Evaluation & Management ServicesEvaluation & Management Services

July 7, 2009July 7, 2009

Brenda Edwards, CPC, CPC-I, CEMCBrenda Edwards, CPC, CPC-I, CEMCCoding & Compliance SpecialistCoding & Compliance Specialist

KaMMCOKaMMCO

Medical Record Medical Record DocumentationDocumentation

Records pertinent facts, findings Records pertinent facts, findings and observations about an and observations about an individual’s health history including individual’s health history including past and present illnesses, past and present illnesses, examinations, tests, treatments and examinations, tests, treatments and outcomesoutcomes

Chronologically documents the care Chronologically documents the care of the patientof the patient

Is an important element Is an important element contributing to high quality care.contributing to high quality care.

Golden Rule of Golden Rule of Coding:Coding:

If it is not documented,If it is not documented,

it is not done and it is not done and therefore not billable!therefore not billable!

Accuracy is of the Accuracy is of the Utmost ImportanceUtmost Importance

Legibly document what you Legibly document what you have done.have done.

Something that may seem Something that may seem trivial for you to document trivial for you to document could be the reason you could be the reason you could bill a higher level of could bill a higher level of service.service.

Principles of Principles of DocumentationDocumentation

Complete and legibleComplete and legible At least two patient identifiersAt least two patient identifiers The reason for the encounter The reason for the encounter Relevant history, physical examination findings and Relevant history, physical examination findings and

prior diagnostic test resultsprior diagnostic test results Assessment, clinical impression or diagnosis and plan Assessment, clinical impression or diagnosis and plan

for care includedfor care included Appropriate health risk factors identified as well as the Appropriate health risk factors identified as well as the

patient’s progress, response to and changes in patient’s progress, response to and changes in treatment and revision of diagnosis should be treatment and revision of diagnosis should be documenteddocumented

The CPT and ICD-9 codes submitted must be supported The CPT and ICD-9 codes submitted must be supported by the documentation in the medical recordby the documentation in the medical record

Evaluation & Management Evaluation & Management ServicesServices

An E&M (evaluation & management) An E&M (evaluation & management) service is any non-procedural service service is any non-procedural service provided to a patient. Office visit, provided to a patient. Office visit, hospital admission, subsequent days, hospital admission, subsequent days, discharge, ER visits and nursing home discharge, ER visits and nursing home services are all examples of E&M services are all examples of E&M servicesservices

Documentation guidelines for E&M Documentation guidelines for E&M services were first introduced by the services were first introduced by the Health Care Finance Administration Health Care Finance Administration and the AMA in 1995. and the AMA in 1995.

Documentation Documentation GuidelinesGuidelines

New patients vs. established New patients vs. established patientpatient New patient - One who hasn’t been New patient - One who hasn’t been

seen by any provider of the same seen by any provider of the same practice (same tax id) in the past 3 practice (same tax id) in the past 3 yearsyears

Established patient – May be “new” Established patient – May be “new” to the provider but not “new” to the to the provider but not “new” to the practicepractice

Evaluation & Management Evaluation & Management ServicesServices

Three components to an E&M Three components to an E&M visitvisit

HistoryHistory History of Present Illness (HPI)History of Present Illness (HPI) Review of Systems (ROS)Review of Systems (ROS) Past, Family, Social History (PFSH)Past, Family, Social History (PFSH)

ExamExam Medical Decision Making (MDM)Medical Decision Making (MDM)

Assignment of the E&M CodeAssignment of the E&M Code

Based on the documentation by the Based on the documentation by the provider, the level of the E&M service is provider, the level of the E&M service is determined by the level of history, determined by the level of history, exam and MDMexam and MDM

New patient office visits, must all meet New patient office visits, must all meet 3 out of 3 levels of the History, Exam 3 out of 3 levels of the History, Exam and MDMand MDM Example: History was comprehensive, Example: History was comprehensive,

exam was detailed and MDM was moderate, exam was detailed and MDM was moderate, the criteria only a 99203 was met – only 2 the criteria only a 99203 was met – only 2 out of the 3 levels for a 99204 were metout of the 3 levels for a 99204 were met

3 of 3 versus 2 of 33 of 3 versus 2 of 3

3 of 3 means each required element (History, Exam & 3 of 3 means each required element (History, Exam & MDM) are at least the same level or higher (can only code MDM) are at least the same level or higher (can only code as high as the lowest level of the three that is documented)as high as the lowest level of the three that is documented)

New patient office visit, ER, Inpatient H&P or consult New patient office visit, ER, Inpatient H&P or consult require 3 of 3require 3 of 3 Detailed history, detailed exam and detailed MDM = Detailed new Detailed history, detailed exam and detailed MDM = Detailed new

patient encounterpatient encounter Problem Focused HPI, detailed exam and detailed MDM = Detailed Problem Focused HPI, detailed exam and detailed MDM = Detailed

established patient encounterestablished patient encounter Established patient only requires 2 of 3Established patient only requires 2 of 3

Example: History was comprehensive, exam was Example: History was comprehensive, exam was detailed and MDM was moderate, the criteria only a detailed and MDM was moderate, the criteria only a 99203 was met – only 2 out of the 3 levels for a 99204 99203 was met – only 2 out of the 3 levels for a 99204 were metwere met

99201, 99241, 99212

99202, 99242, 99213

99203, 99243, 99214

99204, 99244, 99215

HPI Brief(1-3)

Brief(1-3)

Extended(4+)

Extended(4+)

ROS N/A 1 System Extended(2-9)

Complete(10+)

PFSH N/A N/A Pertinent(1-3)

Complete(3)

Type of History

Problem Focused

Expanded Detailed Comprehensive

History ElementsHistory Elements

Chief Complaint is a clear and concise Chief Complaint is a clear and concise statement in the patient’s own words statement in the patient’s own words and documented by the providerand documented by the provider

3 Major sections of the Encounter3 Major sections of the Encounter HistoryHistory

Includes chief complaint (CC), history of present Includes chief complaint (CC), history of present illness (HPI), review of systems (ROS) and past illness (HPI), review of systems (ROS) and past medical, family and social history (PFSH)medical, family and social history (PFSH)

ExamExam Medical Decision MakingMedical Decision Making

The provider’s “thought” process on paperThe provider’s “thought” process on paper

History of Present IllnessHistory of Present Illness

The medical record should clearly reflect The medical record should clearly reflect the chief complaint (the reason the the chief complaint (the reason the patient came through the door)patient came through the door)

History of present illness can either be History of present illness can either be brief (1-3 elements) or extended (4+)brief (1-3 elements) or extended (4+) Location Location QualityQuality Severity Severity Duration Duration TimingTiming Context Context Modifying FactorsModifying Factors Associated Signs and/or SymptomsAssociated Signs and/or Symptoms

Review of SystemsReview of Systems

ConstitutionalConstitutional EyesEyes ENTENT CardiovascularCardiovascular RespiratoryRespiratory GastrointestinalGastrointestinal GenitourinaryGenitourinary

MusculoskeletalMusculoskeletal IntegumentaryIntegumentary NeurologicalNeurological PsychiatricPsychiatric Allergic/ImmunologicAllergic/Immunologic EndocrineEndocrine Hematologic/Hematologic/

LymphaticLymphatic

Review of systems is the patientReview of systems is the patient’’s positive s positive and pertinent negative response to a series of and pertinent negative response to a series of questions. questions.

Past, Family & Social Past, Family & Social HistoryHistory

Can be obtained once in the Can be obtained once in the medical record and then referred medical record and then referred to at subsequent visits, with to at subsequent visits, with additions or changes added, as additions or changes added, as encounteredencountered

Must be initialed and dated to Must be initialed and dated to validate review by providervalidate review by provider

ExaminationExamination

Problem focused (examination of the Problem focused (examination of the affected body area) affected body area)

Expanded problem focused (2-4 body Expanded problem focused (2-4 body areas/systems)areas/systems)

Detailed (5-7 body areas/systems)Detailed (5-7 body areas/systems) Comprehensive (8+ body Comprehensive (8+ body

areas/systems)areas/systems)

Medical Decision MakingMedical Decision Making

Medical decision making is the Medical decision making is the provider’s “thought process”provider’s “thought process”

Hardest element to translate into Hardest element to translate into an audit forman audit form

The reason for encounter The reason for encounter typically dictates the level of typically dictates the level of service selectedservice selected

Medical Decision MakingMedical Decision Making

Based on Based on Complexity of the diagnosis/management Complexity of the diagnosis/management

optionsoptions Amount of complexity of data reviewed Amount of complexity of data reviewed Risk to the patientRisk to the patient

Documentation of the MDM is hardest to Documentation of the MDM is hardest to quantify quantify

Putting provider’s “thought process” on Putting provider’s “thought process” on paperpaper

Medical Decision MakingMedical Decision Making

Levels of Risk (examples are not all Levels of Risk (examples are not all inclusive)inclusive) Minimal riskMinimal risk

Sunburn, common cold, something a patient Sunburn, common cold, something a patient might not typically see a doctor for.might not typically see a doctor for.

Low riskLow risk Well controlled hypertension, ankle sprain, cystitisWell controlled hypertension, ankle sprain, cystitis

Moderate RiskModerate Risk Exacerbation (mild) COPD, undiagnosed breast Exacerbation (mild) COPD, undiagnosed breast

lump, pneumonialump, pneumonia High RiskHigh Risk

Severe exacerbation of COPD, acute renal failure, Severe exacerbation of COPD, acute renal failure, abrupt change in neurological statusabrupt change in neurological status

Medical Decision MakingMedical Decision Making

To qualify for a given level of decision To qualify for a given level of decision making, 2 of the 3 elements must be making, 2 of the 3 elements must be met or exceededmet or exceeded Example: A patient has stable diabetes, Example: A patient has stable diabetes,

stable hypertension and stable COPD (2 stable hypertension and stable COPD (2 or more stable chronic conditions-or more stable chronic conditions-moderate), the provider orders lab moderate), the provider orders lab (minimal) and continues the patient on (minimal) and continues the patient on current medication regimen (moderate) current medication regimen (moderate) the level of Medical Decision Making is the level of Medical Decision Making is moderatemoderate

Time Based VisitsTime Based Visits

Provider must document Provider must document amount of amount of time related to counseling (more than time related to counseling (more than 50%) and total time spent with patient50%) and total time spent with patient

Provider must document subject matter Provider must document subject matter discussed, the more detailed the betterdiscussed, the more detailed the better Example: 99213=a provider typically spends Example: 99213=a provider typically spends

15 minutes face-to-face. If more than 8 15 minutes face-to-face. If more than 8 minutes was spent counseling the patient on minutes was spent counseling the patient on a new diagnosis of hypertension, then the a new diagnosis of hypertension, then the visit can be coded based on time, regardless visit can be coded based on time, regardless of the complexity of the history, exam or of the complexity of the history, exam or MDMMDM

The Hospital CardThe Hospital Card

History & Physical (99221-History & Physical (99221-99223)99223)

3 of 3 elements need to be met3 of 3 elements need to be met No other E&M services provided No other E&M services provided

on the same day (ER or office on the same day (ER or office visit) if the admission is knownvisit) if the admission is known

Date of H&P should match date Date of H&P should match date of admission to the floorof admission to the floor

Subsequent Visits 99231-99233Subsequent Visits 99231-99233

2 of 3 elements need to be met2 of 3 elements need to be met Review of medical record, Review of medical record,

reviewing results, changes in pt reviewing results, changes in pt status since last assessment, status since last assessment, examinationexamination

Time can be spent face to face Time can be spent face to face oror on the unit or flooron the unit or floor

Discharge 99238 & 99239Discharge 99238 & 99239

Must be a face to face encounterMust be a face to face encounter Time must be documented Time must be documented

99238 30 minutes99238 30 minutes 99239 Greater than 30 minutes99239 Greater than 30 minutes

Preparation of discharge instructions, Preparation of discharge instructions, medications and/or placement arrangementsmedications and/or placement arrangements

If a patient was seen in the AM and dies in the If a patient was seen in the AM and dies in the afternoon (without provider present) cannot afternoon (without provider present) cannot be billed as a “discharge”. Only subsequent be billed as a “discharge”. Only subsequent care provided in the AM encounter.care provided in the AM encounter.

Newborn CareNewborn Care

Initial assessment of newbornInitial assessment of newborn Initial treatment of a normal newborn, born in the hospitalInitial treatment of a normal newborn, born in the hospital

Subsequent visitsSubsequent visits Evaluation of a normal newborn, per dayEvaluation of a normal newborn, per day

Discharge is the same as inpatient (99238 or 99239)Discharge is the same as inpatient (99238 or 99239) No charges are done by SFHC provider for NICU No charges are done by SFHC provider for NICU

babies followed by a pediatrician babies followed by a pediatrician Can bill for “normal” newborn care on day 1 if baby was Can bill for “normal” newborn care on day 1 if baby was

“healthy” and complications arise on day 2 that warrant “healthy” and complications arise on day 2 that warrant pediatrician involvement. Documentation should support pediatrician involvement. Documentation should support the change in billingthe change in billing

Circumcision is separately billable by performing providerCircumcision is separately billable by performing provider

Hospital ConsultationsHospital Consultations

Entire care of patient is not Entire care of patient is not assumedassumed

In order to bill must have 3 “R”s in In order to bill must have 3 “R”s in writingwriting RequestRequest for an opinion for an opinion RenderRender your opinion your opinion ReplyReply back to requesting provider of back to requesting provider of

findings or recommendations findings or recommendations

Concurrent CareConcurrent Care

Patient is managed by multiple Patient is managed by multiple providers/specialtiesproviders/specialties

Each can bill for their services, if Each can bill for their services, if specific conditions are being specific conditions are being followed by each providerfollowed by each provider

Can’t bill for “courtesy visits”Can’t bill for “courtesy visits”

Emergency Room VisitsEmergency Room Visits

5 levels of services that follow 5 levels of services that follow standard billing guidelines for a new standard billing guidelines for a new patient (3 of 3 elements)patient (3 of 3 elements)

Procedures done during the visit are Procedures done during the visit are separately billable with supporting separately billable with supporting diagnosesdiagnoses

No card requiredNo card required Billing is done off of dictated ER Billing is done off of dictated ER

reportreport

OB H&P and DeliveryOB H&P and Delivery

No card required if normal delivery No card required if normal delivery and aftercareand aftercare

Subsequent days may be billed if Subsequent days may be billed if diagnosis supports additional care diagnosis supports additional care and treatment for and treatment for complications/conditionscomplications/conditions

Management of a patient admitted Management of a patient admitted for observation for observation isis separately billable separately billable (premature contractions, injury or (premature contractions, injury or accident)accident)

Critical CareCritical Care

Can be performed in any setting (inpatient, ER or Can be performed in any setting (inpatient, ER or office)office)

Not billed just because a patient is in the ICUNot billed just because a patient is in the ICU Time-based codes-documentation of time is Time-based codes-documentation of time is

requiredrequired Direct delivery of medical care for a critically ill Direct delivery of medical care for a critically ill

or injured patientor injured patient Time spent providing critical care is based on Time spent providing critical care is based on

total time spent engaging in work directly total time spent engaging in work directly related to the individual patientrelated to the individual patient

Critical CareCritical Care

Physician is not required to be at constant Physician is not required to be at constant bedside, but may be involved in patient care bedside, but may be involved in patient care decisions on the same floor or unitdecisions on the same floor or unit

Time spent outside the unit or floor may not Time spent outside the unit or floor may not be reported as critical care since the be reported as critical care since the physician is not immediately available to the physician is not immediately available to the patientpatient

Involves high complexity decision making to Involves high complexity decision making to assess, manipulate and support vital system assess, manipulate and support vital system functions to prevent further life threatening functions to prevent further life threatening deterioration of the patient’s conditiondeterioration of the patient’s condition

Assistant SurgeryAssistant Surgery

Billable by Resident if not related to rotation Billable by Resident if not related to rotation or covering rotation for another residentor covering rotation for another resident

Hospital card required (mainly for tracking)Hospital card required (mainly for tracking) Billing is done from surgery report and Billing is done from surgery report and

surgeon’s billingsurgeon’s billing Charge is typically 25% of the surgeon’s feeCharge is typically 25% of the surgeon’s fee Billable by Resident Billable by Resident ifif rotation service rotation service butbut

established patient of the resident is the established patient of the resident is the recipient of the surgeryrecipient of the surgery

Outpatient ProceduresOutpatient Procedures

Billable by the Resident if not Billable by the Resident if not related to rotation or covering related to rotation or covering rotation for another Residentrotation for another Resident

Hospital card required (mainly Hospital card required (mainly for tracking)for tracking)

QuestionsQuestions