Transcript Slide 1

Evaluation and Management
Strategies For Success
American Academy of
Professional Coders
Woodland Hills California Chapter
Meeting June 2010
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Part One
Fundamentals of Coding Evaluation
and Management Services
Presented by:
Elizabeth McAllister, CPC,
CPC-H, CPC-I, CEMC
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Evaluation and Management …
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Identify traditional physician
(or physician extender)
encounter
Account for approximately
30% of charges received by
third party payers
In some practices, these
services generate between
80-90% of total revenue
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E/M Services have been
included in every work plan
issued by OIG
Chart auditing is a
component of an effective
compliance plan
Documentation Principles
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The medical record should be complete and legible.
The documentation for the encounter should include
the following:
– reason for the encounter and a relevant history,
physical examination findings and prior diagnostic
test results;
– plan for care and
– date and legible identity of the observer
Documentation Principles
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Past and present diagnoses should be accessible to
the treating and/or consulting physician.
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Appropriate health risk factors should be identified.
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The patient’s progress, response to and changes in
treatment, and revision of diagnosis should be
documented.
S O A P Note
S Subjective
O Objective
A Assessment
P Plan
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Subjective includes all of the
information that the patient
tells the provider.
Objective: includes the
physical exam, diagnostic
testing and observations.
Physician’s documentation
of the diagnosis or problem.
Further work up that is
planned.
Evaluation and Management
Definitions and Guidelines
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A new patient is defined as one who has not received face-toface services rendered by a physician or a physician of the
same specialty who belongs to the same medical group within
the last three years.
On Call Service Exception
If a patient is seen by a physician who is “on call” or
“covering” for a colleague – the patient encounter is
considered an established patient.
New Patient
California Workers’ Compensation Cases
A new patient is one who
is new to the physician
or an established
patient with a new
industrial injury or
condition.
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Evaluation and Management
Definitions and Guidelines
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Transfer of care is the
process whereby a
physician who is providing
management for some or all
of the patient’s problems
relinquishes the
responsibility to another
physician who explicitly
agrees to accept
responsibility, and who, from
the initial encounter is not
providing consultative
services.
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(New for 2010)
The physician transferring
the care is then no longer
providing care for these
problems though he or she
many continue providing
care for other conditions as
appropriate.
Evaluation and Management
Definitions and Guidelines
(New for 2010)
A consultation is a type of evaluation and
management service provided by a physician at the
request of another physician or appropriate source to
either recommend care for a specific condition or
problem or to determine whether to accept
responsibility for ongoing management of the
patient’s entire care of for the care of a specific
condition or problem.
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CMS Consultation Code Update
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Effective January 1, 2010 CMS will eliminate the use of all consultation
CPT/HCPC codes. This includes inpatient codes (99251-99255) and
office/outpatient codes (99241-99245) for various places of service,
instead of consultation codes, providers are instructed to bill initial
hospital care (99221-99223), initial nursing facility care (99304-99306)
or initial office visits (99201-99205), as applicable.
Evaluation and Management
Definitions and Guidelines
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Physician assistant, NP, OT,
psychologist, social worker,
attorney are all considered
appropriate source for
requesting a consultation.
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“Consultation” requested by
the patient and/or family is
reported by using the office
visit, home visit or other
evaluation and management
codes.
Evaluation and Management
Definitions and Guidelines
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Concurrent care is the provision of similar
services to the same patient by more than
one physician on the same day.
Evaluation & Management
Components
KEY COMPONENTS
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History
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Examination
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Medical Decision Making
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Counseling
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Coordination of Care
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Nature of Present Problem
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Time*
History
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The history is one of the three key components of E/M
documentation.
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Acts as a narrative which provides information about the clinical
problems or symptoms being addressed during the encounter.
History
Four Elements
The selection of the level of history obtained will
depend on the following factors:
Chief Complaint
 History of Present Illness
 Review of Systems
 Past, Family & Social History
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Chief Complaint
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The chief complaint
should be the first
notation in the medical
record.
It is required for all levels
of service.
The physician uses the chief
complaint to :
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derive a diagnosis
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discover if any additional
body systems or
anatomical areas are
affected.
History of Present Illness
Chronological description of the
development if the patient’s
present illness from the first sign
and/or symptom or from the
previous encounter to the
present.
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History of Present Illness
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Every type of encounter requires some form of HPI.
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When documenting a follow-up encounter, it is
acceptable to label the HPI an Interval History.
The physician must personally complete and record
the HPI. The HPI is the only part of the history which
cannot be recorded by ancillary staff.
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History of Present Illness
HPI
Eight Elements
1.
2.
3.
4.
5.
6.
7.
8.
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Location
Quality
Severity
Duration
Timing
Context
Modifying Factors
Associated Signs &
Symptoms
Brief and Extended HPIs are
distinguished by the amount
of detail needed to
accurately characterize the
clinical problem(s).
Location
The area of the body where the pain or discomfort occurs.
Quality
This is a description of the character of the symptoms.
Dull, Throbbing, Burning, Stabbing…….
Severity
Describes the Magnitude of the Presenting Problem.
May be stated using a scale of one out of ten, with one
being the least amount of pain or severity. Ten is the most
severe.
Duration
Describes when the symptoms first appeared.
Timing
This may further describe the symptoms, describes
whether the symptoms are constant, transient or appear at
specific times throughout the day.
Context
Describes
Modifying Factors
This is a list of interventions that the patient may have
taken to relieve the symptoms. This may include
medications, therapy, rest, whether they were successful
or not.
Associated Signs &
Symptoms
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Identifies additional problems associated with specific
symptoms. May indicate a new disease or underlying
problem.
“The Big Picture”
Brief 1 – 3 Elements
Extended
4 – 8 Elements or (using the 1997 documentation guidelines) the
status of at least three inactive chronic conditions.
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Extended HPI
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HPI: Patient complains of chest
pain which began three hours
ago duration. Pain has been off
and on since that time with
each episode lasting two to
three minutes. The pain is
described as “crushing” and at
times is rated as an eight on a
scale of one to ten. The pain
occurs with minimal exertion
and is associated with nausea
and shortness of breath. The
pain was relieved with
sublingual NTG in the
ambulance.
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Location
Duration
Timing
Quality
Severity
Context
Associated signs and
symptoms
Modifying factors
Review of Systems
ROS
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An inventory of body systems
obtained through a series of
questions seeking to identify
signs and or symptoms which
the patient may be experiencing
or may have experienced.
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Helps define the problem,
clarify the differential diagnosis,
identify needed testing or
serves as baseline data for
other systems that might be
affected by any possible
management options.
ROS
CMS/AMA Systems
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Constitutional Symptoms
Eyes
Ears, Nose, Mouth & Throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentatry System
Neurological
Psychiatric
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic
Review of Systems
General/Constitutional
Average weight, weight loss or
gain, general state of health,
sense of well-being, strength,
ability to conduct usual
activities, exercise tolerance
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Eyes/Ears/Nose/Mouth/Throat
Headaches (location, time of
onset, duration, precipitating
factors), vertigo,
lightheadedness, injury
Vision, double vision, tearing,
blind spots, pain
Nose bleeding, colds,
obstruction, discharge
Dental difficulties, gingival
bleeding, dentures
Neck stiffness, pain,
tenderness, masses in thyroid
or other areas
Review of Systems
Cardiovascular
Precordial pain, substernal
distress, palpitations,
syncope, dyspnea on
exertion, orthopnea,
nocturnal paroxysmal
dyspnea, edema, cyanosis,
hypertension, heart
murmurs, varicosities,
phlebitis, claudication
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Respiratory
Pain (location, quality,
relation to respiration),
shortness of breath,
wheezing, stridor, cough
(time of day, of productive,
amount in tablespoons or
cups per day and color of
sputum), hemoptysis,
respiratory infections,
tuberculosis (or exposure to
tuberculosis), fever or night
sweats
Review of Systems
Gastrointestinal
Appetite, dysphagia, indigestion, food idiosyncrasy, abdominal
pain, heartburn, eructation, nausea, vomiting, hematemesis,
jaundice, constipation, or diarrhea, abnormal stools (clay-colored,
tarry, bloody, greasy, foul smelling), flatulence, hemorrhoids, recent
changes in bowel habits
Genitourinary
Urgency, frequency, dysuria, nocturia, hematuria, polyuria,
oliguria, unusual (or change in) color of urine, stones, infections,
nephritis, hesitancy, change in size of stream, dribbling, acute
retention or incontinence, libido, potency, genital stores, discharge,
venereal disease
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(Female) Age of onset of menses, regularity, last period,
dysmenorrhea, menorrhagia, or metrorrhagia, vaginal discharge,
post-menopausal bleeding, dyspareunia, number and results of
pregnancies (gravida, para)
Review of Systems
Musculoskeletal
Pain, swelling, redness or heat of muscles or joints,
limitation, of motion, muscular weakness, atrophy, cramps
Neurologic/Psychiatric
Convulsions, paralyses, tremor, coordination, parathesias,
difficulties with memory of speech, sensory or motor
disturbances, or muscular coordination (ataxia, tremor)
Predominant mood "nervousness" (define), emotional
problems, anxiety, depression, previous psychiatric care,
unusual perceptions, hallucinations
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Review of Systems
Allergic/Immunologic/
Lymphatic/Endocrine
Reactions to drugs, food,
insects, skin rashes, trouble
breathing
Anemia, bleeding tendency,
previous transfusions and
reactions, Rh incompatibility
Local or general lymph node
enlargement or tenderness. Polydipsia, polyuria, asthenia,
hormone therapy, growth,
secondary sexual
development, intolerance to
heat or cold
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Skin/Breast
Rash, itching, pigmentation,
moisture or dryness, texture,
changes in hair growth or loss,
nail changes
Breast lumps, tenderness,
swelling, nipple discharge
Review of Systems
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Problem Pertinent ROS - positive or negative responses for
at least 1 system related to the presenting problem
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Extended ROS – Inquires about the system directly related to
the problem(s) identified in the HPI and a limited number of
additional systems. Positive or negative responses for 2 – 9
systems.
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Complete ROS – positive or negative responses for all
additional body systems. At least 10 identified.
Past (Medical) Family and/or Social History (PFSH)
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Past History - Review of patient’s previous illness, injuries,
hospitalization, current medications, allergies, immunization
status.
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Family History – Review of patient’s family health status or
cause of death of parents, siblings, children. Also includes a
review of any diseases that may be hereditary, that may put
patient at risk.
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Social – Review of current activities, may include alcohol,
tobacco use, marital status, occupation, sexual history.
Past Medical Family & Social History
Pertinent PFSH
Describes 1 – 3 components
Complete PFSH
Describes 1 from each of the 3
components
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The Problem Focused History
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The Problem Focused
History is the lowest and
least descriptive level of
history. This history
requires only a chief
complaint and a Brief HPI
(which requires one to three
HPI elements).
No ROS or PFSH are
required.
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Chief complaint: Follow-up
nephrolithiasis
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Interval History: The patient’s
left flank pain has resolved.
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chief complaint is clearly
stated and only one HPI
element (location) is utilized.
The Expanded Problem Focused History
The Expanded Problem Focused History is the second lowest level of
history. This history requires a chief complaint, a brief HPI (containing one to
three HPI elements), plus one ROS. No PFSH is required.
CC : Follow-up for allergic rhinitis .
Interval History: The patient’s nasal congestion has significantly improved with
steroid nasal spray and is now described as “mild” in severity.
ROS is negative for cough, hoarseness, or shortness of breath.
Expanded Problem Focused History does not require a lot of information. In
this case, 2 HPI elements were used - location and severity. The ROS
required review of only one system. In this case the respiratory system was
reviewed.
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The Detailed History
CC : Follow-up hypertension and diabetes
Interval History : The patient’s
hypertension is stable on current
medications. Diabetes, however,
remains sub-optimally controlled with
hgbA1c greater than 7. There is also a
history of osteoarthritis, which requires
only intermittent Tylenol for
symptomatic relief .
ROS
General--Negative for fatigue, weight
loss, anorexia
Cardiovascular--Negative for CP,
orthopnea, PND
Endocrine--Negative for polyuria,
polydipsia, cold intolerance
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Pertinent PMH is positive for CAD,
which has been quiescent
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Extended HPI was constructed
by commenting on the status of
three chronic or inactive
problems (hypertension,
diabetes, OA).
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The ROS described three
systems, although technically
only two systems are required.
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This example utilized an
element of PMH (CAD) to
satisfy the requirement of one
pertinent PFSH.
The Comprehensive History
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The Comprehensive History is the highest level of history
and requires a chief complaint, an extended HPI (four HPI elements
OR the status of three chronic or inactive problems - if using the 1997 E/M
guidelines), plus a 10 system ROS, plus a Complete PFSH .
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The Comprehensive History
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CC : Chest pain
HPI : The patient is a 65 year old male who developed sudden onset of chest pain, which
began early this morning. The pain is described as “crushing” and is rated nine out of 10 in
terms of intensity .
PMH is remarkable for GERD and hypertension
FH : Mother died at 78 of breast cancer; Father at 75 of CVA. No history of premature
cardiovascular disease in first degree relatives.
SH : Negative for tobacco abuse; consumes moderate alcohol; married for 39 years
ROS
Constitutional--Negative for fevers, chills, fatigue
Cardiovascular--Negative for orthopnea, PND, positive for intermittent lower extremity
edema
Gastrointestinal--Positive for nausea without vomiting; negative for diarrhea, abdominal
pain
Pulmonary--Positive for intermittent dyspnea on exertion, negative for cough or
hemoptysis
All other systems reviewed and are negative
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Putting it together
Determining the Level of History
Type of History
Review of
Patient, Family,
Systems (ROS) Social History
(PFSH)
History of
Present
Illness (HPI)
Problem
Focused
N/A
N/A
Brief
(1 – 3)
Expanded
Problem
Focused
Problem
Pertinent
(1 system)
N/A
Brief
(1 – 3)
Detailed
Extended
(2-9 Systems)
Pertinent
(1 area)
Extended
(2 – 9)
Complete
(2 or 3 areas)
Extended
(4 or more)
Complete
Comprehensive (10 0r more)
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Examination
Key Component
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Examination
Determining the Extent
Factors to consider:
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Documentation
Clinical judgment
Nature of the presenting
problem(s).
Ranges from limited
examinations of single body
areas to general multisystem or complete single
organ system examinations.
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Evaluation and Management
Examination - Four Levels
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Problem Focused -a limited examination
of the affected body
area or organ system.
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Expanded Problem
Focused -- a limited
examination of the
affected body area or
organ system and
other symptomatic or
related organ
system(s).
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Detailed -- an
extended examination
of the affected body
area(s) and other
symptomatic or related
organ system(s).
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Comprehensive -- a
general multi-system
examination or
complete examination
of a single organ
system.
Examination
For purposes of examination, the following
body areas are recognized:
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Head, including the face
Neck
Chest, including breasts and axillae
Abdomen
Genitalia, groin, buttocks
Back, including spine
Each extremity
Examination
The following organ systems are recognized:
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Constitutional (e.g., vital signs, general appearance)
Eyes
Ears, nose, mouth and throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
Neurologic
Psychiatric
Hematologic/lymphatic/immunologic
1997 Problem Focused Examination
One to five bullets from one
or more organ systems
Example
Vitals: 120/80, 88, 98.6
General appearance: NAD,
conversant
Lungs: CTA
CV: RRR, no MRGs
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Three vital signs
general appearance
auscultation of lungs
auscultation of the heart
1997 Expanded Problem Focused Exam
At least six bullets from any
organ systems
Example
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Vitals: 120/80, 88, 98.6
General appearance: NAD,
conversant
Lungs: Clear to auscultation
CV: RRR, no MRGs
Abdomen: Soft, nontender
Extremities: No peripheral
edema
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Three vital signs
general appearance
auscultation of lungs
auscultation of the heart
examination of the abdomen
examination of extremities for
edema
The Detailed Physical Exam
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The Detailed Physical Exam is the second highest level of
physical exam.
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1997 Detailed Exam requires at least 12 bullets from any
organ systems.
1997 Detailed Exam
At least two bullets from six organ systems OR 12
bullets from two or more organ systems
Vitals: 120/80, 88, 98.6
General appearance: NAD, conversant
Neck: FROM, supple
Lungs: Clear to auscultation
CV: RRR, no MRGs; normal carotid upstroke and
amplitude without bruits
Abdomen: Soft, non-tender; no masses or HSM
Extremities: No peripheral edema or digital cyanosis
Skin: no rash, lesions or ulcers
Psych: Alert and oriented to person, place and time
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1997 Detailed Exam
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three vital signs
general appearance
examination of neck
auscultation of lungs
auscultation of the heart
assessment of carotid arteries
examination of the abdomen
examination of liver and spleen
examination of extremities for edema
examination and/or palpation of digits and nails
inspection of skin and subcutaneous tissue
brief assessment of mental status—orientation
1997 Comprehensive Examination
Vitals: 120/80, 88, 98.6
General appearance: NAD, conversant
Eyes: anicteric sclerae, moist conjunctivae; no lid-lag; PERRLA
HENT: Atraumatic; oropharynx clear with moist mucous membranes and no
mucosal ulcerations;
normal hard and soft palate
Neck: Trachea midline; FROM, supple, no thyromegaly or lymphadenopathy
Lungs: CTA, with normal respiratory effort and no intercostal retractions
CV: RRR, no MRGs
Abdomen: Soft, non-tender; no masses or HSM
Extremities: No peripheral edema or extremity lymphadenopathy
Skin: Normal temperature, turgor and texture; no rash, ulcers or subcutaneous
nodules
Psych: Appropriate affect, alert and oriented to person, place and time
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1997 Comprehensive Examination
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Constitutional
three vital signs, general appearance
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Eyes
inspection of conjunctivae and lids,
examination of pupils and irises)
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Lymphatic
examination of lymph nodes in neck
examination of lymph nodes in
extremities
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Ears, Nose, Mouth and Throat
external inspection of ears and nose—
“atraumautic”
examination of oropharynx
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Skin
of skin and subcutaneous tissues
palpation of skin and subcutaneous
tissues
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Neck
examination of neck
examination of the thyroid
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Respiratory
auscultation of lungs
assessment of respiratory effort
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Cardiovascular
auscultation of heart
examination of extremities for edema or
varicosities
Gastrointestinal
examination of the abdomen
examination of liver and spleen
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Psychiatric
description of patient’s judgment and
insight
assessment of mental status—
orientation
Medical Decision Making
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Medical Decision Making
Four Levels
Medical decision making refers to the complexity of
establishing a diagnosis and/or selecting a management
Option(s).
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Straight-forward
Low complexity
Moderate complexity
High complexity
Nature of the Presenting Problem
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Five types of presenting problems
are defined.
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The presenting problem, similar, to
the chief complaint, it is the
disease, condition, injury, symptom,
finding, complaint or other reason
for the patient encounter.
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The diagnosis may or may not be
established during that encounter.
Nature of the Presenting Problem
Minimal – may or may not require a
physician’s presence.
Self-limited or Minor problem
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Definite & prescribed course
 Transient in nature
 Unlikely to alter health status permanently
 Good prognosis with management
Low Severity
 Without treatment: Risk of morbidity
 is low. Little or no risk of mortality
 Full recovery without impairment is expected
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Nature of the Presenting Problem
Moderate Severity
 Increased probability of
prolonged functional
impairment
 Without treatment risk of
morbidity and or mortality
is moderate
 Uncertain prognosis
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High Severity
 Without treatment: risk of
morbidity is high to
extreme.
 Without treatment risk of
mortality is moderate to
high
 Prolonged Functional
Impairment
Medical Decision Making
Levels
Straightforward is the lowest level
of Medical Decision-Making. It is
impossible not to qualify for it.
Low Complexity Medical
Decision-Making requires only
slightly more intellectual energy
than straightforward MDM.
The degree of risk remains quite
low and corresponds to a patient
with one chronic illness which is
completely stable.
If there is an acute problem, it
should be an uncomplicated clinical
issue such as allergic rhinitis,
cystitis or a sprained ankle.
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Medical Decision Making
Levels
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Detailed Complexity Medical Decision-Making describes a
patient with one chronic illness with a mild exacerbation or two
stable chronic illnesses would satisfy the risk requirement for
this level of medical decision-making.
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Clinical Example
An established office patient with diabetes, hypertension and
dyslipidemia all of which are optimally controlled. Routine labs
are checked and routine labs and schedule return visit in four
months. No changes are made to any medications.
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Medical Decision Making
Levels
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High Complexity Medical
Decision-Making truly is
complex. Either the patient is
quite ill or the physician must
review a significant amount of
primary data.
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The patient would need to have
a severe exacerbation of a
chronic problem or an acute
illness which threatens life or
bodily function to qualify for this
level of risk.
Medical Decision Making
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The number of possible diagnoses and/or the number of
management options that must be considered;
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the amount and/or complexity of medical records,
diagnostic tests, and/or other information that must be
obtained, reviewed and analyzed; and
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the risk of significant complications, morbidity and/or
mortality, as well as comorbidities, associated with the
patient's presenting problem(s), the diagnostic procedure(s)
and/or the possible management options
Medical Decision Making
Number of Diagnoses or Management Options
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Based on the number and types of problems addressed during
the encounter.
The complexity of establishing a diagnosis and the
management decisions that are made by the physician.
The number and type of diagnostic tests employed may be an
indicator of the number of possible diagnoses.
Problems which are improving or resolving are less complex
than those which are worsening or failing to change as
expected.
The need to seek advice from others is another indicator of
complexity of diagnostic or management problems
Medical Decision Making
Amount and/or Complexity of Data Reviewed
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Based on the types of diagnostic testing ordered or reviewed.
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A decision to obtain and review old medical records and/or
obtain history from sources.
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Discussion of contradictory or unexpected test results with the
physician who performed or interpreted .
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The physician who ordered a test may personally review the
image, tracing or specimen.
Medical Decision Making
Risk of significant complications
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The risk of significant
complications, morbidity,
and/or mortality is based on
the risks associated with the
presenting problem(s), the
diagnostic procedure(s), and
the possible management
options.
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Comorbidities or underlying
diseases are not considered
in selecting E/M unless their
presence significantly
increases the complexity of
the decision making.
Time
Determining Factor
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In the case where counseling
and/or coordination of care
dominates (more than 50%) of
the physician/patient and/or
family encounter (face-to-face
time in the office or other
outpatient setting or floor/unit
time in the hospital or nursing
facility), time is considered the
key or controlling factor to
qualify for a particular level of
E/M services.
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If the physician elects to
report the level of service
based on counseling and/or
coordination of care, the
total length of time of the
encounter (face-to-face or
floor time, as appropriate)
should be documented and
the record should describe
the counseling and/or
activities to coordinate care.
Counseling & Coordination of Care
Discussion with Patient and or Family
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
65
Diagnostic results, impressions and/or recommended
studies
Prognosis
Risks & benefits for treatment and follow-up
Instructions
Importance of Compliance with treatment plan
Risk factor reduction
Patient and family education
Evaluation and Management
Information Flow
66
Evaluation and Management
CPT Guidelines
67

Most categories and
many of the subcategories have special
guidelines or instructions
unique to that category or
subcategory.

Be sure to review the
special instructions
preceding the levels of
E/M services in your CPT
book.
CPT Coding Conventions

68
Who is the Patient?

Where was the Service Rendered?

Level of Service

Key Components

Levels of Key Components

Determine Level of Service Performed
Evaluation and Management
The Fundamentals
69

1. Identify the Category of Service

2. Identify the Subcategory of Service

3. Determine the Extent of History Obtained

4. Determine the Extent of Examination Performed

5. Determine the Complexity of Medical Decision Making

6. Record the Approximate Amount of Time

7. Verify Compliance with Reporting Requirements

8. Verify Documentation

9. Assign the Code
Putting it all together
3 of 3
Key Components
Required





70
New outpatient
Inpatient admission
Consultation
Hospital Observation
Emergency Department
New Patient Codes Office or Other Outpatient Visit
3 of 3 Key Components Required
71
CPT Code
History
Examination
Medical Decision Making
99201
Problem
Focused
Problem Focused
Straight Forward
99202
Expanded
Problem
Focused
Expanded Problem
Focused
Straight Forward
99203
Detailed
Detailed
Low Complexity
99204
Comprehensive
Comprehensive
Moderate Complexity
99205
Comprehensive
Comprehensive
High Complexity
Established Patient Codes Office or Other Outpatient Visit
2 of 3 Key Components Required
72
CPT Code
History
Examination
Medical Decision Making
99211
Minimal
May Not Require
Presence of Physician
99212
Problem
Focused
Problem Focused
Straight Forward
99213
Expanded
Problem
Focused
Expanded Problem
Focused
Low Complexity
99214
Detailed
Detailed
Moderate Complexity
99215
Comprehensive
Comprehensive
High Complexity
Putting it all together
2 of 3
Key Components
Required


73
Established patient
Subsequent Inpatient
Encounters
Part Two – Next Month




74
Inpatient and
Outpatient Hospital
Services
Consultations
Chart Audits
…..and more