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04/08/23 1
Coding Education & Training Program, HIM Department
Documentation Requirements forEvaluation & Management
Services
04/08/23 2
Coding Education & Training Program, HIM Department
Presentation Goals
Introduce the 3 Key Components to an E/M Service History Examination Medical Decision MakingIntroduce the UC Davis Health System Audit Tool, version 2.4Review time and how it may effect a level of serviceReview critical care documentation guidelinesReview Teaching Physician Guidelines
04/08/23 3
Coding Education & Training Program, HIM Department
Overview of E/M Services
Classification of Common E/M ServicesOffice or Other Outpatient Services New Patient 99201-99205 Established Patient 99211-99215Consultations Office or Other Outpatient Consultations 99241-99245 Initial Inpatient Consultations 99251-99255Hospital Inpatient Services Initial Hospital Care 99221-99223 Subsequent Hospital Care 99231-99233 Hospital Discharge Services 99238-99239Emergency Department Services New or Established 99281-99285Critical Care Over 24 months of age 99291-99296Preventive Medicine Initial Preventive Medicine 99381-99387 Established Patient 99391-99397
04/08/23 4
Coding Education & Training Program, HIM Department
Overview of E/M Services
Classification of Other E/M Services
Nursing Facility/SNF/Rest Homes, etc 99304-99350
Prolonged Services 99354-99359
Care Plan Oversight 99374-99380
04/08/23 5
Coding Education & Training Program, HIM Department
Overview of E/M Section
Code assignment in the CPT E/M Section vary according to three factors:
Place of Service office, hospital, emergency room, nursing home
Type of Service consultation, admission, office visit
Patient Status new patient, established patient, inpatient, outpatient
Each E/M category includes three to five levels of service
The levels indicate the wide variations in skill, time, effort, responsibility and knowledge required to diagnose, treat or prevent an illness or injury
04/08/23 6
Coding Education & Training Program, HIM Department
Overview of E/M Section
In a Teaching Setting, a fourth factor needs to be considered:
Reimbursement Factor(s) Performing Provider vs Billing Provider (NP/PA vs
MD)? Are there additional Payor Specific Guidelines
(Medi-cal/Medicare)?1. Have the documentation guidelines been met?
Is the clinician (NP/PA) on the Hospital Cost Report?
04/08/23 7
Coding Education & Training Program, HIM Department
Overview of E/M Section
All providers who are licensed to provide medical services may use the same E/M codes for reporting their services regardless of specialty
The specific level is referring to the last digit in each E/M service code for example, a 99201 is referred to as a “New Patient, level 1”
This level requires meeting or exceeding the following Three Key Components:
a problem focused Historya problem focused Examstraightforward Medical Decision Making
04/08/23 8
Coding Education & Training Program, HIM Department
Overview of E/M Section
The E/M levels are selected based on the clinicians documentation
Therefore, it is important that the clinician documents each patient encounter as accurate and complete as possible
What should be considered when analyzing the patient’s medical record?
Does the documentation justify the medical necessity of the service and/or procedure performed?Does the documentation support the level of service reported?Is the documentation legible?Are there specific payer documentation guidelines and have they been met?
04/08/23 9
Coding Education & Training Program, HIM Department
Overview of E/M Section
Medical Necessity
Medicare defines "medical necessity" as services or items reasonable
and necessary for the diagnosis or treatment of illness or injury or to
improve the functioning of a malformed body member
Clinician vs Coder Questions regarding an extensive write up for a minor
problem should be referred back to the clinician for clarification
04/08/23 10
Coding Education & Training Program, HIM Department
Overview of E/M Section
Medicare-Selection of Level of E/M Service
The CMS Manual, Publication 100-4, Chapter 12, §30.6.1 - Selection of Level of Evaluation and Management Service states the following:
“Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code.
It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted.
04/08/23 11
Coding Education & Training Program, HIM Department
Overview of E/M Section
Medicare-Selection of Level of E/M Service, con’t
The volume of documentation should not be the primary influence upon which a specific level of service is billed.
Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.
Instruct physicians to select the code for the service based upon the content of the service.
The duration of the visit is an ancillary factor and does not control the level of the service to be billed unless more than 50 percent of the face-to-face time (for non-inpatient services) is spent providing counseling or coordination of care.”
04/08/23 12
Coding Education & Training Program, HIM Department
Overview of E/M Section
E/M Guidelines
There are two guidelines that may be utilized, 1995 or 1997
Providers/Coders may use either guideline
Whichever is most advantageous to the provider
Must follow one guideline per patient encounter
Cannot mix and match
04/08/23 13
Coding Education & Training Program, HIM Department
Overview of E/M Section
1995
Based on the number and/or extent of body areas or organ systems examined
1997
Based on the examination of specific bulleted items identified within a body area or organ system
04/08/23 14
Coding Education & Training Program, HIM Department
E/M Terms
New PatientAccording to the American Medical Association, a new patient is one who has not received any professional services from a given physician or another physician of the same specialty who belongs to the same group practice within the past three (3) years
Established PatientAccording to the American Medical Association, an established patient is one who has received professional services from that physician or another physician of the same specialty within the same group within the past three (3) years
ConsultationsA type of service provided by a licensed provider whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another licensed provider or appropriate source. For example, a Physician, NP, PA
04/08/23 15
Coding Education & Training Program, HIM Department
E/M Terms
Consultations vs ReferralConsultation Services rendered to give advice or an opinion to a requesting
provider about a patient’s diagnosis and/or management of a condition1. The 3 R’s
Request Render opinion Report
Referral Transfer of care Referring provider transfers the responsibility for managing
the patient’s complete care for a condition to the receiving physician and the receiving physician documents approval of care
04/08/23 16
Coding Education & Training Program, HIM Department
E/M Services
Remember, documentation must support the medical necessity and the level of service
Billed. The Level of Service is based on the documentation of the 3 Key Components and the Contributing Factors:
3 Key Components History Examination Medical Decision MakingContributing Factors Nature of Presenting Problem Time
1. Outpatient Setting (Counseling by Provider face-to-face)2. Inpatient Setting (Counseling by Provider face-to-face and/or
Coordination of Care)
04/08/23 17
Coding Education & Training Program, HIM Department
E/M – History Component
Now let’s take a look at the History Component on the Audit
Tool
The History is divided into four levels:
Problem Focused
Expanded Problem Focused
Detailed
Comprehensive
These levels are determined by……
04/08/23 18
Coding Education & Training Program, HIM Department
E/M – History Component
Four Elements
History levels are determined by the following 4 elements
1. Chief Complaint (CC)
2. History of Present Illness (HPI)
3. Review of Systems (ROS)
4. Past, Family, and/or Social History (PFSH)
The extent of the history is dependent upon clinical judgment and on the nature of the presenting problem(s)
Not all histories will have or need all elements
04/08/23 19
Coding Education & Training Program, HIM Department
E/M – History Component
The Four Elements of History
1. Chief Complaint (CC) A concise statement describing the symptom, problem, condition,
diagnosis, or other factor as the reason for the encounter. Example:a return visit recommended by the physician
2. History of Present Illness (HPI) Describes the patient’s developing condition/problem from the first
sign and/or symptom or from the previous encounter to the present or the status of three chronic or inactive conditions
3. Review of Systems (ROS) An inventory of body systems obtained through a series of questions
seeking to identify signs and/or symptoms the patient may be experiencing or has experienced
4. Past, Family, and Social History (PFSH) Review of the patient’s past history, family history, and social history
04/08/23 20
Coding Education & Training Program, HIM Department
E/M – History Component
Chief Complaint
The reason for seeking medical care should be recorded in the patient’s own words
“Patient complains of left foot pain due to fall last month.”
04/08/23 21
Coding Education & Training Program, HIM Department
E/M – History Component
The History of Present Illness (HPI)
Two types
1. Brief HPI 1 to 3 HPI Elements
2. Extended HPI 4 or more HPI Elements or the status of at least 3
chronic or inactive conditions
04/08/23 22
Coding Education & Training Program, HIM Department
E/M – History Component
The HPI ElementsLocation – Where the symptom or problem is occurring Abdomen, chest, leg, arm, headSeverity - A rating or description of severity of the symptom or pain Bad, intolerable, minimal, slightTiming – When symptom or pain occurs Before bed, upon waking, two hours after taking medicine, continuousQuality – The character of the sign or symptom Burning, dull, puffy, puss-filled, red, itchyDuration – How long a pain or symptom lasts, has been present, or persisted For two months, since prescription beganAssociated signs/symptoms – Any organ system or body area complaints associated with the chief complaint Rash with blistering, nausea and vomiting, abdominal painContext – Instances or items that can be associated with the chief complaint When walking, in company of smokers, at workModifying factors – Actions taken or things done to effect the symptom or pain, making it better or worse Improves when lying down, worse after eating
04/08/23 23
Coding Education & Training Program, HIM Department
E/M – History Component
The HPI
Example of an extended HPI with 4 or more elements
HPI: For the past two days she has had chills, fever and muscle aches. She feels worse in the evening. Her illness is so severe she has not been able to work.
Duration Associated Signs Timing Severity
04/08/23 24
Coding Education & Training Program, HIM Department
E/M – History Component
The HPI
Extended HPI with status of at least three chronic or inactive conditions.
Example:
The patient is currently under my care for the management of hypertension controlled with diet and exercise, diabetes controlled with insulin, and asthma requiring inhaler twice daily.
04/08/23 25
Coding Education & Training Program, HIM Department
E/M – History Component
The Review of Systems (ROS)
ROS includes 14 systems1. Constitutional symptoms (fever, weight loss, etc)
2. Eyes
3. Ears, nose, mouth, throat
4. Cardiovascular
5. Respiratory
6. Gastrointestinal
7. Genitourinary
8. Musculoskeletal
9. Integumentary (skin and/or breast)
10. Neurological
11. Psychiatric
12. Endocrine
13. Hematologic/Lymphatic
14. Allergic/Immunologic
04/08/23 26
Coding Education & Training Program, HIM Department
E/M – History Component
The ROS
ROS has 3 types
1. Problem Pertinent 1 system
2. Extended 2-9 systems
3. Complete 10 or more systems
04/08/23 27
Coding Education & Training Program, HIM Department
E/M – History Component
The ROS
Medicare Documentation Guidelines
Problem Pertinent ROS The patient's positive responses and pertinent negatives for the system
related to the problem should be documented.Extended ROS The patient's positive responses and pertinent negatives for two to
nine system should be documented.Complete ROS At least ten organ systems must be reviewed. Those systems with
positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented.
04/08/23 28
Coding Education & Training Program, HIM Department
E/M – History Component
The ROS
Example of a complete ROS:
The provider can list pertinent findings in 2 or more systems and note allother systems are negative
A patient is seen in the physician’s office with flu-like symptoms. For the past two days she has had chills, fever, and muscle aches. She feels worse in the evening. Her illness is so severe she has not been able to work. (Provider queries patient on at least ten systems, notes pertinent findings) She has lost 7 pounds in the last month. She denies abdominal pain, diarrhea, and vomiting. All other systems are negative.
Constitutional Gastrointestinal “All other systems are negative” gives provider credit for a complete ROS
04/08/23 29
Coding Education & Training Program, HIM Department
E/M – History Component
The Past, Family, and Social History (PFSH)
Past History The patient’s past experience with illnesses, operations,
injuries and treatments
Family History A review of medical events in the patient’s family, including
diseases that may be hereditary or place the patient at risk
Social History Age appropriate review of past and current activities
04/08/23 30
Coding Education & Training Program, HIM Department
E/M – History Component
The PFSHThere are two types of PFSH, pertinent and completeThe required elements for each differs based on the patient status New patient status
1. Pertinent 1 specific item from any of the 3 history areas
2. Complete 1 specific item from each of the 3 history areas
Established patient status1. Pertinent
1 specific item from any of the 3 history areas2. Complete
1 specific item from any 2 of the 3 history areas
04/08/23 31
Coding Education & Training Program, HIM Department
E/M – History Component
The PFSH
If the PFSH is non-contributory a statement is required in the documentation to qualify it for a complete PFSH Example:
1. “Reviewed PFSH, non-contributory to current condition.”
For those categories of E/M services that require only an interval history, it is not necessary to record information about PFSH Example:
1. Subsequent hospital care
2. Subsequent nursing facility care
04/08/23 32
Coding Education & Training Program, HIM Department
Overall History Component
Each history element must be met or exceeded to determine an overall history level
Let’s look at an exampleCC Must be present in patient’s medical recordHPI ExtendedROS CompletePSFH PertinentOverall History level = Detailed
04/08/23 33
Coding Education & Training Program, HIM Department
E/M – History Component
Example Outpatient Grid
Detailed
Pertinent
Extended2-9
Extended4 or more
Comprehensive
Complete
Complete
ExpandedProblem Focused
ProblemFocused
OVERALL HISTORY LEVEL
NonePFSHPast Medical History Family History Social HistoryEstablished Patient: only need 2 to be considered “Complete”New Patient: Requires all 3 to be considered “Complete”
Pertinent to
Problem1
None
ROSConstitutional Ears, Nose Throat, Mouth Skin/breast Endo Hem/LymphEyes Card/Vasc GI Neuro Allergy/ImmuneResp Musculo GU Psych All Others Neg
Brief1-3
HPILocation Severity Timing Modifying Factors
Quality Duration Context Associated Signs & Symptoms
04/08/23 34
Coding Education & Training Program, HIM Department
E/M History
Caveat
Patient is unable to speak
Physician must document this “Patient intubated, unable to obtain History”
Provider gets credit for a complete History!
04/08/23 35
Coding Education & Training Program, HIM Department
E/M – Examination Component
Now let’s look at the Examination Portion of the Audit Tool
Four Levels Problem Focused Expanded Problem Focused Detailed Comprehensive
Exam Elements Body Areas Organ Systems
(Cannot combine Body Areas and Organ Systems for Comprehensive Exam)
2 Types Multi-system Single Organ System
04/08/23 36
Coding Education & Training Program, HIM Department
E/M Examination Elements
Organ Systems:
Constitutional ears, nose, mouth, throat
Eyes resp GI GU
Cardio skin neuro psych
Hem, lymph, immune musculoComprehensiveDetailedExpanded
ProblemFocused
ProblemFocusedOVERALL EXAMINATION LEVEL
>=85-72-40-1Body Areas:
Head/face chest, including breasts & axillae
Neck back, spine each extremity
genitalia, groin, buttocks abdomen
04/08/23 37
Coding Education & Training Program, HIM Department
Examination Problem Focused ExpandedProblem Focused
Detailed Comprehensive
1995 1 Body Area or Organ System
Limited Exam2-4 Body Areas or Organ Systems
Extended Exam 5-7 Body Areas or Organ Systems
8 Organ Systems or a Comprehensive Single Organ System Exam
1997 Any 1-5 Bullets Any 6+ Bullets General: 2 bullets from 6 or more organ systems/body areas or 12 bullets from 2 or more organ systems/body areasEye/Psych: 9+ bulletsAll Others: 12+ bullets
General: Perform all, document 2 bullets from 9 Organ Systems/body areas
All Others: Perform all, document all elements in each bolded box and 1 element in each un-bolded box
04/08/23 38
Coding Education & Training Program, HIM Department
E/M – Medical Decision Making Component
Now let’s look at the Medical Decision Making Portion of the Audit Tool
Four Levels1. Straightforward2. Low Complexity3. Moderate Complexity4. High ComplexityTo determine the level of Medical Decision Making, two of the three following Elements must meet or exceed
Elements Number of Diagnoses or Treatment Options Amount and/or Complexity of Data to be Reviewed Risk of Complication and/or Morbidity/Mortality
04/08/23 39
Coding Education & Training Program, HIM Department
E/M – Medical Decision Making Component
Number of Diagnoses or Treatment Options
3 Categories
1. Self-limited or minorstable, improved or worse
2. Established problem stable, improved, worsening
3. New problem to examinerno additional work up plannedadditional work-up planned
04/08/23 40
Coding Education & Training Program, HIM Department
E/M – Medical Decision Making Component
1.Self-limited or minor (stable, improved or worse)
Sore throatEarache (simple)Simple laceration This category does not indicate that the problem is new or
established American Medical Association (AMA)
1. “A problem that runs a definitive and prescribed course, is transient in nature, and is not likely to permanently alter health status or has a good prognosis with management/compliance.”
04/08/23 41
Coding Education & Training Program, HIM Department
E/M – Medical Decision Making Component
2.
Established problem; stable, improved
For this provider/specialty group – usually diagnosis and treatment has already been started
Established problem; worsening
For this provider/specialty group; must be documented or CLEARLY implied, (pain has increased, etc.)
04/08/23 42
Coding Education & Training Program, HIM Department
E/M – Medical Decision Making Component
3.
New problem to examiner; no additional work- up planned
New problem to examiner; additional work-up Planned Starting treatment does not constitute “additional work-up”. Any diagnostic study or plan to help find a definitive diagnosis.
Example: Radiology Laboratory Consultation with another physician
04/08/23 43
Coding Education & Training Program, HIM Department
NUMBER OF DIAGNOSES AND/OR TREATMENT OPTIONS
A B C = D
Problem(s) status Number Points Result
Self–limited or minor (stable, improved or worse)
max=2 1
Est. problem; stable, improved
1
Est. problem; worsening 2
New problem; no additional workup planned
max=1 3
New Problem; additional workup planned
4
Total
04/08/23 44
Coding Education & Training Program, HIM Department
E/M – Medical Decision Making Component
Amount and/or Complexity of Data to be Reviewed
Review &/or order of clinical lab tests
Review &/or order in the radiology section of the CPT
Review &/or order of tests in the medicine section
Discussion of test results with performing physician
Decision to obtain old records &/or history from someone other than patient
Review and summarization of old records &/or obtaining history from someone other than patient &/or discussion of case with another health care provider
Independent visualization of image, tracing or specimen itself (not simple review of report)
04/08/23 45
Coding Education & Training Program, HIM Department
E/M – Medical Decision Making Component
Review &/or order of clinical lab tests
Any documentation of the review of tests previously ordered
Example(s): Test results documented in notes Documentation that Provider reviewed results
Documentation that indicates tests are ordered
04/08/23 46
Coding Education & Training Program, HIM Department
E/M – Medical Decision Making Component
Review &/or order in the radiology section of the CPT
Review of Report not actual film
Example(s): Documentation of review of x-ray report Documentation that a x-ray was ordered
Not viewed in Stentor (review of actual film)
04/08/23 47
Coding Education & Training Program, HIM Department
E/M – Medical Decision Making Component
Review &/or order of tests in the medicine Section
Report(s) is reviewed or ordered
Example(s): EKG Report Stress Test Documentation that a medicine test was ordered
04/08/23 48
Coding Education & Training Program, HIM Department
E/M – Medical Decision Making Component
Discussion of test results with performing physician
Discussion = verbal communication and NOT a report or letter
Example: Pathologist viewing specimen then pages ordering MD to discuss
results PCP MD pages MD Specialist to discuss test results
04/08/23 49
Coding Education & Training Program, HIM Department
E/M – Medical Decision Making Component
Decision to obtain old records &/or history from someone other than
patient
Documentation should support the reason/need to get old records or obtain the history from someone other than the patient
Does not include: Parent’s of pediatric patient Interpreter
04/08/23 50
Coding Education & Training Program, HIM Department
E/M – Medical Decision Making Component
Review and summarization of old records &/or obtaining history from
someone other than patient &/or discussion of case with another
health care provider
Summarize the review of old record or history and document how it pertains to the patients current problem
It must be Additional/Relevant information
04/08/23 51
Coding Education & Training Program, HIM Department
E/M – Medical Decision Making Component
Independent visualization of image, tracing or
specimen itself (not simple review of written report)
Does not include: Rapid Strep Test Urine Pregnancy Test
Does include: Reviewing image in Stentor, etc. EKG Strip
04/08/23 52
Coding Education & Training Program, HIM Department
AMOUNT AND/OR COMPLEXITY OF DATA REVIEWED
Points
Review &/or order of clinical lab tests 1
Review &/or order in the radiology section of CPT 1
Review &/or order of tests in the medicine section of CPT 1
Discussion of test results with performing physician 1
Decision to obtain old records &/or obtain history from someone other than patient
1
Review and summarization of old records &/or obtaining history from someone other than patient &/or discussion of case with another health care provider
2
Independent visualization of image, tracing or specimen itself (not simply review of report)
2
Total
04/08/23 53
Coding Education & Training Program, HIM Department
E/M – Medical Decision Making Component
Risk of Complication and/or Morbidity/Mortality
Four Levels Minimal Low Moderate High
04/08/23 54
Coding Education & Training Program, HIM Department
Table of Risk
Level of Risk
Presenting Problem(s) Diagnostic Procedure(s) Ordered Management Option Selected
Minimal * One self–limited or minor problem, e.g. cold, insect bite
* Lab tests requiring venipuncture* CXRs* ECG/EEG, U/A, echo
* Rest* Gargles* Elastic bandages* Superficial dressings
Low * 2 or more self–limited or minor problems* 1 stable chronic illness•* Acute uncomplicated illness or injury, e.g. cystitis, sprain
* Physiologic tests not under stress, e.g. PFTs* Non–CV imaging with contrast, e.g. barium enema* Superficial needle biopsy* Clinical lab test requiring arterial puncture* Skin biopsies
* OTC drugs* Minor surgery w/ no identified risk factors* PT, OT•IV fluids w/out additives
Moderate
* 1 or more chronic illnesses with mild exacerbation, progression, or side effects of treatment* 2 or more stable chronic illnesses* Undiagnosed new problem with uncertain prognosis, e.g., lump in breast* Acute illness with systemic symptoms, e.g. pyelonephritis, pneumonia, colitis* Acute complicated injury, e.g. head injury with brief LOC
* Physiologic test under stress, e.g. cardiac stress test, fetal contraction stress test* Diagnostic endoscopies with no identified risk factors* Deep needle or incisional biopsy* CV imaging studies with contrast and no identified risk factors, e.g. arteriogram and cardiac cath* Obtain fluid from body cavity
* Minor surgery with identified risk factors* Elective major surgery (open, percutaneous, or endoscopic) with no identified risk factors* Prescription drugs* Therapeutic nuclear medicine* IV fluids w/ additives* Closed tx of fracture or dislocation without manipulationHigh * 1 or more chronic illnesses with severe
exacerbation, progression, or side effects of treatment* Acute or chronic illnesses or injuries that may pose a threat to life or bodily functions, e.g. peritonitis, acute failure, multiple injuries, acute MI* An abrupt change in neurological status, e.g. seizure
* CV imaging studies with contrast with identified risk factors* Cardiac EP test* Diagnostic endoscopies with identified risk factors* Discography
* Elective major surgery w/ identified risk factors* Emergency major surgery* Parenteral controlled substances* Drug therapy requiring intensive monitoring for toxicity* Decision not to resuscitate or to de–escalate care because of poor prognosis
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Coding Education & Training Program, HIM Department
Final Medical Decision-Making Level
2 of the 3 Elements must be met or exceeded
Number of Diagnosis or Treatment Options
Amount and/or Complexity of Data Reviewed
Risk of Complication and/or Morbidity/Mortality
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Coding Education & Training Program, HIM Department
Final Result for Medical Decision Making (must meet or exceed two out of three elements)
Number diagnoses/treatment options
<=1Minimal
2Limited
3Multiple
>=4Extensive
Amount & complexity of data
<=1Minimal
2Limited
3Multiple
>=4Extensive
Highest risk Minimal Low Moderate High
Type of decision making
Straight forward
Low Complex
Moderate Complex
High Complex
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Coding Education & Training Program, HIM Department
Example of Medical Decision Making
Number of Diagnoses or Treatment Options
Assessment: The diabetes is controlled with diet and exercise, blood glucose levels are within acceptable limits. The high blood pressure that we have been monitoring and trying to control with diet and exercise is now far above an acceptable range. The first problem is considered an established stable problem while the blood pressure is an established problem worsening.
Established Problem – Stable Improved Established Problem – Worsening
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Coding Education & Training Program, HIM Department
Example of Medical Decision Making
Amount &/or Complexity of Data Reviewed
The patient comes in for a recheck of diabetes that is controlled with diet and exercise, blood glucose levels are within acceptable limits, and high blood pressure that you have been monitoring and trying to control with diet and exercise is through the roof. A CBC, Chemical profile, urinalysis,electrocardiogram, and chest x-ray are ordered.
Review &/or order of clinical lab tests Review &/or order of tests in the medicine section of CPT Review &/or order in the radiology section of CPT
04/08/23 59
Coding Education & Training Program, HIM Department
Example of Medical Decision Making
Risk of Complications &/or Morbidity of Mortality
The patient comes in for a recheck of diabetes that is controlled with diet and exercise, blood glucose levels are within acceptable limits, and high blood pressure that you have been monitoring and trying to control with diet and exercise is through the roof. A CBC, Chemical profile, urinalysis,electrocardiogram, and chest x-ray are ordered. Impression: 1. Diabetes-controlled. 2. Hypertension- uncontrolled. Atenolol 50 mg prescribed. The patient is to return in one week for recheck.
1 or more chronic illnesses with mild exacerbation, progression or side effects of treatment
Lab test requiring venipuncture/CXRs/ECG Prescription Drugs
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Coding Education & Training Program, HIM Department
Contributing Factors
Time The American Medical Association guidelines state that when counseling and/or coordination of care dominates (MORE THAN 50%) the physician/patient and/or family encounter (face-to-face time) then time may be considered the key or controlling factor to qualify for a particular level of E/M services
Documentation of time is key if time is the determining factor The total amount of time spent with the patient must be clearly documentedThe record should describe the counseling and/or activity to coordinate care “A total of 30 minutes was spent with the patient, more than half
of this time was spent discussing treatment options and subsequent effects of chemotherapy.”
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Coding Education & Training Program, HIM Department
Time
Typical Times
New Office Visit 99201-10 99202-20 99203-30 99204-45 99205-60Office Consult 99241-15 99242-30 99243-40 99244-60 99245-80Inpatient Consult 99251-20 99252-40 99253-55 99254-80 99255-
110
Established Office Visit 99211- 5 99212-10 99213-15 99214-25 99215-40
Initial Hospital Observation 99218-30 99219-50 99220-70Initial Hospital Visit 99221-30 99222-50 99223-70
Subsequent Hospital Visit 99231-15 99232-25 99233-35
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Coding Education & Training Program, HIM Department
E/M – Critical Care
Critical Care
Definition
Critical care is the care of critically ill or critically injured patients who require the full, exclusive attention by a physician(s). A critical illness or injury “acutely impairs one or more vital organ systems such that there is high probability of imminent or life threatening deterioration in the patient’s condition”.
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Coding Education & Training Program, HIM Department
E/M – Critical Care
Critical Care, con’t
Documentation RequirementsSince critical care is a time-based code, the physician progress note must contain documentation of the total time involved providing critical care services. In a teaching environment, the time recorded as critical care time is the actual time spent by the physician, not a resident, fellow, or allied health provider. The time must be personally documented by the teaching physician. Teaching time does not count toward critical care time. Critical care of less than 30 minutes duration on any given day is reported with an evaluation and management code.
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Coding Education & Training Program, HIM Department
E/M – Critical Care
Critical Care, con’t
Example Documentation
Patient seen and examined with Dr. Resident. Reviewed and agree with his note and the plan of care we developed together.
One hour of critical care time personally performed due to patient’s hemodynamic instability. Patient was resuscitated with 2 units of packed red blood cells. Obtained additional studies to determine possible causes for patient’s instabilities.
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Coding Education & Training Program, HIM Department
E/M – Teaching Facility
Teaching Facility
Documentation requirements for State and Federal Payers The teaching physician saw the patient The teaching physician reviewed the resident’s note, and
agreed or revised the findings The teaching physician actively participated in the care by
either documenting involvement in the development of the plan or by changing the plan
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Coding Education & Training Program, HIM Department
E/M – Teaching Facility
Teaching Physician
Examples of minimally acceptable documentation “I saw the patient with the resident and agree with the
resident’s findings and plan we developed.” “I saw and evaluated the patient. Discussed with the resident
and agree with the resident’s findings and plan we developed as documented in the resident’s note.”
“See the resident’s note for details. I saw and evaluated the patient and agree with the resident’s findings and plans we developed as written.”
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E/M – Teaching Facility
Teaching Physician
Examples of unacceptable documentation for State and Federal Payers “Agree with above.” “Rounded, Reviewed, Agree.” “Discussed with resident.” “Agree.” “Seen and Agree.” “Patient seen and evaluated.” A legible countersignature and/or identity alone does not meet
State and Federal payer requirements
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E/M – Teaching Facility
Teaching Physician
Non-State and Non-Federal Documentation Requirements
(Commercial Payers):
Minimum evidence of review by the attending shall be demonstrated by countersignature in the patient medical record
Other requirements:
The teaching physician shall be promptly available
If the service includes direct patient contact, the teaching physician’s availability must include the ability to be physically present to review the resident’s note and ensure the services were furnished appropriately
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E/M – Teaching Facility
Medical Students
The teaching physician and/or resident must reference the medical student’s dated documentation
The medical student’s documentation may only contribute in two elements of the History component The Review of Systems and the Past Medical, Family, Social
History (ROS and PFSH)
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E/M – Differences, Inpatient vs Outpatient
Inpatient Encounters vs Outpatient Encounters
Inpatient Encounters Key Components are the same
1. History
2. Examination
3. Medical Decision Making Elements within each component are the same Difference
1. Levels Example: Initial H&P has 3 levels, not 5
2. Number of Elements Required Example: Initial H&P requires a Complete ROS (10 or more
systems) for levels 2 and 3
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E/M – Differences, Inpatient vs Outpatient
Inpatient Encounters vs Outpatient Encounters Inpatient Encounters
Initial Hospital Visit/Hospital Observation Levels1. Detailed2. Comprehensive
Subsequent Hospital Visit/Follow-up Consult Levels1. Problem Focused2. Expanded Problem Focused3. Detailed
Initial Hospital Consultation Levels1. Problem Focused2. Expanded Problem Focused3. Detailed4. Comprehensive
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Pulling it All Together
Overall E/M Code SelectionPlace of Service
Hospital vs Physician’s OfficeType of Service
Consultation vs Office Visit vs Admission Patient Status
New Patient vs Established Patient Outpatient vs Inpatient
Documentation Requirements State/Federal Payer vs Non-State/Non-Federal Payer
Any Contributing Factors? Time
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Pulling It All Together
Overall E/M Code Selection
Key Components must be met or exceeded New Patient/ER/Consultation
1. Requires all three key components Established Patient
1. Requires two of three key components
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Resources
UCDHS Coding Education & Training Programhttp://www.ucdmc.ucdavis.edu/cet
(916) 734-8856
Coding Advisory Board (CAB)http://intranet.ucdmc.ucdavis.edu/cab/
Medicare Medlearn Mattershttp://www.cms.hhs.gov/MedlearnMattersArticles/
Compliance Officehttp://www.ucdmc.ucdavis.edu/compliance/
(916) 734-8808