and murmurs Examination of: Carotid arteries e.g. pulse, amplitude, bruits Abdominal aorta e.g. size bruits Femoral arteries e.g. pulse, amplitude, bruits Pedal pulses e.g. pulse amplitude Extremities for edema and/or varieosities Chest (breasts) Inspection of breasts e.g. symmetry, nipple discharge Palpation of breasts and axillae e.g. masses or lumps, tenderness Gastrointestinal Examination of abdomen with notation of (abdomen presence of masses or tenderness Examination of liver and spleen Examination for presence or absence of hernia Examination when indicated of anus, perineum and rectum, including sphincter tone, presence of hemorrhoids, rectal masses Obtain stool sample for occult blood test when indicated

52. 97 Examination General Multisystem Genitourinary Examination of the scrota! Contents e.g. hydrocele, spermatocele, tenderness of cord, (Male) testicular mass Examination of the penis Digital rectal examination of prostate gland e.g. size symmetry, nodularity, tenderness Genitourinary Pelvic examination (with or without specimen collection for smears and cultures) including: (Female) Examination of external genitalia e.g. general appearance, hair distribution, lesions and Vagina e.g. general appearance, estrogen effect, discharge lesions, pelvic support, cystocele, rectocele Examination of the urethra e.g. masses, tenderness, scarring Examination of the bladder e.g. fullness, masses tenderness Cervix e.g.general appearance, lesions, discharge Uterus e.g. size, contour, position, mobility, tenderness, consistency, descent or support Adnexa/parametria e.g. masses, tenderness, organomegaly, nodularity Lymphatics Palpation of lymph nodes in two or more areas: Neck Axillae Groin Other

53. 97 Examination General Multisystem Musculoskeletal Examination of gait and station Inspection and/or palpations of digits and nails e.g. clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes Examination of joints, bones and muscles of one or more of the following six areas: 1) head and neck, 2) spine, ribs and pelvis, 3) right upper extremity 4) left upper extremity, 5) right lower extremity, 6) left lower extremity. The examination of a given area includes: Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions Assessment of range of motion with notation of any pain, creptitation or contracture Assessment of stability with notation of any dislocation (luxation), subluxation or laxity Assessment of muscle strength and tone e.g. flaccid cog wheel, spastic with notation of any atrophy or abnormal movements Skin Inspection of skin and subcutaneous tissue e.g. rash, lesions, ulcers Palpation of skin and subcutaneous tissue e.g. induration, subcutaneous nodules, tightening Neurologic Test cranial nerves with notation of any deficits Examination of deep tendon reflexes with notation of pathological reflexes e.g. Babinski Examination of sensation e.g. tough, pin, vibration, proprioception Psychiatric Description of patient's judgement and insight Brief assessment of mental status including: Orientation to time, place, and person Recent and remote memory Mood and affect e.g. depression, anxiety, agitation

54. 97 Examination General Multisystem Problem FocusedOne to five elements identified by a bullet Exp Prob FocusedAt least six elements identified by a bullet DetailedAt least two elements identified by a bullet from each six areas/systems OR at least twelve elements identified by a bullet in two or more areas/systems Comprehensive Performed all elements identified by a bullet and document at least two elements by a bullet from each of nine area/system

55. Medical Decision Making - MDM The medical decision making portion of the documentation includes information that tells the diagnosis of the patient and how the diagnosis or diagnoses will be treated. Three areas of documentation: Diagnosis Complexity Risk

56. MDM - Diagnosis Cannot get credit for mentioning a diagnosis that may not be applicable to the day’s visit EMR’s often list all “problems”  Some require an ICD-9 code to order a test, even if the reason for the test is not addressed during the current encounter Minimum of one diagnosis treated with a developed plan of care. Diagnosis should have relevance to the treatment. Mentioning diagnosis may be a secondary issue

57. Points # of Diagnoses or Management Options – Problem Categories (Multiplier) Self-limited/minor (stable, improved, or worsening)1 (max = 2) Established/stable/improved1 Established/worsening/not responding to treatment2 New, no additional workup planned3 (max = 1) New, workup planned4 MDM - Diagnosis

58. What is additional work-up? Extensive procedures that do not have the results on the date of service can be considered as additional workup. These may include: MRI, CT, biopsies, nuclear medicine testing, laboratory testing, etc

59. MDM – Diagnosis Self Limited/Minor ? Improved ? Worsening? New Problem, no work-up? New Problem, additional work-up? Self Limited or minor (stable, improved, or worsening) (Max 2) 1x Established problem, stable, improved1/dxx Established problem, worsening2/dxx New problem; no additional work-up planned (Max 1)3x New problem; additional work-up planned ie; referred, testing4x Total

60. MDM - Complexity of Data Points are assigned based on the following: Review and/or order:  clinical lab tests  tests in radiology section  tests in medicine section Decision to obtain old records and/or obtain history from someone other than patient Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider Independent visualization of image, tracing or specimen itself (not simple review of report)

61. Ordering Test Providers are assigned pointed based on the category of test ordered. One point per category ordered and not based on the number of tests ordered Example: CBC and Strep tests are ordered – only one point for Review and/or order clinical lab tests

62. Medical Record Requesting medical from the patient’s previous provider. Must be documented Reviewing of the medical record Guidelines require a brief summarization of the findings and not a simple statement that they were reviewed

63. Independent Visualization Two points are given for every test they interpret. If they interpret the test, they do not receive points for ordering the test. Provider needs only to include a copy of the findings with his/her interpretation to obtain credit.

64. MDM – Complexity of Data Reviewed or Ordered Review and/or order clinical lab tests 1 Review and/or tests in radiology section 1 Review and/or tests in medicine section 1 Decision to obtain old records and/or obtain history from someone other than patient 1 Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health provider 2 Independent visualization of image, tracing or specimen itself (not simple review of report 2 TOTAL

65. Labs, radiology, medicine? Discuss with another health provider? Independent visualization? Review and/or order clinical lab tests 1 1 Review and/or tests in radiology section 1 1 Review and/or tests in medicine section 1 Decision to obtain old records and/or obtain history from someone other than patient 1 Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health provider 2 2 Independent visualization of image, tracing or specimen itself (not simple review of report 2 TOTAL 4

66. Diagnosis1 or less234 or more Complexity1 or less234 or more RiskMinimalLowModerateHigh Level Straight Forward LowModerateHigh Medical Decision Making

67. MDM - Risk of Complications The level of risk must be assigned to every patient’s medical record as the level of risk assigned mirrors the medical necessity of the documentation. The level of risk tells the reader of the note exactly what it implies: the level of risk the provider has assumed in treating the patient on this date of service.

68. Table of Risk There are three components to the table of risks: Presenting problem Diagnostic procedures Management options

69. MDM - Presenting Problem Presenting Problem M I One self-limited, minor problem e.g. cold, insect bite LOWLOW 2 or more self limited or minor problems, 1 stable chronic, acute illness or injury uncomplicated MODMOD One or more chronic illness with mild exacerbation, 2 or more chronic illness, acute illness with uncertain prognosis, acute complicated injury H I G H 1 or more chronic illness with severe exacerbation, progression or side effect of treatment, acute or chronic illness or injury that may pose a threat to life or body function, abrupt change in neurological status

70. MDM - Diagnostic Procedure Diagnostic Procedure Lab testing requiring venipuncture, chest x-ray or US, EKG/EEG, KOH prep or UA Physiological test not under stress, PFT, non cardiovascular image study with contrast, superficial needle biopsy, clinical lab requiring arterial puncture, skin biopsy Physiological test under stress, diagnostic endoscopy with no identified risk factors, deep needle or incision biopsy, cardio imaging study with contrast no identified risk factors, obtain fluid from body cavity Cardiovascular imaging studies with contrast with identified rsk factors, cardiac electrophysiological test, diagnostic endoscopy with identified risk factors, discography M I LOWLOW MODMOD H I G H

71. MDM - Management Options Management Options Rest, gargles, dressing, bandaid OTC drugs, PT or OT, IV fluids w/o additive. Minor surgery no identified risk factors Minor surgery with identified risk factors, elective major surgery with no identifiable risk factors, prescription drug management, therapeutic nuclear medicine, IV with additives, closed treatment of fracture or dislocation w/o manipulation Elective major surgery with identifiable risk factors, emergency major surgery, IV controlled substances, drug therapy requiring intensive monitoring for toxicity, decision not to resuscitate or de-escalate because of poor prognosis M I LOWLOW MODMOD HIGHHIGH

72. Choosing the Level of Risk The highest level of risk in any one category; presenting problem, diagnostic procedure or management options determines the overall risk. Presenting ProblemDiagnostic ProcedureManagement Options M I One self-limited, minor problem e.g. cold, insect bite Lab testing requiring venipuncture, chest x-ray or US, EKG/EEG, KOH prep or UA Rest, gargles, dressing, band aid LOWLOW 2 or more self limited or minor problems, 1 stable chronic, acute illness or injury uncomplicated Physiological test not under stress, PFT, non cardiovascular image study with contrast, superficial needle biopsy, clinical lab requiring arterial puncture, skin biopsy OTC drugs, PT or OT, IV fluids w/o additive. Minor surgery no identified risk factors MODMOD One or more chronic illness with mild exacerbation, 2 or more chronic illness, acute illness with uncertain prognosis, acute complicated injury Physiological test under stress, diagnostic endoscopy with no identified risk factors, deep needle or incision biopsy, cardio imaging study with contrast no identified risk factors, obtain fluid from body cavity Minor surgery with identified risk factors, elective major surgery with no identifiable risk factors, prescription drug management, therapeutic nuclear medicine, IV with additives, closed treatment of fracture or dislocation w/o manipulation H I G H 1 or more chronic illness with severe exacerbation, progression or side effect of treatment, acute or chronic illness or injury that may pose a threat to life or body function, abrupt change in neurological status Cardiovascular imaging studies with contrast with identified rsk factors, cardiac electrophysiological test, diagnostic endoscopy with identified risk factors, discography Elective major surgery with identifiable risk factors, emergency major surgery, IV controlled substances, drug therapy requiring intensive monitoring for toxicity, decision not to resuscitate or de-escalate because of poor prognosis

73. MDM Level is determined with 2-3 or center level What is the level – Straight Forward, Low, Moderate, High Diagnosis1 or less234 or more Complexity1 or less234 or more RiskMinimalLowModerateHigh Level Straight Forward LowModerateHigh Calculating the Level of MDM

74. Score Sheet HISTORYMinimal Problem Focused Exp Problem Focused DetailedComprehensive EXAMN/A Problem Focused Exp Problem Focused DetailedComprehensive MDM N/A Straight Forward LowModerateHigh LEVEL9921199212992139921499215 TIME 5 minutes10 minutes15 minutes25 minutes40 minutes Established Patient

75. Code Selection Nancy Enos, FACMPE CPMA CPC-I

76. Audit Feedback -Involve your EMR administrator Extent of History, Exam, MDM Copy and paste capabilities-  What does your practice allow? Review of Systems Templates Physical exam Templates Provider Education Re-Audit if the provider needs monitoring Use the information gained to effect change!

77. Parting thoughts- Does your Electronic Medical Record “suggest” the E/M Level of Code? Do your providers accept or reject the Level of Service code? Are your providers trained (and proficient) to correct or edit any “smart text” that is not authentic? Does your EMR require a diagnosis code when a physician is entering orders? Do you have annual compliance audits as a part of your practice’s Compliance Program?

78. Nancy M Enos, FACMPE, CPMA, CPC-I, CEMC is an independent consultant with the MGMA Health Care Consulting Group. Nancy was a practice manager for 18 years before she joined LighthouseMD in 1995 as the Director of Physician Services and Compliance Officer. In July 2008 Nancy established an independent consulting practice. As an Approved PMCC Instructor by the American Academy of Professional Coders, Nancy provides coding certification courses and consultative service. Nancy frequently speaks on coding, compliance and reimbursement issues. Nancy became an AAPC Certified ICD-10 Instructor in June, 2013. Nancy is a Fellow of the American College of Medical Practice Executives. She is a past Chair of the Eastern Section MGMA and is a past President of MA/RI MGMA and serves on the Section Council Steering Committee for MGMA. Email: nancy@enosmedicalcoding.comnancy@enosmedicalcoding.com