Transcript CPT & ICD-9-CM Coding For Family Planning Services
Evaluation & Management Services
1
What is documentation and why is it important?
Medical record documentation is required for reporting
history.
pertinent findings, facts and observations about a patients health
The medical record documents
patient care
showing the
chronology of treatment, communication
between
physicians
,
quality of care,
and
collection of data.
2
General principles of documentation
Medical record should be
complete and legible.
Documentation should include: Chief complaint Exam and Diagnostic Test results Assessment Plan 3
E/M Coding
Key Components
History
Physical Examination
Medical Decision Making
Contributory Factors
Nature of the presenting problem •
Medical Necessity drives code selection
Extent of counseling Coordination of care Time 4
E/M Guidelines
Medicare and Commercial Insurance
CMS
1995
and
1997
E/M guidelines • Use either set • 1997 approved by AMA
Medicaid
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 Service”
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Medical Necessity
A service that is
reasonable
and
necessary
for the
diagnosis
and
treatment
of illness or injury,
or to improve the functioning of a malformed body member.
Government definition 6
STEP ONE -
HISTORY
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History
Definitions Chief complaint
(CC)
• Reason for the visit History of present illness
(HPI)
• chronological description of the development of the patient’s illness from the
1 st sign
and/or
symptom to the present.
Review of systems
(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)
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History
Definitions Cont
Past, Family, Social, History
(PFSH)
The
PFSH
consists of a review of one or more of the following three areas of the patient’s history: • Past History (P) • Family History (F) • Social History (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 9
History
Problem Focused Chief Complaint Brief HPI (1-3) No ROS No PFSH Expanded Problem Focused Chief Complaint Brief HPI (1-3) Problem pertinent ROS (1) No PFSH
ALL 3 elements must be met: HPI,ROS,PFSH, FOR A NEW PATIENT.
Detailed Chief Complaint Extended HPI (4 or status of 3 chronic/inactive) Extended ROS (2-9) Pertinent PFSH (1) Comprehensive Chief Complaint Extended HPI (4 or status of 3 chronic/inactive) Complete ROS (10) Complete PFSH (2 or 3 based on category of E/M) 10
CPT History Guidelines (Medicaid)
Problem focused:
CC; brief HPI
Expanded problem focused:
pertinent ROS CC; brief HPI, problem
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:
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 11
Elements of History
HPI
Location Quality Severity Duration Timing Context Modifying factors Associated signs and symptoms 12
Elements of History -
HPI
Location
– place, whereabouts, site, position.
Where on the body is the patient experiencing signs or symptoms?
(e.g., pain in groin)
Quality
–
A description,
characteristics, or statement to identify the type of sign or symptom .
(e.g., burning pain in groin)
Severity –
Degree, intensity, ability to endure.
(e.g., History of mild burning pain in groin that has become more intense)
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Elements of History -
HPI
Duration
–
Length of time.
How long has patient been experiencing the signs or symptoms?
(e.g., History of intermittent mild burning pain in groin that has become more intense and frequent for the last two weeks)
Timing
–
Regulation of occurrence.
A description of when the patient experiences signs or symptoms
(e.g., history of intermittent mild burning in groin that has become more intense and frequent for the last two weeks).
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Elements of History -
HPI
Context
factors.
–
experienced
Circumstances, cause, precursor, outside
A description of where the patient is or what the patient does when the signs or symptoms are
(e.g., history of intermitted mild burning pain in groin that has become more intense and frequent for the last two weeks since the patient bent down to pick up son and continues to feel intense pain when bending).
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Elements of History -
HPI
Modifying Factors
–
Elements that change, alter or have some effect on the complaint or symptoms
(e.g., history of intermittent mild burning pain in the groin that has become more intense and frequent for last two weeks since the patient bent down to pick up son; continues to feel intense pain when bending.
currently on Motrin 800 mg BID for past 3 weeks without relief) Patient
Associated Signs and Symptoms –
Factors or symptoms that accompany the main symptoms. this discomfort/pain?
What other factors does patient experience in addition to
(e.g., Shortness of breath, light headedness, nausea/vomiting)
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Elements of History -
ROS
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 17
Documentation
Example
of
ROS
Patient denies loss of consciousness. He has not had any bowel or bladder problems. All other systems are negative.
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Evaluation of Sample ROS
Patient denies
loss of consciousness bowel/bladder problem.
or All other systems are
negative
.
Neurological
= loss of consciousness
Gastrointestinal
= no bowel Program
Genitourinary
= no bladder problems All other neg 19
Element of History Past/Family/Social History -
(PFSH)
Past History:
the patient’s history of illnesses, operations, injuries, treatments, medications.
Family History:
a review of medical events in the patient’s family, including diseases which may be hereditary or place the patient at risk.”
Social 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. 20
Body Areas vs.
Organ Systems
The
exam components
are divided up between
body areas
and
organ systems
. These can be combined when counting elements for exam.
BODY AREAS Head, incl. Face Neck Chest, incl. Breasts & axillae Abdomen Genitalia, groin, buttocks Back, incl. Spine Each extremity
ORGAN SYSTEMS Constitutional (vitals & general appearance) Eyes ENT, mouth Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic/Lymphatic/Immunologic
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History CASE 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 22
History CASE STUDY
What is the patient’s CC ?
Vaginal Discharge
What are the patient’s Elements of HPI?
1.
Location -
vaginal
2.
3.
4.
Duration -
past 2 days
Timing -
a heavier flow in the morning
Modifying factor -
There is no change with Monistat
What is the Level of HPI ?
Ans: Detailed CASE 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 CASE STUDY What is/are the ROS ?
Integumentary
- itching
Genitourinary -
burning with urination
Constitutional
- fever
What is the Level of ROS?
Ans: Detailed What is/are the patient’s PFSH
PH (past history) – N/A
FH (family History) - N/A SH
–
(social history)
past 60 days - Patient has had 2 sexual partners in the
What is the Level of PFSH?
Ans: Detailed CASE 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 CASE STUDY ANSWER/EXPLANATION
History Level = Detailed (3 of 3)
CC
HPI
= Extended (4+ elements)
ROS
= Extended (3 elements)
PFSH
= Pertinent (1 element)
EXAMPLE
CC
- Vaginal discharge
HPI
- 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), (genitourinary)
or fever
(constitutional).
burning with urination
PFSH
- Patient has had 2 sexual partners in the past 60 days
(social)
STEP TWO – EXAMINATION
Performed by Physician
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Physical Exam
Problem Focused
(95)<1 body area/ organ system (97) 1-5 elements
Detailed
(95) 5-7 body areas/organ systems (97) 12 elements in 2+areas/systems
Expanded Problem Focused
(95) 2-4 body areas/ organ systems (97) 6 - 11 elements
Comprehensive
(95) 8 organ systems (97) General exam: Perform all elements document at least 2 elements in each of 9 areas/systems 27
CPT Physical Exam Guidelines (Medicaid)
Problem focused: limited exam
body area or organ system of the affected Expanded problem focused:
limited exam
of the affected body area or organ system and other
symptomatic or related organ system(s)
Detailed:
extended exam
of the affected body area(s) and other symptomatic or related organ system(s) Comprehensive: general a
complete exam multi-system exam
of a single organ system or 28
Physical Exam Example
Vaginal Discharge Exam Constitutional • BP, temp, pulse Genitourinary • Examination of external genitalia • Examination of cervix
What is the Level of the Physical Exam?
ANS: Problem Focused =
(
At least two body areas/organ systems)
CASE 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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STEP THREE
MEDICAL DECISION-MAKING
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MEDICAL DECISION-MAKING
MDM
refers to the
complexity of establishing a diagnosis and/or selecting a management option.
MDM
is the function of 3 variables 1. Number of diagnoses and/or management options 2. Amount &/or complexity of data that must be obtained, reviewed &/or analyzed 3. Risk of significant complications, morbidity &/or mortality 31
Number of Diagnosis and/or Management Options
Self Limited or Minor; stable, improving, worsening Established Problem*; stable, improved Established Problem*; worsening New Problem*; no workup planned New Problem*; addl. workup planned Total Diagnosis or management options x1 x1 X2 X3 x4 32
Amount and/or Complexity of Data
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 33
Risk of Complications, Morbidity and/or Mortality
Refers to patient’s level of
risk
visit at the Sources of risk Presenting problem Diagnostic procedures ordered Management options selected Illustrated by clinical examples in
“Table of Risk”
34
Documented Example of MDM
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. 35
Evaluation of MDM
A/P: By history, suspect possible
herniated disk
. Patient will be referred for
MRI
scan. Prescribe
Motrin 800
mg, tid with food,
Vicodin
for pain.
Number of dx/tx
options = new problem with addl workup
Amt/complexity of data
MRI = ordered
Risk
= prescription management 36
Decision Making
Straightforward
#Diagnostic/
treatment
options
(0 -1)
Amt./complexity of data
(0 -1)
Risk (minimal)
Low Complexity
#Diagnostic/
treatment
options
(2)
Amt./complexity of data
(2)
Risk (low)
Moderate Complexity
#Diagnostic/
treatment
options
(3)
Amt./complexity of data
(3)
Risk (moderate)
High Complexity
#Diagnoses/mgmt options
(4)
Amt./complexity of data
(4)
Risk (high) 37
Decision Making
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. 38
Decision Making
Moderate 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 Guidelines (Medicaid)
Complexity measured by:
# of possible diagnoses
and/or
the number of management options
that must be considered.
Amount/complexity
of records, tests, other information that must be obtained, reviewed, and analyzed.
Risk of significant complications, morbidity, mortality, as well as co-morbidities, associated with the patient’s presenting problem(s), the diagnostic procedure(s) and/or the possible management options.
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Table of Risk Examples
Presenting 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 Example
Vaginal Discharge Exam
New problem, additional workup planned • Lab is ordered
(4)
Review/order tests in 8xxxx series
(1)
What is the Level of Medical Decision Making ?
ANS: Moderate (2 0f 3)
Moderate decision making • Undiagnosed new problem with uncertain prognosis • Prescription drug management – Prescription written
Extensive # Diagnosis/treatment options Minimal amount of data to be reviewed Table of Risk
-
Moderate
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Level Assignment EXAMPLE /CASE STUDY CPT BOOK
History
= Detailed
Physical Exam
= Problem Focused
Decision Making
= Moderate
What is the code for a New & Established Patient?
ANSWER
Level
=
99203
, new patient If Established Patient =
99214
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Contributing Factors
Presenting 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 OVER 50% of the total visit time
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Consultation Code Selection
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Definition of Consultation
“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 46
Consultation vs.
Referral
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:
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 Distinguish A Consultation
1.
A type of service provided by a physician
opinion or advice regarding
and/or management of an
unknown or uncertain problem whose
evaluation is requested by another physician or appropriate source.
2.
The written or verbal
request
for a consultation
must be documented
in the medical record.
3. The consulting physician
may initiate diagnostic or therapeutic services
at the consultation or subsequent visit.
4. The consulting physician ’ s opinion and any services ordered or performed must be:
a) b) Documented in the medical record; and Communicated by written report to the requesting physician or other appropriate source
.
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Types of Inpatient Consultations
Initial Inpatient
No difference in new or established Reported one time during hospital stay Requires
3 of 3
components be documented key
Follow-up Inpatient
Used to complete an initial consultation • Complete initial consult, initiated by consulting physician • Subsequent consult, initiated by attending physician Requires
2 of 3
components be documented key 49
Counseling/Coordination of 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 50
Counseling Examples
Established patient, 20 minute visit to follow up on oral contraceptive use
NP
99213
RN
99211 (
MA
99213) 15 minutes of a 20 minute visit spent counseling the patient on alcohol and cigarette use during pregnancy
NP
99213
RN
99211 (
MA
99213) 51
Definitions
New Patient Has
not
from received face-to-face services • 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) 52
Selecting a Level of E/M
Identify
Place of service
(POS)
= where (office) Type of service
(TOS)
= what (Problem/Preventive) Status of Patient = who (New/Established) Determine the extent of
history - physical exam - decision making - counseling
Must consider all factors, and make sure adequate
DOCUMENTATION
in chart to justify code.
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Office 99201-99215
Report Problem visit (vs. Preventive visit)
99201-99205, 99212-99215
MD, NP, PA,CNS performed by
99211
- Ancillary staff i.e. RN, LPN, CNA MD/NP must be in the clinic
Report only 1 E/M per day
Report
diagnostic tests, studies, procedures
separately 54
Office 99201-99215 (Medicaid)
99201-99205, 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 55
Preventive Medicine Services
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Preventive Medicine 99381-99397
Routine management of patients without presenting problems,
i.e. annual, routine, well child exams
Performed by (MD,NP,PA,CNS) Includes other clinic staff if Medicaid Codes New/established patients Age Not used for scheduled
specified problems follow-up visits for
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CASE 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
58
CASE 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.
First - Identify Place of service
(POS)
= where (office) Type of service
(TOS)
= what (Problem/Preventive) Status of Patient = who (New/Established) Determine the extent of
history - physical exam - decision making counseling 99395
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CASE STUDY
A 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.
99231
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