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© Copyright 2006 American Health Information Management Association. All rights reserved.

Assigning Evaluation and Management Code Levels

Practical Tools for Seminar Learning

Disclaimer

i

The American Health Information Management Association makes no representation or guarantee with respect to the contents herein and specifically disclaims any implied guarantee of suitability for any specific purpose. AHIMA has no liability or responsibility to any person or entity with respect to any loss or damage caused by the use of this audio seminar, including but not limited to any loss of revenue, interruption of service, loss of business, or indirect damages resulting from the use of this program. AHIMA makes no guarantee that the use of this program will prevent differences of opinion or disputes with Medicare or other third party payers as to the amount that will be paid to providers of service.

How to earn one (1) CEU for participation

To earn one (1) continuing education unit, each participant must do the following: Step 1: Listen to the seminar, via Webcast link, audio CD, or MP3. Step 2: Complete the assessment quiz contained in this resource book.

Use the included answer key. Do not return the quiz to AHIMA. Save it for your records.

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After listening to the seminar, please let us know what you think, by completing our online evaluation survey at http://campus.ahima.org/audio/fastfactsresources.htm

Faculty

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Susan M. Hull, MPH, RHIA, CCS, CCS-P Susan M. Hull, MPH, RHIA, CCS, CCS-P is a professional practice resources manager for the American Health Information Management Association (AHIMA). In her role as manager, Susan provides professional expertise to AHIMA members, the media, and outside organizations on coding practice issues, and develops written products aimed at furthering the art and science of coding. Susan has over 20 years experience in the HIM field. Before joining AHIMA in 2002, she served as Senior Executive Director for HMI Corporation where she oversaw coding reviews; chargemaster maintenance and development; and presented seminars in outpatient, inpatient, and physician documentation and coding. Prior to this, she worked in numerous HIM roles, including consultant, HIM department director, and HIM software developer and manager. In addition to AHIMA, Susan is actively involved as a volunteer in the HIM profession. She has presented on timely HIM topics to the Health Information Management Associations of California, Tennessee, and Southern Illinois, as well as the Southern Illinois Healthcare Financial Management Association. Susan received a bachelor of arts degree and a master of public health in Health Services and Hospital Administration from the University of California, Los Angeles.

Table of Contents

Disclaimer ..................................................................................................................... i How to earn one (1) CEU for participation ......................................................................... i Faculty .........................................................................................................................ii Basis for E&M level coding .............................................................................................. 1 New vs. established patients ........................................................................................... 1 History ........................................................................................................................ 2 Review of systems.............................................................................................. 2 PFSH................................................................................................................. 3 Time as a determining factor........................................................................................ 4-5 Who may document ....................................................................................................... 5 Physical examination ................................................................................................... 6-7 Physical examination (1995 guidelines) ............................................................................ 7 Physical examination (1997 guidelines) ............................................................................ 8 Medical decision making ................................................................................................. 8 Categories of problems ....................................................................................... 9 Categories of data reviewed ................................................................................ 9 Management options .........................................................................................10 Summary......................................................................................................................11 AHIMA Audio Seminars ..................................................................................................12 About assessment quiz ..................................................................................................12 Thank you for attending (with link for evaluation survey) .................................................13 Appendix ..................................................................................................................14 Assessment Quiz Continuing Education Credit and Compliance Sign-in Form Certificate of Attendance and Quiz Completion Quiz Answer Key

Assigning E&M Code Levels

1

Notes/Comments

Basis for E&M level coding

• Evaluation and management levels are assigned based upon documentation of:

• History

• Physical examination

• Medical decision making

• In specific cases, time is the determining factor

1

New vs. established patients

• A “New” patient has not received face-to-face professional services from the provider or another provider of the same specialty who belongs to the same group with in the past 3 years.

• An “Established” patient has received face-to-face professional services from the provider or another provider of the same specialty who belongs to the same group with in the past 3 years.

2

Assigning E&M Code Levels

2

Notes/Comments

History

• History of present illnessSeven parameters:

• Location – where it is

• Duration – how long you have had it

• Timing – when it occurs

• Context – what you are doing when it occurs

• Severity – how bad is it

• Modifying factors – what makes it better or worse

• Associated signs and symptoms – what else do you feel at the same time

3

History — Review of systems

• Constitutional• Eyes• ENT• Cardiovascular• Respiratory• Gastrointestinal • Genitourinary

• Musculoskeletal • Integumentary• Neurological• Psychiatric• Endocrine• Hematologic/lymphatic• Allergic/immunologic

4

Assigning E&M Code Levels

3

Notes/Comments

History — PFSH

• Past history • Prior major illnesses, injuries,

hospitalizations and operations

• Current medications

• Allergies

• Immunization status (age appropriate)

• Feeding/dietary status (age appropriate)

Continued…

5

History — PFSH

• Family history • Significant inherited conditions• Anything that might place the patient at risk

• Social history • Marital status/living arrangements• Occupational history • Use of drugs, alcohol, tobacco• Educational history • Sexual history

(Continued)

6

Assigning E&M Code Levels

4

Notes/Comments

Time as a determining factor

• When counseling accounts for more than half the total visit time

• Document both the time in counseling and the total visit time

• Document what was discussed in the counseling

• Assign the appropriate evaluation and management code for the total time, not the time spend in counseling

Continued…

7

Time as a determining factor

• Counseling may include:• Advice re lifestyle modifications• Treatment/management options• Prognosis • Medication administration and side-effects• Educational resources• Risk factor reduction

Continued…

8

(Continued)

Assigning E&M Code Levels

5

Notes/Comments

Time as a determining factor

• Time is the determining factor for:• Pediatric critical care patient transport• Critical care services

• Assuming that the criteria for critical care have been met • Critical injury or illness that acutely impairs one

or more vital organ systems• High complexity medical decision making • Both illness and treatment must meet criteria

9

(Continued)

Who may document

• History of present illness, PFSH, ROS may be documented by:• Physician• “Historian”• Nurse• Patient or patient advocate• Physician should document that he or she

reviewed the information

• Physical examination must be documented by physician or other practitioner (PA, RNP, etc.)

10

Assigning E&M Code Levels

6

Notes/Comments

Physical examination

• Two sets of documentation guidelines for physical examination

• 1995 guidelines –better for general examination

• 1997 guidelines –better for specialty examination

May use either, but must be consistent within a patient encounter

11

Physical examination

• 1995 and 1997 guidelines are available on the CMS web site at: http://new.cms.hhs.gov/MedlearnProducts/20_DocGuide.asp

• Basically the only thing that is different is the documentation guidelines for physical examination

(Continued)

12

Assigning E&M Code Levels

7

Notes/Comments

Physical examination

• 1995 guidelines – based on either body areas or organ systems

• For purposes of examination, the following body areas are recognized:• Head, including the face• Neck• Chest, including breasts and axillae• Abdomen• Genitalia, groin, buttocks• Back, including spine• Each extremity

(Continued)

13

Physical examination – organ systems

• Constitutional (e.g., vital signs, general appearance)

• Eyes• Ears, nose, mouth and

throat• Cardiovascular• Respiratory• Gastrointestinal

• Genitourinary• Musculoskeletal• Skin• Neurologic• Psychiatric• Hematologic/lymphatic

/immunologic

14

Assigning E&M Code Levels

8

Notes/Comments

Physical examination

• 1997 guidelines • General multisystem examination • Single system (specialty) examination

• Cardiovascular• Ears, Nose, Mouth and Throat• Eyes• Genitourinary (Female)• Genitourinary (Male)• Hematologic/Lymphatic/Immunologic• Musculoskeletal• Neurological• Psychiatric• Respiratory• Skin

(Continued)

15

Medical decision making

• The most difficult to quantify

• Based upon nature of the presenting problem, amount and complexity of information that must be analyzed

• Nature of the diagnosis and treatment plans

• Risk of significant disability or impairment if an error is made

16

Assigning E&M Code Levels

9

Notes/Comments

Medical decision making

• Categories of problems• Minor or self-limited, stable, improving or

worsening – 1 point

• Established problem, stable – 1 point

• Established problem, worsening – 2 points

• New problem, no additional workup – 3 points

• New problem, workup planned – 4 points

(Continued)

17

Medical decision making

• Categories of data reviewed• Order/review clinical laboratory tests – 1 point

• Order/review radiology tests – 1 point

• Order/review “medicine” tests – 1 point

• Discuss test results with performer – 1 point

• Obtain old records/obtain history from third party/discuss case with provider – 2 points

• Independent review of images, tracing or report – 2 points

(Continued)

18

Assigning E&M Code Levels

10

Notes/Comments

Medical decision making

• Management options• Minimal – rest, superficial dressings or none

• Low – OTC medications, minor surgery without risk factors, PT/OT, IV fluids without additives

• Moderate – Minor surgery with risk, major surgery (elective) without risk, prescription drug management, IV fluids with additives, closed treatment of skeletal injury

Continued…

(Continued)

19

Medical decision making

• Management options (Continued)

• High – Elective major surgery with risk, emergency major surgery, parenteral/controlled substances, drug therapy requiring intensive monitoring, DNR decision

(Continued)

20

Assigning E&M Code Levels

11

Notes/Comments

Summary

• Assignment of evaluation and management codes is based upon documentation of history, physical examination and medical decision making in most cases

• Guidelines apply to most evaluation and management code sets

• Time is determinant is select cases

21

Summary

• All criteria applied must be documented in the medical record and readily available

• Established patients require that two of three components meet the level to be assigned; new patients and ED patients require that all be met

(Continued)

22

Assigning E&M Code Levels

12

Notes/Comments

AHIMA Audio Seminars

Visit our Web site http://campus.AHIMA.orgfor updated information on the current seminar schedule. While online, you can also register for live seminars or order CDs and Webcasts of past seminars.

© 2006 American Health Information Management Association

Assessment

To access the assessment quiz that follows this seminar, download the seminar’s resource book at

http://campus.ahima.org/audio/fastfactsresources.html

Your sign-in form and certificate of completion are also found in the resource book.

Assigning E&M Code Levels

13

Notes/Comments

Thank you for attending!

Please visit the AHIMA Audio Seminars Web site to complete your evaluation form online at:

http://campus.ahima.org/audio/fastfactsresources.html

Appendix

Assessment Quiz Continuing Education Credit and Compliance Sign-in Form Certificate of Attendance and Quiz Completion Quiz Answer Key

Assessment Quiz – Assigning Evaluation and Management Code Levels

ANSWERS to this quiz are found on the last page of the seminar resource book, Practical Tools for Seminar Learning.

To earn continuing education credit of one (1) AHIMA CEU, Fast Facts Audio Seminar listeners must also complete this 10-question quiz. This CE credit is for attending the audio seminar AND completing this quiz. Please keep a copy of the completed quiz with your certificate of attendance. Do not send a copy to AHIMA.

1. For purposes of assigning evaluation and management codes, an “established” patient is one who __________. a. has been seen by the provider before b. has received face-to-face professional services

from the provider or other member of the same specialty in the same group within the past three years

c. has received professional services from the provider or other member of the same specialty in the same group within the past three years

d. has received face-to-face professional services from the provider or other member of the same specialty in the same group within the past year

2. Time is the determining factor in assigning evaluation and management codes when __________. a. counseling consumes more than half the time

of the visit b. the visit takes longer than usual c. any time that the provider feels that it is

appropriate d. coding visits to patients in skilled nursing

facilities

3. For purposes of assigning evaluation and management codes, which of the following is not considered counseling? a. Advice re life style modification in combating

effects of disease b. Interactive psychotherapy c. Discussion of medication administration and

side-effects d. Provision of educational resources

4. True or false? Only the physician may document history, physical examination and medical decision making.

a. True b. False

5. Which of the following statements re selection of 1995 vs. 1997 documentation guidelines is false? (answer choices are in next column)

a. Either may be chosen for a specific patient. b. The physician must use the same set of

guidelines for all patients. c. The 1995 guidelines are better to use for

general examinations. d. The guidelines are available for download on

the CMS website.

6. A description of what you are doing when a symptom occurs is considered to be documentation of the __________ of the complaint. a. context b. timing c. location d. None of the above

7. True or false? Medical decision making is the most difficult of the three components of evaluation and management coding to quantity as it can be somewhat subjective.

a. True b. False

8. An established problem that is worsening is worth how many points in the medical decision making process? a. 1 point b. 2 points c. 3 points d. 4 points

9. Elective major surgery without identified significant risk is considered to be a __________ level management option. a. low b. minimal c. moderate d. high

10. True or false? In assigning risk, pick the lowest level in any of the three sections of data review, management options and nature of presenting problem.

a. True b. False

Do not send a copy of completed quizzes to AHIMA. Please keep them with your certificate of attendance, for your records. Be sure to complete and send the seminar sign-in sheet found on the next page of this resource book.

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Please visit the AHIMA Audio Seminars Web site to complete the evaluation form online at http://campus.ahima.org/audio/fastfactsresources.html

Certificate of Attendance

Fast Facts Audio Seminar

Assigning Evaluation and Management Code Levels

_____________________________________ Name

_____________________________________

AHIMA ID Number

_____________________________________ Date Attended

_____________________________________

Anne M. Willmore Project Manager

Distance Education

The American Health Information Management Association has approved this program for one (1) continuing education unit. Participant certifies that he or she has attended this audio seminar

and completed the accompanying quiz.

Retain this certificate as evidence of participation. No record will be kept at AHIMA of your participation.

Quiz Answer Key Fast Facts Audio Seminar: Assigning Evaluation and Management Code Levels 1: b; 2: a; 3: b; 4: false; 5: b; 6: b; 7: true; 8: b; 9: c; 10: false Do not send a copy of your completed Fast Facts Audio Seminar quiz to AHIMA. Please keep it with your certificate of attendance, for your records.


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