Transcript Evaluation & Management Coding and Documentation

Evaluation & Management
Coding and Documentation
101 – the basics
Stephanie Ann Call, MD MSPH
VCU Internal Medicine Training Program
The Practice of Medicine Series - 2009
Learning Objectives
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At the end of this session, residents will be able
to
describe what medical documentation facilitates
 identify three key components in selecting the levels
of E/M services
 select the appropriate level of an E&M service for a
new and established patient in either the outpatient
or inpatient setting
 identify resources for compliance
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Evaluation and Management (E&M)
Documentation
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One of most commonly billed procedures
May be billed for new or established patients
Includes office, hospital, nursing home visits,
consultations, phone and overall management, ICU
care, discharge planning
1995/1997 Medicare guidelines – can use both
Medicare Physician Guide: A Resource for Residents, Practicing
Physicians, and Other Health Care Professionals –
http://www.cms.hhs.gov/MLNProducts/downloads/
physicianguide.pdf
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Chapter 5 – E&M Documentation
Great references and resource lists
Why document?
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Medical /legal issues
To tell the story of the patient – communicate to
others
To have the opportunity for reimbursement for
the service provided
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“E&M documentation is the pathway that translates
a physician’s patient care work into the claims and
reimbursement mechanism”
Medicare … “if it is not documented, it wasn’t
done.”
What does documentation facilitate?
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The ability to evaluate and plan the patient’s
treatment
The ability to monitor patients health over time
Communication and continuity of care among
healthcare professionals
Appropriate utilization review and quality of
care evaluations
Collection of data for research and evaluation
General Principles of Documenting
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Legibility – all documents MUST be legible
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Defined as easily read by peers (other clinicians)
Required information:
Patient name, MR, date of service on each page
 Date AND time (for inpatient)
 Reason for encounter, relevant history, PE findings
 Review of lab, x-ray data, other ancillary services
 Assessment, clinical impression or diagnosis
 Plan of care (including d/c plan if appropriate)
 Legible identity of observer (authenticated)
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General Principles of Documenting
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If not documented, rationale for ordering
diagnostics or ancillary services should be easily
inferred
Past and present diagnoses should be accessible
to physician – can be in chart
Appropriate health risk factors should be
identified
Patient progress, response to and changes in
treatment should be documented
General Principles of Documenting
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Documentation should support the intensity of
the evaluation or treatment, including thought
processes and complexity of medical decision
making
All entries should be dated and authenticated by
physician signature
CPT and ICD-9-CM codes reported should
reflect documentaton in the medical records
Components of an E&M service
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Seven components use to define level of E&M
service (exceptions to rule if predominantly
counseling or coordination of care)
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Key components
History
 Examination
 Medical Decision Making
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Contributory components
Counseling
 Coordination of Care
 Nature of Presenting Problem
 Time
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Components of an E&M service
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Seven components use to define level of E&M
service (exceptions to rule if predominantly
counseling or coordination of care)
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Key components
History
 Examination
 Medical Decision Making
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Contributory components
Counseling
 Coordination of Care
 Nature of Presenting Problem
 Time
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Used in selecting
level of E/M service
(some exceptions)
Determining Level of Service
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Table to determine appropriate level of service based
on documentation (as a reflection of complexity of care
provided) in three key component areas
Each key component has graded levels
Different criteria for new patient vs established
Different criteria for inpatient vs outpatient
Procedure codes identified by tables – determine the
level of service and amount of reimbursement (99201,
99202, 99203, etc)
Key Components
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History
Physical Examination
Decision Making
History – elements (4)
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Chief complaint (CC)
Required for ALL levels of E/M coding
 Reason for encounter
 If follow up … “follow up for …”
 NOT “routine f/u”
 Must be documented by resident, NP, PA or attending
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History of Present Illness (HPI)
Review of Systems (ROS)
Past, Family, Social History (PFSH)
History
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HPI elements
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Location
Quality
Severity
Duration
Timing
Context
Modifying Factors
Associated Signs and Symptoms
Level of History
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Brief – status of 1-2 chronic conditions or 1-3 above
Extended – status of 3 chronic conditions or 4+ above
History
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Review of Systems (ROS)
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Do not have to write a notation for all systems
Document the positive and pertinent negatives
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Level for ROS based on number of systems
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“all other systems negative” – include number checked
Should have “usual” template
Problem pertinent – related to problem only +/Extended – positive and pertinent responses for 2-9 systems
Complete ROS is 10+
ROS
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Constitutional, eyes, ears, nose, throat, cv, respiratory, gi, gu,
musculoskeletal, skin, neuro, psych, endo, heme, lymph, allergic,
immunological
History
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Past, Family and Social (PFSH)
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Past History – review of patient’s past illnesses,
injuries, treatments
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Social History – age appropriate review of past and
current activities
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Includes major illness, injury, operations, prior
hospitalizations, current meds, allergies
May include marital status, living situation, employment
and occupational hx, use of drugs/alcohol/tobacco, ed
Family History – review of medical events in family
History
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PFSH
Pertinent – review of history area directly related to
problem identified in HPI – at least one item from
any of P, F, S
 Complete – review of 2-3 PFSH areas if f/u visit,
3/3 areas if new patient
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History – E/M levels
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Problem Focused
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Expanded Problem Focused
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CC, 1-3 HPI, problem pertinent system review (>1)
Detailed
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CC, 1-3 HPI elements
CC, 4+ HPI, problem pertinent ROS + 2-9
additional ROS, pertinent PFSH (1 element)
Comprehensive
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CC, 4+ HPI, complete ROS (10+), complete PFSH
History
Type of
History
HPI
ROS
PFSH
Problem
Focused
Brief
1-3
N/A
N/A
Expanded
Problem
Focused
Brief
1-3
Problem
Pertinent >1
N/A
Detailed
Extended
4+
Extended
2-9
Pertinent
1
Comprehensive
Extended
4+
Compete
(10+)
Complete 2/3
or 3/3*
Exam
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Organ systems
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For a general multi-system exam
Body areas
Exam – Organ Systems
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Vital Signs, General
Symptoms
Eyes
ENT
CV
Respiratory
GI
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GU
Musculoskeletal
Skin
Neurological
Psychiatric
Heme/Lymph/Immuno
Exam – Body Areas
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Head/face
Neck
Breast/Axillary
Abdomen
Genitalia
Back/spine
Extremity
Exam
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Document specific abnormal and relevant
negative findings of affected or symptomatic
area
Document abnormal or unexpected findings of
unaffected or asymptomatic areas
“abnormal” is insufficient
Templates ok
Reference cards, review sheets
Exam – levels (see p81 guide)
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Problem focused
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Expanded Problem Focused
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Affected system plus other symptomatic or related (6)
Detailed
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Limited to affected body area or organ system (1-6 elements)
Extended exam of affected area and other symptomatic or
related organ system
Comprehensive
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Multisystem exam (8-12) or complete single system
Medical Decision Making
Medical Decision Making - tips
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TELL THE STORY
The medical record must clearly support all
diagnoses reported on the claim
Document impressions, diagnoses, tests ordered
and/or reviewed AND the plan of care
What is the complexity of care for this patient AT
THIS TIME?
Is the patient improved, resolved, unresponding?
Medical Decision Making
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Complexity of establishing a diagnosis
Four types/levels – guided by …
The number of diagnoses or management options
 The amount or complexity of data ordered or
reviewed
 The risk of complications and morbidity/mortality
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Medical Decision Making
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4 levels
Straightforward
 Low Complexity
 Moderate Complexity
 High Complexity
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3 subcomponents
Diagnoses and Management Options
 Amount and Complexity of Data
 Risk of Complications
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Decision Making
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To qualify for a specific level of Decision
Making, 2 of the 3 elements listed for that
specific category must be met or exceeded
Diagnosed problems less complex than
undiagnosed
Consider
How many diagnostic tests ordered
 Did you request a consult
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Diagnoses and Management Options
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For established diagnosis
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If diagnosis not established
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Possible, probable, rule out
Document treatment plan
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Improved, resolved, unresponding
Include medication changes
Therapies
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Patient instructions, nursing instructions
Amount and complexity of data
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Review and/or order of clinical lab and XR tests
Review and/or order of diagnostic tests
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XR, scans, nuclear med, cardiac cath, echo, ekg, eeg,
non-invasive vasc, PFTs
Document review of old records
Document information from family or caretaker
Summarize relevant findings, if any
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If not, document fact that reviews done
Risk of complication
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Minimal
Low
Moderate
High
Documenting Risk
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See tables on “risk”
Make sure to document
Co-morbidities
 Underlying diseases
 Other factors increasing risk
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Medical Decision Making
MDM - Level
Dx/Mgmt
Data
Risk
Straightforward
Minimal
< 2 elements
Minimal/none
< 1 element
Minimal
Low
Limited
3-4 elements
Limited
2 elements
Low
Moderate
Multiple
5-6 elements
Multiple
3 elements
Moderate
High
Extensive
> 7 elements
Extensive
> 4 elements
High
What code do I choose?
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Step 1: Is the patient New or Established,
Inpatient or Outpatient?
New = 3 key components
 Established = 2 of 3 key components
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Step 2: What level of History and Exam was
performed?
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Use reference card for definitions
Step 3: Review the 3 subcomponents for
Medical Decision Making
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‘meets or exceeds’ is issue
What code do I choose?
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Step 4: Compare your assessments against the
requirements for a given level of service
May not match exactly
 ‘meets or exceeds’ is key phrase
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New and Established Patients
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3 of 3 Key Components
New patient office
 Initial Inpatient Admission
 Initial Consultation
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2 of 3 Key Components
Established Office
 Subsequent Inpatient care
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Time
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Choose code based on face-to-face time with
the patient when OVER 50% of the visit was
spent in counseling
Document the total time spent with the patient
 Document the total time spent in counseling
 Document the content of the counseling, and
 Choose the level of E/M by the total amount of
time
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Other E&M Issues
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Consultations
Incident to
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Shared visits
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NPs, PAs, midwives, Clinical Nurse Specialists
Involves physician and non-physician practitioner
Prolonged services
Critical Care
Teaching Physicians (including GE exemption
codes)
Learning Objectives
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At the end of this session, residents will
Be able to describe what medical documentation
facilitates
 Be able to identify three key components in selecting
the levels of E/M services
 Be able to select the appropriate level of an E&M
service for a new and established patient in either the
outpatient or inpatient setting
 Be able to identify resources for compliance
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