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1 Evaluation & Evaluation & Management Services Management Services
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Evaluation & Management Evaluation & Management ServicesServices
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What is documentation and What is documentation and
why is it important?why is it important?
Medical record documentation is required for reporting pertinent findings, facts pertinent findings, facts
and observations about a patients and observations about a patients health history.health history.
The medical record documents patient patient care care showing the chronology of treatment, communication between physicians, quality of care, quality of care, and collection of data.
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General principles of General principles of documentationdocumentation
Medical record should be complete and legible.
Documentation should include: Chief complaint Exam and Diagnostic Test results Assessment Plan
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E/M CodingE/M CodingKey ComponentsKey Components
History Physical Examination Medical Decision Making
Contributory FactorsContributory Factors Nature of the presenting problem
•Medical Necessity drives code selection Extent of counseling Coordination of care Time
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E/M GuidelinesE/M GuidelinesMedicare and Medicare and Commercial Commercial
InsuranceInsurance CMS 1995 and 1997 E/M guidelines
• Use either set• 1997 approved by AMA
MedicaidMedicaid Does not use ‘95 or ‘97 guidelines Uses AMA guidelines found in the CPT
book• E/M Service Guidelines section list
“Instructions for selecting a Level of E/M “Instructions for selecting a Level of E/M Service”Service”
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Medical NecessityMedical Necessity
A service that is reasonable and necessary for the diagnosisdiagnosis and treatment treatment of illness or injury, or to improve the functioning of a malformed body member.
Government definition
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STEP ONE -STEP ONE - HISTORYHISTORY
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HistoryHistoryDefinitions
Chief complaint (CC)(CC)• Reason for the visit
History of present illness (HPI)(HPI)• chronological description of the development of the
patient’s illness from the 1st sign and/or symptom to the present.
Review of systems (ROS)(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
Past, Family, Social, History (PFSH)(PFSH)
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HistoryHistory Definitions - Definitions - ContContPast, Family, Social, History (PFSH)(PFSH)
The PFSH consists of a review of one or more of the following three areas of the patient’s history:
• Past History (P)(P)• Family History (F)(F)• Social History (S)(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
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HistoryHistoryProblem 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.FOR A NEW PATIENT.
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CPT History GuidelinesCPT History Guidelines(Medicaid)(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
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Elements of HistoryElements of HistoryHPIHPI
Location Quality Severity Duration Timing Context Modifying factors Associated signs and symptoms
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Elements of History - Elements of History - HPIHPI
LocationLocation – place, whereabouts, site, position. Where on the body is the patient experiencing signs or symptoms? (e.g., pain in (e.g., pain in groingroin))
QualityQuality – – A description, characteristics, or statement to identify the type of sign or symptom. (e.g., (e.g., burning painburning pain in groin) in groin)
Severity Severity –– Degree, intensity, ability to endure. (e.g., History of mild burning pain in groin that (e.g., History of mild burning pain in groin that has become has become more intensemore intense))
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Elements of History - Elements of History - HPIHPI
DurationDuration – Length of time. How long has patient been experiencing the signs or symptoms? (e.g., (e.g., History of intermittent mild burning pain in History of intermittent mild burning pain in groin that has become more intense and groin that has become more intense and frequent for the last frequent for the last two weekstwo weeks))
TimingTiming – Regulation of occurrence. A description of when the patient experiences signs or symptoms (e.g., history of intermittent mild burning in (e.g., history of intermittent mild burning in groin that has become more intense and groin that has become more intense and frequent for the last frequent for the last two weekstwo weeks).).
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Elements of History - Elements of History - HPIHPI
Context –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 (e.g., history of intermitted mild burning pain in groin that intermitted mild burning pain in groin that has become more intense and frequent for has become more intense and frequent for the last two weeks since the patient the last two weeks since the patient bent bent down to pick up sondown to pick up son and continues to feel and continues to feel intense pain when bending).intense pain when bending).
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Elements of History - Elements of History - HPIHPI
Modifying Factors Modifying Factors – Elements that change, alter or have some effect on the complaint or symptoms (e.g., history of intermittent mild burning pain in (e.g., history of intermittent mild burning pain in the groin that has become more intense and the groin that has become more intense and frequent for last two weeks since the patient frequent for last two weeks since the patient bent down to pick up son; continues to feel bent down to pick up son; continues to feel intense pain when bending.intense pain when bending. Patient currently on Patient currently on Motrin 800 mgMotrin 800 mg BID for past BID for past 3 weeks without 3 weeks without reliefrelief))
Associated Signs and Symptoms –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., (e.g., Shortness of breath, light-Shortness of breath, light-headedness, nausea/vomitingheadedness, nausea/vomiting))
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Elements of History - Elements of History - ROSROS
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
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Documentation ExampleExample of ROSROS
Patient denies loss of consciousness. He has not had any bowel or bladder problems. All other systems are negative.
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Evaluation ofEvaluation of Sample ROSROS
Patient denies loss of consciousness or bowel/bladder problem. All other systems are negative.
Neurological Neurological = loss of consciousness
GastrointestinalGastrointestinal = no bowel Program
Genitourinary Genitourinary = no bladder problems
All other neg
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Element of History - Element of History -
Past/Family/Social HistoryPast/Family/Social History - - (PFSH)(PFSH)
Past HistoryPast History:: the patient’s history of illnesses, operations, injuries, treatments, medications.
Family HistoryFamily History:: a review of medical events in the patient’s family, including diseases which may be hereditary or place the patient at risk.”
Social HistorySocial 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.
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Body AreasBody Areas vs.vs. Organ Organ SystemsSystems
BODY AREASBODY AREASHead, incl. FaceNeckChest, incl. Breasts & axillaeAbdomenGenitalia, groin,
buttocksBack, incl. SpineEach extremity
ORGAN SYSTEMSORGAN SYSTEMSConstitutional (vitals & general appearance)EyesENT, mouthCardiovascularRespiratoryGastrointestinalGenitourinaryMusculoskeletalSkinNeurologicPsychiatricHematologic/Lymphatic/
Immunologic
The exam components exam components are divided up between body areas body areas and organ systemsorgan systems. These can be combined when counting elements for exam.
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History History CASE STUDYCASE 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
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History History CASE STUDYCASE STUDYWhat is the patient’s CC ? CC ?
Vaginal DischargeWhat are the patient’s Elements of HPI?Elements of HPI?
1.1. LocationLocation - - vaginal2.2. DurationDuration - - past 2 days3.3. TimingTiming - - a heavier flow in the morning4.4. Modifying factor - Modifying factor - There is no change with
Monistat What is the Level of What is the Level of HPIHPI??
Ans: DetailedAns: Detailed
CASE STUDYCASE STUDYNew 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
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History History CASE STUDYCASE STUDY What is/are the ROSROS??
Integumentary - itching Genitourinary - burning with urination Constitutional - fever
What is the Level of ROS?Ans: Detailed
What is/are the patient’s PFSHPFSH 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: DetailedAns: DetailedCASE STUDYCASE 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
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History History CASE STUDY CASE STUDY ANSWER/EXPLANATIONANSWER/EXPLANATION
History Level = Detailed (3 of 3) CCCC HPIHPI = Extended (4+ elements) ROSROS = Extended (3 elements) PFSHPFSH = Pertinent (1 element)
EXAMPLECC - Vaginal dischargeHPI - 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)
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STEP TWO –STEP TWO – EXAMINATIONEXAMINATIONPerformed by PhysicianPerformed by Physician
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Physical ExamPhysical ExamProblem
Focused (95)<1 body area/ organ system (97) 1-5 elements
Expanded Problem Focused
(95) 2-4 body areas/ organ systems
(97) 6 - 11 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
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CPT Physical Exam CPT Physical Exam GuidelinesGuidelines(Medicaid)(Medicaid)
Problem focused:Problem focused: limited examlimited exam of the affected body area or organ system
Expanded problem focused:Expanded problem focused: limited examlimited exam of the affected body area or organ system and other symptomatic or related organ system(s)
Detailed:Detailed: extended examextended exam of the affected body area(s) and other symptomatic or related organ system(s)
Comprehensive:Comprehensive: general multi-system exammulti-system exam or a complete examcomplete exam of a single organ system
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Physical Exam Physical Exam ExampleExampleVaginal Discharge Exam
Constitutional• BP, temp, pulse
Genitourinary• Examination of external genitalia• Examination of cervix
What is the Level of the What is the Level of the Physical Exam?Physical Exam?ANS: Problem Focused = Problem Focused = (At least two body
areas/organ systems)
CASE STUDYCASE STUDYNew 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
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STEP THREESTEP THREE MEDICAL DECISION-MEDICAL DECISION-
MAKINGMAKING
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MEDICAL DECISION-MAKINGMEDICAL DECISION-MAKING
MDMMDM refers to the complexity of complexity of establishing a diagnosis and/or establishing a diagnosis and/or selecting a management option.selecting a management option.
MDMMDM is the function of 3 variables1. Number of diagnoses and/or management
options2. Amount &/or complexity of data that must
be obtained, reviewed &/or analyzed3. Risk of significant complications, morbidity
&/or mortality
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Self Limited or Minor; stable, improving, worsening x1
Established Problem*; stable, improved x1
Established Problem*; worsening X2
New Problem*; no workup planned X3
New Problem*; addl. workup planned x4
Total Diagnosis or management options
Number of DiagnosisNumber of Diagnosis and/or
Management OptionsManagement Options
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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 Amount and/or Complexity of DataData
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Refers to patient’s level of riskrisk at the visit
Sources of risk Presenting problem Diagnostic procedures ordered Management options selected
Illustrated by clinical examples in “Table of Risk”“Table of Risk”
Risk of Complications, Risk of Complications, MorbidityMorbidity and/orand/or MortalityMortality
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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 Documented ExampleExample of of MDMMDM
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Evaluation of MDMEvaluation of MDM
A/P: By history, suspect possible herniated diskherniated disk. Patient will be referred for MRIMRI scan. Prescribe Motrin 800Motrin 800 mg, tid with food, VicodinVicodin for pain.
Number of Number of dx/txdx/tx options = new problem with addl workup
Amt/Amt/complexity of complexity of datadata = ordered MRI
RiskRisk = prescription management
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Decision MakingDecision MakingStraightforward
#Diagnostic/treatment options (0 -1)(0 -1)
Amt./complexity of data (0 -1)(0 -1)
Risk (minimal)
Low Complexity #Diagnostic/treatment
options (2) (2) Amt./complexity
of data (2) (2)
Risk (low)
Moderate Complexity
#Diagnostic/treatmentoptions (3)(3)
Amt./complexity of data (3)(3) Risk (moderate)
High Complexity #Diagnoses/mgmt options
(4)(4) Amt./complexity of data (4)(4) Risk (high)
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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 MakingDecision Making
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Decision MakingDecision MakingModerate 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) .
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CPT MDM GuidelinesCPT MDM Guidelines(Medicaid)(Medicaid)
Complexity measured by: # of possible diagnoses and/or the number the number
of management optionsof management options that must be considered.
Amount/complexity of records, tests, other tests, other informationinformation that must be obtained, reviewed, and analyzed.
Risk of significant complications, morbidity, morbidity, mortality, as well as co-morbidities, mortality, as well as co-morbidities, associated with the patient’s presenting associated with the patient’s presenting problem(s),problem(s), the diagnostic procedure(s) the diagnostic procedure(s) and/or the possible management options.and/or the possible management options.
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Table of Risk Table of Risk ExamplesExamples
Presenting ProblemPresenting 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.
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Decision Making Decision Making ExampleExample
Vaginal Discharge Exam New problem, additional workup planned
• Lab is ordered (4)(4) Review/order tests in 8xxxx series (1)(1)
What is the Level of What is the Level of Medical Decision Medical Decision MakingMaking??
ANS: ANS: Moderate (2 0f 3)Moderate (2 0f 3) Moderate decision making
• Undiagnosed new problem with uncertain prognosis• Prescription drug management
– Prescription written
Extensive # Diagnosis/treatment optionsExtensive # Diagnosis/treatment options Minimal amount of data to be reviewedMinimal amount of data to be reviewed Table of Risk - Moderate
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Level Assignment Level Assignment EXAMPLEEXAMPLE/CASE STUDY /CASE STUDY CPT CPT
BOOKBOOK
HistoryHistory = Detailed Physical ExamPhysical Exam = Problem Focused Decision MakingDecision Making = Moderate
What is the code for a New & What is the code for a New & Established Patient?Established Patient?
ANSWERLevel = 9920399203, new patientIf Established Patient = 9921499214
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Contributing FactorsContributing FactorsPresenting 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 Counseling or coordination of care takes up OVER 50% of the total visit timeOVER 50% of the total visit time
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Consultation Code Consultation Code SelectionSelection
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Definition of Definition of ConsultationConsultation
“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
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Consultation Consultation vs.vs. ReferralReferral
Consultation: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: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.
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Four Elements That Four Elements That Distinguish A ConsultationDistinguish A Consultation
1. A type of service provided by a physician whose whose opinion or advice opinion or advice regardingregarding evaluation and/or management of an unknown or unknown or uncertain problemuncertain problem is requested by another physician or appropriate source.
2. The written or verbal requestrequest for a consultation must be must be documenteddocumented in the medical record.
3. The consulting physician may initiate may initiate diagnostic or diagnostic or therapeutic servicestherapeutic services at the consultation or subsequent visit.
4. The consulting physician’s opinion and any services ordered or performed must be:a) DocumentedDocumented in the
medical record; andb) Communicated by Communicated by
written reportwritten report to the requesting physician or other appropriate source.
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Types of Inpatient Types of Inpatient ConsultationsConsultations
Initial InpatientInitial Inpatient
No difference in new or established
Reported one time during hospital stay
Requires 3 of 3 key components be documented
Follow-up Follow-up InpatientInpatient
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
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Counseling/Coordination Counseling/Coordination of Careof 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
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Counseling Counseling ExamplesExamples
Established patient, 20 minute visit to follow-up on oral contraceptive use
NPNP 99213 RN RN 99211 (MAMA 99213)
15 minutes of a 20 minute visit spent counseling the patient on alcohol and cigarette use during pregnancy
NPNP 99213 RNRN 99211 (MAMA 99213)
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DefinitionsDefinitions
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)
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Selecting a Level of E/MSelecting a Level of E/M
IdentifyIdentify Place of service (POS)(POS) = where (office) Type of service (TOS) (TOS) = what
(Problem/Preventive) Status of Patient = who (New/Established)
Determine the extent of history - history - physical exam - decision making - physical exam - decision making - counselingcounseling Must consider all factors, and make sure
adequate DOCUMENTATIONDOCUMENTATION in chart to justify code.
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OfficeOffice99201-9921599201-99215
Report Problem visit (vs. Preventive visit) 99201-99205, 99212-9921599201-99205, 99212-99215 performed
by MD, NP, PA,CNS 9921199211 - Ancillary staff i.e. RN, LPN, CNA
MD/NP must be in the clinicMD/NP must be in the clinic
Report only 1 E/M per dayReport diagnostic tests, studies,
procedures separately
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OfficeOffice99201-9921599201-99215
(Medicaid)(Medicaid) 99201-99205, 99212-9921599201-99205, 99212-99215 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
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Preventive Medicine Preventive Medicine ServicesServices
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Preventive MedicinePreventive Medicine 99381-9939799381-99397
Routine management of patients without presenting problems, i.e. i.e. annual, routine, well child examsannual, routine, well child exams
Performed by (MD,NP,PA,CNS) Includes other clinic staff if Medicaid
Codes New/established patients Age
Not usedNot used for scheduled follow-up follow-up visits for specified problemsvisits for specified problems
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CASE STUDYCASE 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.
99243
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CASE STUDYCASE 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.
9939599395
First - IdentifyPlace of service (POS)(POS) = where (office)Type of service (TOS) (TOS) = what (Problem/Preventive)Status of Patient = who (New/Established)
Determine the extent of history - physical exam - decision history - physical exam - decision making - counselingmaking - counseling
First - IdentifyPlace of service (POS)(POS) = where (office)Type of service (TOS) (TOS) = what (Problem/Preventive)Status of Patient = who (New/Established)
Determine the extent of history - physical exam - decision history - physical exam - decision making - counselingmaking - counseling
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CASE STUDYCASE STUDYA 2-year-old boy with bacterial pneumonia is hospitalized and has had 5 days of antibiotic therapy. Today the child developed a fever of 101.1 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.
9923199231
