Physician Coding II Evaluation and Management Codes

Physician Coding II

Evaluation and Management Codes

E. Douglas Norcross, MD FACS

Professor of SurgeryMedical University of South

Carolina

For most surgeons, procedure

codes provide the

bulk of codes used for billing.

However, surgeons perform

Evaluation and

Management services as

well.

What are E and M codes anyway?

Procedure codes are descriptors of specific procedures and activities

Evaluation and Management Codes (E & M codes) are those used to describe patent encounters

E and M Service Types Commonly Used by

Surgeons Initial inpatient hospital visit Subsequent inpatient hospital visit New outpatient visit Established patient outpatient visit Observation/Inpatient visit:

Admitted/Discharged on Same Date Inpatient Hospital Discharge Service Outpatient consultation Inpatient consultation Critical Care

What follows is going to seem almost unbelievably complicated!

• That’s because it is!• Unfortunately, these are the

rules nonetheless

But there are easy tools available one can carry in one’s pocket to help figure out the

appropriate level of coding.

Each coding category is associated with a number of “levels of care”

An example 99221 Initial Hospital Care for the evaluation and

management of a patient which requires these 3 components: A detailed or comprehensive history A detailed or comprehensive examination Medical decision making that is straightforward or of low

complexity 99222 Initial Hospital Care for the evaluation and

management of a patient which requires these 3 components: A comprehensive history A comprehensive examination Medical decision making of moderate complexity

99223 Initial Hospital Care for the evaluation and management of a patient which requires these 3 components: A comprehensive history A comprehensive examination Medical decision making of high complexity

Another ExampleSubsequent Hospital Care

99231 Subsequent Hospital Care, per day, for the evaluation and management of a patient, which requires at least two of these three components

A problem focused interval history A problem focused examination Medical decision making that is straightforward or of low complexity


An expanded problem focused interval history A expanded problem focused examination Medical decision making of moderate complexity


A detailed interval history A detailed examination Medical decision making of high complexity

So, to bill an Evaluation and Management Code, a

physician must decide not only what type of

service was provided, but also at what level.

So how does one decide which level to use?

Picking a Coding Level

• Level of E and M service depends primarily upon 4 components– History– Physical Examination– Complexity of Decision Making

– Time (Applies only for certain codes and/or special circumstances)

This is important!!

The ONLY thing that matters is how much you document in each of these

areas. What you actually do is irrelevant if it isn’t documented!

History

• Level of history depends upon extent of documentation of:– History of Present Illness– Past Medical History/Family History/Social History– Review of Systems

A chief complaint must ALWAYS be

documented or you can not send a bill!

Physical Examination

• Level of physical examination depends upon the extent of documentation of the completeness of a physical examination performed.

Complexity of Medical Decision Making

• Level of history depends upon extent of documentation of:– Number of Diagnoses– Amount of information reviewed– Risk of Morbidity and mortality

History

Physical Examination Medical Decision

Making

HPI PFSH ROS

Code level

# diagnoses

Data reviewed

M & M risk

Determining Level of Code

Let’s talk about the

patient history first

HistoryFour recognized levels

• Problem Focused History• Expanded Problem Focused History• Detailed History• Comprehensive History

So how do we decide if this is a problem focused

history, an expanded problem focused history,

a detailed history, or a comprehensive History?

History• Problem Focused

– Chief Complaint– Brief history of present illness or problem

• Expanded Problem Focused– Chief Complaint– Brief history of present illness or problem– Problem pertinent system review

• Detailed– Chief Complaint– Extended history of present illness or problem– Problem pertinent system review extended to include a review of a limited number of

additional systems– Pertinent past, family, and/or social history directly related to the patient’s problems

• Comprehensive– Chief Complaint– Extended history of present illness or problem– Review of systems that is directly related to the problem(s) identified in the history of

present illness plus a review of all additional body systems– Complete past, family, and social history

So there are levels for each component of the history

• History of Present Illness• Past medical Surgical History/Family

History/Social History• Review of Systems

Let’s start with the History of Present Illness

History• Problem Focused

– Chief Complaint

– Brief history of present illness or problem• Expanded Problem Focused

– Chief Complaint

– Brief history of present illness or problem– Problem pertinent system review

• Detailed– Chief Complaint

– Extended history of present illness or problem– Problem pertinent system review extended to include a review of a limited number of additional

systems– Pertinent past, family, and/or social history directly related to the patient’s problems

• Comprehensive– Chief Complaint

– Extended history of present illness or problem– Review of systems that is directly related to the problem(s) identified in the history of present illness

plus a review of all additional body systems– Complete past, family, and social history

So the HPI can be either brief or extended

So what the heck is the difference

between a brief History of Present

Illness and an extended History of

Present Illness?

That depends on how many of the following components are

documented.• Location• Duration• Timing• Severity• Quality• Context• Modifying Factors• Associated Signs/symptoms

History of Present Illness Components

Location “Where does it hurt”Duration “How long has it hurt”Timing “How often does it hurt”Severity “How badly does it hurt”Quality “What does the pain feel like”Context “When does it hurt”Modifying factors “What makes the pain better or worse”Sign symptoms “What other things related to the pain are

present”

History of Present Illness

HPI Level Needed components

Brief HPI 1-3 components

Extended HPI ≥4 components

Remember. You MUST have a chief complaint documented. It can be

contained in the HPI or a narrative history but it has to be there.

An Example

Patient is a 25 yo F with abdominal pain.

Chief Complaint

There is no HPI component. Therefore, according to the rules which require at least a brief HPI for any level of history, no billable history is documented

for this patient encounter.

That may be OK for some E and M codes which require that only two of the three

billing components (History, Physical Examination, and Complexity of Decision

Making) are documented.

For example, inpatient follow up visits only require two of the three

components.

But any new patient encounter requires all three components! So, if

this is all that is documented for a new patient you are seeing in the ER, you just provided an unbillable service no

matter how extensive your documentation of physical

examination, and no matter how complex the medical decision making!

You are now working for free!!!

An ExampleLet’s document a bit better!

Patient is a 25 yo F with 24 hr hx of worsening, continuous, moderately severe, dull, RLQ

abdominal pain worsened with movement that awoke patient from sleep. No reported

nausea or vomiting.

Patient is a 25 yo F with 24 hr hx of worsening continuous moderately severe dull RLQ


nausea or vomiting.Location

Duration

Timing

Severity

Quality

Context

Modifying factors

Sign symptoms



nausea or vomiting.Location RLQ

Duration

Timing

Severity

Quality

Context

Modifying factors

Sign symptoms




Duration 24 hr hx

Timing

Severity

Quality

Context

Modifying factors

Sign symptoms




Duration 24 hr hx

Timing Continuous

Severity

Quality

Context

Modifying factors

Sign symptoms




Duration 24 hr hx

Timing Continuous

Severity Moderately severe

Quality

Context

Modifying factors

Sign symptoms




Duration 24 hr hx

Timing Continuous


Quality Dull

Context

Modifying factors

Sign symptoms




Duration 24 hr hx

Timing Continuous


Quality Dull

Context Awoke patient from sleep

Modifying factors

Sign symptoms




Duration 24 hr hx

Timing Continuous


Quality Dull


Modifying factors Worsened with movement

Sign symptoms




Duration 24 hr hx

Timing Continuous


Quality Dull


Modifying factors Worsened with movement

Sign symptoms No reported nausea or vomiting

This is an extended HPI with all 8 components and is only two sentences long!

Seriously… how hard is that?

So, on the sample coding tool……

Now let’s talk about the Past Medical History, Social History and Family History Components of the

overall History

There are three components(And this one is easy!)

• Past Medical/Surgical History• Family History• Social History

Past Medical History, Family History, Social History

Overall History level Needed components

Problem Focused 0

Expanded problem focused 0

Detailed 1 of the 3 PFSH components

Comprehensive (est. pt.) 2 of the 3 PFSH components

Comprehensive (new. pt.) All 3 PFSH components

Adding To Our ExampleHow many components of the PFSH are documented in this note?

Patient is a 25 yo insulin dependent diabetic F with 24 hr hx of worsening, continuous, moderately severe, dull, RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting.

We have one component (PMH) documented

Adding To Our Example Some MoreHow many components of the PFSH are documented in this note now?

Patient is a 25 yo insulin dependent diabetic F with 24 hr hx of worsening, continuous, moderately severe, dull, RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. The patient is a social drinker. No history of recent febrile illness in the family.

Past Medical HistorySocial History

Family History

This is adequate for a comprehensive PFSH history!

Isn’t that easy?

So, adding to our example

If this were for an established patient, we would only need two components to achieve the highest level.

Which of these has the higher coding level?

• 75 year old female with a history of Insulin dependent Diabetes Mellitus, Coronary Artery Disease including having had a Coronary Artery Bypass Graft five years ago. She had a CVA after that surgery and was recently diagnosed with Chronic Obstructive Pulmonary Disease. She takes NSAIDS for arthritis and was recently diagnosed with ALS.

• Pt is a 25 yo F S/P Lap appy. No smoking. Parents healthy.

Which of these has the higher coding level?

• 75 year old female with a history of Insulin dependent Diabetes Mellitus, Coronary Artery Disease including having had a Coronary Artery Bypass Graft five years ago. She had a CVA after that surgery and was recently diagnosed with Chronic Obstructive Pulmonary Disease. She takes NSAIDS for arthritis and was recently diagnosed with ALS.

(Contains only PMH)• Pt is a 25 yo F S/P Lap appy. No smoking. Parents healthy.

(Contains PMH, SH and FH)

So the second has the higher level of coding!

No one said this all made

sense!

And now, the Review of Systems!

The level of coding is based, simply on how many systems you ask

about.

Review of SystemsRecognized Systems

• Constitutional• Eyes• Ears, Nose, Throat• Cardiovascular• Respiratory• Gastrointestinal• Genitourinary• Musculoskeletal• Skin/Integumentary• Neurologic• Psychiatric• Endocrine• Hematologic/lymph• Allergy/Immunologic

Review of Systems

ROS Requirement Needed components

None 0

Problem pertinent 1

Limited 2-9

Complete ROS ≥10

Continuing Our ExampleHow many components of the ROS are documented in this note?

Patient is a 25 yo insulin dependent diabetic F with 24 hr hx of worsening, continuous, moderately severe, dull, RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. The patient is a social drinker. No history of recent febrile illness in the family.Patient reports no chest pain, no dyspnea, no bleeding disorders. No urinary frequency. Wears contact lenses. Occasional sinus problems.


Constitutional

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Hematologic/lymph

Eyes

Ears, Nose, Throat

Musculoskeletal

Skin/Integumentary

Neurologic

Psychiatric

Endocrine

Allergy/Immunologic


Constitutional

Cardiovascular No Chest Pain

Respiratory

Gastrointestinal

Genitourinary

Hematologic/lymph

Eyes

Ears, Nose, Throat

Musculoskeletal

Skin/Integumentary

Neurologic

Psychiatric

Endocrine

Allergy/Immunologic


Constitutional


Respiratory No Dyspnea

Gastrointestinal

Genitourinary

Hematologic/lymph

Eyes

Ears, Nose, Throat

Musculoskeletal

Skin/Integumentary

Neurologic

Psychiatric

Endocrine

Allergy/Immunologic


Constitutional



Gastrointestinal

Genitourinary

Hematologic/lymph No Bleeding Disorders

Eyes

Ears, Nose, Throat

Musculoskeletal

Skin/Integumentary

Neurologic

Psychiatric

Endocrine

Allergy/Immunologic


Constitutional



Gastrointestinal

Genitourinary No Urinary Frequency


Eyes

Ears, Nose, Throat

Musculoskeletal

Skin/Integumentary

Neurologic

Psychiatric

Endocrine

Allergy/Immunologic


Constitutional



Gastrointestinal



Eyes Wears Contact Lenses

Ears, Nose, Throat

Musculoskeletal

Skin/Integumentary

Neurologic

Psychiatric

Endocrine

Allergy/Immunologic


Constitutional



Gastrointestinal




Ears, Nose, Throat Occasional Sinus Problems

Musculoskeletal

Skin/Integumentary

Neurologic

Psychiatric

Endocrine

Allergy/Immunologic

So we have commented on 6 different systems.

ROS Requirement Needed components

None 0

Problem pertinent 1

Limited 2-9

Complete ROS ≥10

So this is a limited review of systems

Can we make this a complete review of systems?

Continuing Our ExampleHow many components of the ROS are documented in this note?

Patient is a 25 yo insulin dependent diabetic F with 24 hr hx of worsening, continuous, moderately severe, dull, RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. The patient is a social drinker. No history of recent febrile illness in the family.Patient reports no chest pain, no dyspnea, no bleeding disorders. No urinary frequency. Wears contact lenses. Occasional sinus problems. All other systems negative.

Patient is a 25 yo insulin dependent diabetic F with 24 hr hx of worsening, continuous, moderately severe, dull, RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. The patient is a social drinker. No history of recent febrile illness in the family.Patient reports no chest pain, no dyspnea, no bleeding disorders. No urinary frequency. Wears contact lenses. Occasional sinus problems. All other systems negative.Constitutional All other systems negative.



Gastrointestinal All other systems negative.





Musculoskeletal All other systems negative.

Skin/Integumentary All other systems negative.

Neurologic All other systems negative.

Psychiatric All other systems negative.

Endocrine All other systems negative.

Allergy/Immunologic All other systems negative.

This is a complete review of systems with all 14 components documented!

That’s not so bad is it!

Review of Systems

• You can include questions asked in the HPI as part of the review of systems unless you count them as part of the HPI!

• It is perfectly fine to document “all other systems negative” but, you have to have asked about them all.

You do NOT want to have documented “all other systems negative” and a few days later document that the patient has had auditory hallucinations for five years! The OIG (Office of the Inspector General) would wonder about your initial coding and that is never a good thing.

So let’s go back to our example without the risky “all other systems negative” comment


So, adding ROS to our example

So, is this a detailed history or a comprehensive history?

The level for coding depends upon the lowest component

So this is a detailed history

Can I improve the documentation to get to a comprehensive history?

Patient is a 25 yo insulin dependent diabetic F with 24 hr hx of worsening, continuous, moderately severe, dull, RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. The patient is a social drinker. No history of recent febrile illness in the family. Patient reports no chest pain, no dyspnea, no bleeding disorders. No urinary frequency. Wears contact lenses. Occasional sinus problems. No psychiatric history, joint pain, seizures. Patient is allergic to Penicillin (rash)

Patient is a 25 yo insulin dependent diabetic F with 24 hr hx of worsening, continuous, moderately severe, dull, RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. The patient is a social drinker. No history of recent febrile illness in the family. Patient reports no chest pain, no dyspnea, no bleeding disorders. No urinary frequency. Wears contact lenses. Occasional sinus problems. No psychiatric history, joint pain, seizures. Patient is allergic to Penicillin (rash)Constitutional



Gastrointestinal





Musculoskeletal

Skin/Integumentary

Neurologic

Psychiatric No Psychiatric History

Endocrine

Allergy/Immunologic




Gastrointestinal





Musculoskeletal No Joint Pain

Skin/Integumentary

Neurologic


Endocrine

Allergy/Immunologic




Gastrointestinal






Skin/Integumentary

Neurologic No seizures


Endocrine

Allergy/Immunologic




Gastrointestinal






Skin/Integumentary

Neurologic No seizures


Endocrine

Allergy/Immunologic Allergic to Penicillin

We now have ten systems covered on our review of systems

Since all three components of the history are at the highest level, we now have a comprehensive history.

What do I do if the patient received a

little too much morphine in the

emergency department and is barely arousable? How can I obtain a

history?

HPI: Patient is a 25 yo F who, per Dr Smith, has a 24 hr hx of worsening abdominal pain . No other history is obtainable due to patients altered mental status.

This is a comprehensive history!

One can bill as if a history item was completed

if you document that it was unable

to be completed and

why.

Examples

• Further history unobtainable due to patients altered mental status

• Social History, Family History and Review of Systems not obtained due to emergent need for evaluation and treatment

• History obtained from family as above. Further history unobtainable due to patient confusion

So what is the bottom line for history

• Always document a chief complaint• You only need to document the answer to four

HPI questions to get the highest HPI level• PMH, FH and SH are important in choosing a

coding level• No matter what you document for everything

else, if you leave out a review of systems, you have the lowest level of history.

Physical Examination

Physical Examination also has levels

• Problem Focused• Expanded Problem Focused• Detailed• Comprehensive

Physical Examination1995 Rules

Level of code based on number of body areas examined and extent of exam in each area

Physical ExaminationBody Areas

• Head Including the face• Neck• Chest including breast and axilla• Abdomen• Genitalia, groin, and buttocks• Back• Each extremity


• Problem focused: A limited Examination of the affected body area or organ system

• Expanded problem focused: A limited examination of the affected body area or organ system and other symptomatic or related organ system(s)

• Detailed: An extended examination of the affected body area(s) and other symptomatic or related organ system(s)

• Comprehensive: A general multisystem examination or a complete examination of a single organ system

However, 1995 rules were

considered too vague and were

“clarified” in 1997.


Level of code based on number of organ systems examined and extent of exam in each area based on a designated series of “bullets” assigned to each organ system.

Do not even think about trying to memorize the next six slides!!!!

Physical ExaminationOrgan Systems

• Eyes• Ears, nose, mouth, and throat• Cardiovascular• Respiratory• Gastrointestinal• Genitourinary• Musculoskeletal• Skin• Neurologic• Psychiatric• Hematologic/lymphatic/immunologic

Physical Examination “Bullets”• Constitutional

Three vital signs (NOTE: MUST HAVE THREE VITAL SIGNS LISTED, AF/VSS does NOT count!)General appearance

• EyesInspection of conjunctivae and lids Examination of pupils and irises (PERRLA) Ophthalmoscopic discs and posterior segments

• Ears, Nose, Mouth, and Throat External appearance of the ears and nose (overall appearance, scars, lesions, masses) Otoscopic examination of the external auditory canals and tympanic membranesAssessment of hearing Inspection of nasal mucosa, septum and turbinates Inspection of lips, teeth and gums Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx

• Neck Examination of neck (e.g., masses, overall appearance, symmetry, tracheal position, crepitus) Examination of thyroid

Physical Examination “Bullets”1997 rules

• Respiratory (Four possible “bullets”)Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic movement) Percussion of chest (e.g., dullness, flatness, hyperresonance)Palpation of chest (e.g., tactile fremitus) Auscultation of the lungs

• Cardiovascular (Seven possible “bullets”)Palpation of the heart (location, size, thrills) Auscultation of the heart with notation of abnormal sounds and murmurs Assessment of lower extremities for edema and/or varicosities Examination of the carotid arteries (e.g., pulse amplitude, bruits) Examination of abdominal aorta (e.g., size, bruits) Examination of the femoral arteries (e.g., pulse amplitude, bruits) Examination of the pedal pulses (e.g., pulse amplitude)

• Chest (Breasts) (Two possible “bullets”)Inspection of the breasts (e.g., symmetry, nipple discharge) Palpation of the breasts and axillae (e.g., masses, lumps, tenderness)

Physical Examination “Bullets” 1997 rules

• Gastrointestinal (Abdomen) (Five possible “bullets”)Examination of the abdomen with notation of presence of masses or tenderness Examination of the liver and spleen Examination for the presence or absence of hernias Examination (when indicated) of anus, perineum, and rectum, including sphincter tone, presence of hemorrhoids, rectal masses Obtain stool for occult blood testing when indicated

• Genitourinary (Male) (Three possible “bullets”)Examination of the scrotal contents (e.g., hydrocoele, spermatocoele, tenderness of cord, testicular mass) Examination of the penis Digital rectal examination of the prostate gland (e.g., size, symmetry, nodularity, tenderness)

• Genitourinary (Female) Pelvic examination (with or without specimen collection for smears and cultures, which may include: (Six possible “bullets”)

Examination of the external genitalia (e.g., general appearance, hair distribution, lesions) Examination of the urethra (e.g., masses, tenderness, scarring) Examination of the bladder (e.g., fullness, masses, tenderness) Examination of the cervix (e.g., general appearance, discharge, lesions) Examination of the uterus (e.g., size, contour, position, mobility, tenderness, consistency, descent or support) Examination of the adnexa/parametria (e.g., masses, tenderness, organomegaly, nodularity)


• Lymphatic : Palpation of lymph nodes two or more areas: (Four possible “bullets”)

Neck Axillae Groin Other

(NOTE: MUST DOCUMENT EXAMINATION OF TWO NODAL BASINS TO EARN A BULLET!)

• Skin (Two possible “bullets”)Inspection of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers) Palpation of the skin and subcutaneous tissue (e.g., induration, subcutaneous nodules, tightening)

• Neurologic (Three possible “bullets”)Test cranial nerves with notation of any deficits Examination of DTRs with notation of any pathologic reflexes (e.g., Babinksi)Examination of sensation (e.g., by touch, pin, vibration, proprioception

• Psychiatric (Two possible “bullets”)Description of patient’s judgment and insightBrief assessment of mental status which may include

• orientation to time, place, and person • recent and remote memory • mood and affect


• Musculoskeletal (Three possible “bullets”)Examination of gait and station Inspection and/or palpation of digits and nails (e.g., clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes)Examination of the joints, bones, and muscles of one or more of the following six areas:

• head and neck • spine, ribs, and pelvis • right upper extremity • left upper extremity • right lower extremity • left lower extremity

The examination of a given area may include: Inspection and/or palpation with notation of presence of any misalignment,

asymmetry, crepitation, defects, tenderness, masses or effusions Assessment of range of motion with notation of any pain, crepitation or contracture Assessment of stability with notation of any dislocation, subluxation, or laxity Assessment of muscle strength and tone (e.g., flaccid, cogwheel, spastic) with

notation of any atrophy or abnormal movements

Physical Examination Level 1997 rules

Physical Examination Level Needed components

Problem Focused 1 to 5 bullets from one or more organ systems

Expanded problem focused At least six bullets from any organ systems

Detailed At least two bullets from 6 organ systemsOR

12 bullets from 2 or more organ systems

Comprehensive 2 bullets from each of 9 organ systems

But I’m a vascular surgeon. No one

comes to me look in their ears! Can I ever

achieve a comprehensive examination?

The 1997 revision included

descriptions of specialty

examinations

11 recognized specialty examinations

• Cardiovascular• Ear, nose, and throat• Eye• Genitourinary (Male)• Genitourinary (Female)• Hematologic, Lymphatic, Immunologic• Musculoskeletal• Neurologic• Psychiatric• Respiratory• Skin

An exampleThe Cardiovascular Specialty Examination

Cardiovascular Specialty Examination

• The Chest (Breasts), Head/Face, Lymphatic and Genitourinary body systems/body areas are not considered integral parts of the cardiovascular specialty exam

Cardiovascular Specialty Examination

Level of Exam Bullets

Problem Focused 1-5 specialty exam bullets

Expanded Problem Focused 6-11 specialty exam bullets

Detailed ≥ 12 specialty exam bullets

Comprehensive At least 1 specialty examination bullet from each box within box “A”

ANDEvery bullet from each box within box “B”

Cardiovascular Specialty ExaminationBox “A”

Organ System Bullets

Eyes • Inspection of conjunctivae and lids

Ears, Nose, Mouth and Throat

• Inspection of teeth, gums and palate• Inspection of oral mucosa with notation of presence of pallor or cyanosis

Neck •Examination of jugular veins (e.g., distension; a, v or cannon a waves)•Examination of thyroid (e.g., enlargement, tenderness, mass)

Musculoskeletal • Examination of the back with notation of kyphosis or scoliosis• Examination of gait with notation of ability to undergo exercise testing and/or participation in exercise programs•Assessment of muscle strength and tone (e.g., flaccid, cog wheel, spastic) with notation of any atrophy and abnormal movements

Extremities • Inspection and palpation of digits and nails (e.g., clubbing, cyanosis, inflammation, petechiae, ischemia, infections, Osler's nodes)

Skin • Inspection and/or palpation of skin and subcutaneous tissue (e.g., stasis, dermatitis, ulcers, scars, xanthomas)

Cardiovascular Specialty ExaminationBox “B”

Organ System Bullets

Cardiovascular • Palpation of heart (e.g., location, size and forcefulness of the point of maximal impact; thrills; lifts; palpable S3 or S4)•Auscultation of heart including sounds, abnormal sounds and murmurs• Measurement of blood pressure in two or more extremities when indicated (e.g., aortic dissection, coarctation)Examination of:• Carotid arteries (e.g., waveform, pulse amplitude, bruits, apical-carotid delay)• Abdominal aorta (e.g., size, bruits)• Femoral arteries (e.g., pulse amplitude, bruits)• Pedal pulses (e.g., pulse amplitude)• Extremities for peripheral edema and/or varicosities

Constitutional • Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff)• General appearance of patient (e.g., development, nutrition, body habitus, deformities, attention to grooming)

Gastrointestinal (Abdomen) •Examination of abdomen with notation of presence of masses or tenderness•Examination of liver and spleen•Obtain stool sample for occult blood from patients who are being considered for thrombolytic or anticoagulant therapy

Neurological/Psychiatric Brief assessment of mental status including:•Orientation to time, place and person•Mood and affect (e.g., depression, anxiety, agitation)

Respiratory •Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic movement)•Auscultation of lungs (e.g., breath sounds, adventitious sounds, rubs)

Confused yet?So was every physician in the country!

Physical Examination1997 rules

The 1997 rules were so complicated that even congress recognized that they were absurdly complex and unworkable.

So you can apply either the 1995 or the 1997 set of rules as you see fit!

Physical Examination1997 rules

Although 1995 rules are recognized, following the 1997 rules may avoid any unfortunate disagreements in the event of a CMS audit due to the ambiguity of the 1995 rules.

Many available coding tools list both methods

Back to our ExamplePatient is a 25 yo insulin dependent diabetic F with 24 hr hx of worsening, continuous, moderately severe, dull, RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. The patient is a social drinker. No history of recent febrile illness in the family. Patient reports no chest pain, no dyspnea, no bleeding disorders. No urinary frequency. Wears contact lenses. Occasional sinus problems. No psychiatric history, joint pain, seizures. Patient is allergic to Penicillin (rash)On exam, pts. abdomen is tender at McBurney’s point. Pt has rebound tenderness referred to RLQ.

This is probably best described as a limited examination of an affected body area by 1995 rules

1997 Rules On exam, pts. abdomen is tender at McBurney’s point.

Pt has rebound tenderness referred to RLQ.

Gastrointestinal (Abdomen) (Five possible “bullets”)Examination of the abdomen with notation of presence of masses or tenderness Examination of the liver and spleen Examination for the presence or absence of hernias Examination (when indicated) of anus, perineum, and rectum, including sphincter tone, presence of hemorrhoids, rectal masses Obtain stool for occult blood testing when indicated

So we only have one “bullet” documented.

On exam, pts. abdomen is tender at McBurney’s point. Pt has rebound tenderness referred to RLQ.

This would be a problem focused examination by 1995 rules

And also by 1997 rules

Can we do better?The importance of documenting

negative findings!

On exam, the patient is a well developed, well nourished, awake, alert & oriented female. Temp: 98.8F Pulse: 78, BP:

120/75. Heart regular rate and rhythm. Lungs clear. Abdomen is tender at McBurney’s point. Pt has rebound tenderness

referred to RLQ. No hepatosplenomegaly. No hernias noted. No previous abdominal incisions. Normal rectal exam. Stool

hemoccult negative. No cervical tenderness on pelvic examination. No leg edema. No lymphadenopathy noted.

On exam, the patient is a well developed, well nourished, awake, alert & oriented female. Temp: 98.8F Pulse: 78, BP: 120/75. Heart regular rate and

rhythm. Lungs clear. Abdomen is tender at McBurney’s point. Pt has rebound tenderness referred to RLQ. No hepatosplenomegaly. No hernias noted. No

previous abdominal incisions. Normal rectal exam. Stool hemoccult negative. No cervical tenderness on pelvic examination. No leg edema. No

lymphadenopathy noted.

By the 1995 rules this is probably best described as an “extended examination of the affected area and other

symptomatic or related systems”

1997 RulesOn exam, the patient is a well developed, well nourished, awake, alert & oriented female. Temp:

98.8F Pulse: 78, BP: 120/75. Heart regular rate and rhythm. Lungs clear. Abdomen is tender at McBurney’s point. Pt has rebound tenderness referred to RLQ. No hepatosplenomegaly. No

hernias noted. No previous abdominal incisions. Normal rectal exam. Stool hemoccult negative. No cervical tenderness on pelvic examination. No leg edema. No lymphadenopathy noted.

Organ System Physical Exam Findings Bullets

Constitutional WD/WN F, P 78, BP 120/75, Temp 98.8 2 bullets

Eyes

Ears, Nose, Mouth, and Throat

Neck

Respiratory

Cardiovascular

Chest (Breasts)

Gastrointestinal (Abdomen)

Genitourinary (Male)

Genitourinary (Female)

Lymphatic

Musculoskeletal

Skin

Neurologic

Psychiatric






Eyes


Neck

Respiratory Lungs clear 1 bullet

Cardiovascular

Chest (Breasts)




Lymphatic

Musculoskeletal

Skin

Neurologic

Psychiatric






Eyes


Neck


Cardiovascular Heart regular rate and rhythm 1 bullet

Chest (Breasts)




Lymphatic

Musculoskeletal

Skin

Neurologic

Psychiatric






Eyes


Neck



Chest (Breasts)

Gastrointestinal (Abdomen) Abdomen is tender at McBurney’s point. Pt has rebound tenderness referred to RLQ. No hepatosplenomegaly. No hernias noted, Normal rectal exam. Stool hemoccult negative.

5 bullets



Lymphatic

Musculoskeletal

Skin

Neurologic

Psychiatric






Eyes


Neck



Chest (Breasts)


5 bullets


Genitourinary (Female) No cervical tenderness on pelvic examination. 1 bullet

Lymphatic

Musculoskeletal

Skin

Neurologic

Psychiatric






Eyes


Neck



Chest (Breasts)


5 bullets



Lymphatic

Musculoskeletal

Skin No previous abdominal incisions. 1 bullet

Neurologic

Psychiatric






Eyes


Neck



Chest (Breasts)


5 bullets



Lymphatic

Musculoskeletal


Neurologic awake, alert & oriented 1 bullet

Psychiatric






Eyes


Neck



Chest (Breasts)


5 bullets



Lymphatic

Musculoskeletal No leg edema 1 bullet



Psychiatric






Eyes


Neck



Chest (Breasts)


5 bullets



Lymphatic No lymphadenopathy noted 1 bullet




Psychiatric

1997 RulesSo we now have 14 bullets in 9 different systems just by

documenting negative findings!



Eyes


Neck



Chest (Breasts)


5 bullets



Lymphatic No lymphadenopathy noted 1 bullet




Psychiatric

On exam, the patient is a well developed, well nourished, awake, alert & oriented female. Temp: 98.8F Pulse: 78, BP: 120/75. Heart regular rate and rhythm. Lungs clear. Abdomen is tender at

McBurney’s point. Pt has rebound tenderness referred to RLQ. No hepatosplenomegaly. No hernias noted. No previous abdominal incisions. Normal rectal exam. Stool hemoccult negative.

No cervical tenderness on pelvic examination. No leg edema. No lymphadenopathy noted.

This would be a comprehensive examination by 1995 rules

And also by 1997 rules

The bottom line on physical examination

• Perform a thorough physical examination appropriate to the problem. (Just another way of saying be a good doctor!)

• Document all positive AND negative findings.• Use the available tools to figure out what level

examination you have performed

Medical Decision Making

Unlike history, and physical examination, medical decision

making is not divided into problem focused, expanded problem focused, detailed, and comprehensive levels


Instead, medical decision making is divided into straightforward, low,

moderate, and high complexity levels


Level of complexity of medical decision making is based on three factors• Problem Points: The nature and number of clinical

problems for which the patient is being evaluated or managed.

• Data Points: The amount of patient related data reviewed

• Risk: Risk of patient complications, morbidity and/or mortality

Medical Decision MakingProblem Points Data Points Risk

Straightforward Complexity 1 1 MinimalLow Complexity 2 2 LowModerate Complexity 3 3 ModerateHigh Complexity 4 4 High



Level of medical decision making depends upon highest two out of the

three above!



So, for a patient scored as above, this would be a “moderate complexity” level of medical decision

making.



So, would this! You only need two of the three!


It’s a matter of “points” earned for each of the

three areas

Problem PointsEach problem listed in your documentation gets

assigned a certain number of points

Problem Points

Self-limited or minor (maximum of 2 self limited problems can be assigned points)

1

Established problem, stable or improving 1

Established problem, worsening 2

New problem (to you!), with no additional work-up planned (maximum of 1)

3

New problem (to you!), with additional work-up planned 4

So it is important to list, not just each problem, but also whether the problem is stable, worsening, or improving and whether any additional

workup is planned

So, back to our examplePatient is a 25 yo insulin dependent diabetic F with 24 hr hx of worsening, continuous, moderately severe, dull, RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. The patient is a social drinker. No history of recent febrile illness in the family. Patient reports no chest pain, no dyspnea, no bleeding disorders. No urinary frequency. Wears contact lenses. Occasional sinus problems. No psychiatric history, joint pain, seizures. Patient is allergic to Penicillin (rash) On exam, the patient is a well developed, well nourished, awake, alert & oriented female. Temp: 98.8F Pulse: 78, BP: 120/75. Heart regular rate and rhythm. Lungs clear. Abdomen is tender at McBurney’s point. Pt has rebound tenderness referred to RLQ. No hepatosplenomegaly. No hernias noted. No previous abdominal incisions. Normal rectal exam. Stool hemoccult negative. No cervical tenderness on pelvic examination. No leg edema. No lymphadenopathy noted. Assessment: Acute Appendicitis (New), Insulin Dependent Diabetes Mellitus (Stable)Plan: OR for laparoscopic appendectomy

Calculating Problem PointsAssessment: Acute Appendicitis (New), Insulin Dependent Diabetes Mellitus (Stable)Plan: OR for laparoscopic appendectomy

Problem Points

Self-limited or minor (maximum of 2 self limited problems can be assigned points)

1

Established problem, stable or improving 1

Established problem, worsening 2

New problem (to you!), with no additional work-up planned (maximum of 1)

3

New problem (to you!), with additional work-up planned 4

So we have a total of four problem points documented

Adding Diabetes to the problem list increased the documentation to the maximum level

Data Points

Data Reviewed Points

Review or order clinical lab tests 1

Review or order radiology test (except heart catheterization or Echo) 1

Review or order medicine test (PFTs, EKG, cardiac echo or catheterization, etc.)

1

Discuss test with performing physician 1

Independent review of image, tracing, or specimen 2

Decision to obtain old records 1

Review and summation of old records 2

Data Points

• One can only use any one category of data review once for any single encounter. – For example, if you order a CBC as well as a Chem

7, you only get 1 point, not 1 point for each test ordered.

• No “double dipping” is allowed. – For example, if you order labs and then review

those results during the same visit, you only get one point, not one point for ordering and one point for reviewing.

Data Points

• You can claim points for reviewing an image or tracing, even if the image, tracing or specimen has been reviewed by another physician (as when a radiologist provides an official interpretation for an X-ray). However, you must include your own interpretation in the chart in order to claim these points.

Back to our examplePatient is a 25 yo insulin dependent diabetic F with 24 hr hx of worsening, continuous, moderately severe, dull, RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. The patient is a social drinker. No history of recent febrile illness in the family. Patient reports no chest pain, no dyspnea, no bleeding disorders. No urinary frequency. Wears contact lenses. Occasional sinus problems. No psychiatric history, joint pain, seizures. Patient is allergic to Penicillin (rash) On exam, the patient is a well developed, well nourished, awake, alert & oriented female. Temp: 98.8F Pulse: 78, BP: 120/75. Heart regular rate and rhythm. Lungs clear. Abdomen is tender at McBurney’s point. Pt has rebound tenderness referred to RLQ. No hepatosplenomegaly. No hernias noted. No previous abdominal incisions. Normal rectal exam. Stool hemoccult negative. No cervical tenderness on pelvic examination. No leg edema. No lymphadenopathy noted. CBC shows increased WBC count to 11.2. CT scan reviewed which shows inflammatory changes in RLQ of abdomen. Assessment: Acute Appendicitis (New), Insulin Dependent Diabetes Mellitus (Stable)Plan: OR for laparoscopic appendectomy

Calculating Data PointsCBC shows increased WBC count to 11.2. CT scan reviewed which shows inflammatory changes in RLQ of abdomen.

Data Reviewed Points

Review or order clinical lab tests 1

Review or order radiology test (except heart catheterization or Echo) 1

Review or order medicine test (PFTs, EKG, cardiac echo or catheterization, etc.)

1

Discuss test with performing physician 1

Independent review of image, tracing, or specimen 2

Decision to obtain old records 1

Review and summation of old records 2

So we have a total of three data points.

Risk Assessment

Risk assessment is basically a measure

of how sick the patient is and how

much risk their work up and treatment places upon them

Risk assessmentLevel of risk is determined by examining three

separate dimensions of the encounter

• Presenting problems• Diagnostic procedures• Management options selected

Risk Assessment

Risk Level Presenting Problems Diagnostic Procedures Management Options Selected

Minimal Risk

(Requires ONE of these elements in ANY of the three categories listed)

•One self-limited or minor problem, e.g., cold, insect bite, tinea corporis

(Why did this patient even come to see me?)

•Laboratory tests •Chest X-rays •EKG/EEG •Urinalysis •Ultrasound/Echocardiogram •KOH prep

•Rest •Gargles •Elastic bandages •Superficial dressings

Low Risk


•Two or more self-limited or minor problems •One stable chronic illness, e.g., well controlled , DM2, cataract •Acute uncomplicated injury or illness, e.g., cystitis, allergic rhinitis, sprain

•Physiologic tests not under stress, e.g., PFTs •Non-cardiovascular imaging studies with contrast, e.g., barium enema •Superficial needle biopsy •ABG •Skin biopsies

•Over the counter drugs •Minor surgery, with no identified risk factors •Physical therapy •Occupational therapy •IV fluids, without additives

Risk Assessment


Moderate Risk


•Two stable chronic illnesses •One chronic illness with mild exacerbation or progression •Undiagnosed new problem with uncertain prognosis (e.g., lump in breast) •Acute illness with systemic symptoms (e.g., pyelonephritis, pneumonitis, colitis •Acute complicated injury (e.g., head injury with brief loss of consciousness)

•Physiologic tests under stress, e.g., cardiac stress test, fetal contraction stress test •Diagnostic endoscopies, with no identified risk factors •Deep needle, or incisional biopsies •Cardiovascular imaging studies, with contrast, with no identified risk factors, e.g., arteriogram, cardiac catheterization •Obtain fluid from body cavity, e.g., LP/thoracentesis

•Minor surgery, with identified risk factors •Elective major surgery (open, percutaneous, or endoscopic), with no identified risk factors •Prescription drug management •Therapeutic nuclear medicine •IV fluids, with additives •Closed treatment of fracture or dislocation, without manipulation

Risk Assessment


High Risk


•One or more chronic illness, with severe exacerbation or progression •Acute or chronic illness or injury, which poses a threat to life or bodily function, e.g., multiple trauma, acute MI, pulmonary embolism, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness, with potential threat to self or others, peritonitis, ARF •An abrupt change in neurological status, e.g., seizure, TIA, weakness, sensory loss

•Cardiovascular imaging, with contrast, with identified risk factors •Cardiac EP studies •Diagnostic endoscopies, with identified risk factors •Discography

•Elective major surgery (open, percutaneous, endoscopic), with identified risk factors •Emergency major surgery (open, percutaneous, endoscopic) •Parenteral controlled substances •Drug therapy requiring intensive monitoring for toxicity •Decision not to resuscitate, or to de-escalate care because of poor prognosis

Back to our examplePatient is a 25 yo insulin dependent diabetic F with 24 hr hx of worsening, continuous, moderately severe, dull, RLQ abdominal pain worsened with movement that awoke patient from sleep. No reported nausea or vomiting. The patient is a social drinker. No history of recent febrile illness in the family. Patient reports no chest pain, no dyspnea, no bleeding disorders. No urinary frequency. Wears contact lenses. Occasional sinus problems. No psychiatric history, joint pain, seizures. Patient is allergic to Penicillin (rash) On exam, the patient is a well developed, well nourished, awake, alert & oriented female. Temp: 98.8F Pulse: 78, BP: 120/75. Heart regular rate and rhythm. Lungs clear. Abdomen is tender at McBurney’s point. Pt has rebound tenderness referred to RLQ. No hepatosplenomegaly. No hernias noted. No previous abdominal incisions. Normal rectal exam. Stool hemoccult negative. No cervical tenderness on pelvic examination. No leg edema. No lymphadenopathy noted. CBC shows increased WBC count to 11.2. CT scan reviewed which shows inflammatory changes in RLQ of abdomen. Assessment: Acute Appendicitis (New), Insulin Dependent Diabetes Mellitus (Stable)Plan: OR for laparoscopic appendectomy

What is the risk?


Minimal Risk


•One self-limited or minor problem, e.g., cold, insect bite, tinea corporis

(Why did this patient even come to see me?)

•Laboratory tests •Chest X-rays •EKG/EEG •Urinalysis •Ultrasound/Echocardiogram •KOH prep

•Rest •Gargles •Elastic bandages •Superficial dressings

Low Risk


•Two or more self-limited or minor problems •One stable chronic illness, e.g., well controlled , DM2, cataract •Acute uncomplicated injury or illness, e.g., cystitis, allergic rhinitis, sprain

•Physiologic tests not under stress, e.g., PFTs •Non-cardiovascular imaging studies with contrast, e.g., barium enema •Superficial needle biopsy •ABG •Skin biopsies

•Over the counter drugs •Minor surgery, with no identified risk factors •Physical therapy •Occupational therapy •IV fluids, without additives

What is the risk?


Moderate Risk


•Two stable chronic illnesses •One chronic illness with mild exacerbation or progression •Undiagnosed new problem with uncertain prognosis (e.g., lump in breast) •Acute illness with systemic symptoms (e.g., pyelonephritis, pneumonitis, colitis •Acute complicated injury (e.g., head injury with brief loss of consciousness)

•Physiologic tests under stress, e.g., cardiac stress test, fetal contraction stress test •Diagnostic endoscopies, with no identified risk factors •Deep needle, or incisional biopsies •Cardiovascular imaging studies, with contrast, with no identified risk factors, e.g., arteriogram, cardiac catheterization •Obtain fluid from body cavity, e.g., LP/thoracentesis

•Minor surgery, with identified risk factors •Elective major surgery (open, percutaneous, or endoscopic), with no identified risk factors •Prescription drug management •Therapeutic nuclear medicine •IV fluids, with additives •Closed treatment of fracture or dislocation, without manipulation

What is the risk?


High Risk


•One or more chronic illness, with severe exacerbation or progression •Acute or chronic illness or injury, which poses a threat to life or bodily function, e.g., multiple trauma, acute MI, pulmonary embolism, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness, with potential threat to self or others, peritonitis, ARF •An abrupt change in neurological status, e.g., seizure, TIA, weakness, sensory loss

•Cardiovascular imaging, with contrast, with identified risk factors •Cardiac EP studies •Diagnostic endoscopies, with identified risk factors •Discography

•Elective major surgery (open, percutaneous, endoscopic), with identified risk factors •Emergency major surgery (open, percutaneous, endoscopic) •Parenteral controlled substances •Drug therapy requiring intensive monitoring for toxicity •Decision not to resuscitate, or to de-escalate care because of poor prognosis

What is the risk?

Therefore, this is a high risk patient

So what is the level of medical decision making for this encounter?

Problem Points Data Points RiskStraightforward Complexity 1 1 MinimalLow Complexity 2 2 LowModerate Complexity 3 3 ModerateHigh Complexity 4 4 High

Remember, we determine the level of medical decision making based on the lower of the two highest scoring components.

Therefore, this is a high complexity level of medical decision making.

Can we send a bill for this encounter?

This visit is not covered under the global fee for the operative

procedure even though the encounter is occurring within

24 hours of that procedure because the decision to

operate was made during this encounter.

So we can, and should, bill for this encounter

So what E and M code do we use to bill for this patient encounter?

• This is a new patient• The patient will be admitted to the hospital• Thus an initial inpatient hospital visit code is appropriate.

For our example

• We documented a comprehensive history

• We documented a detailed physical examination

• We documented high complexity medical decision making.

So which level do we choose?• 99221 Initial Hospital Care for the evaluation and management of a

patient which requires these 3 components:– A detailed or comprehensive history– A detailed or comprehensive examination– Medical decision making that is straightforward or of low complexity

• 99222 Initial Hospital Care for the evaluation and management of a patient which requires these 3 components:– A comprehensive history– A comprehensive examination– Medical decision making of moderate complexity

• 99223 Initial Hospital Care for the evaluation and management of a patient which requires these 3 components:– A comprehensive history– A comprehensive examination– Medical decision making of high complexity

So this is properly coded as a 99223 encounter since all three components have to be met at the minimum level for that level of care code.

Yes, this looks absurdly complicated.

What do you expect from a government bureaucracy!

This is important!One’s history, physical examination and decision making drives ones documentation which drives

one’s coding NOT the other way around!

This is important too!

One’s chosen code should be appropriate to the chief complaint if one is to avoid scrutiny and

potential compliance violations

So documenting the highest level visit for a patient

with a simple minor laceration

is likely to be questioned!

So what’s the bottom line?

• If you asked the question, document the answer.• If you examined it, document the findings, even if negative.• Document your entire problem list, not just your final

diagnosis.• Document the studies you ordered and reviewed, and

document it.• If you talk to another physician, document it.• If you ask for or review old records, document it.• Use the tools that exist to figure out the level of coding.

And Use the Tools!!

Are there special rules for teaching hospitals?

Of course there are! This is the government after all!

Rules for Teaching Physicians

General ConceptsServices furnished in teaching settings are paid under the Medicare Physician Fee Schedule (MPFS) if the services are:

Personally furnished by a physician who is not a resident or

Furnished by a resident when a teaching physician is physically present during the critical or key portions of the service

So the attending must perform their own history and physical

examination to confirm the findings of the resident or be

physically present when a resident performs a history and

physical examination.

Rules for Teaching PhysiciansResidents

• Both residents and teaching physicians may document physician services in the patient’s medical record. The documentation must be dated and contain a legible signature or identity

• On medical review, the combined entries into the medical record by the teaching physician and resident constitute the documentation for the service.

• Documentation by only the resident of the presence and participation of the teaching physician is not sufficient to establish the presence and participation of the teaching physician.

Rules for Teaching PhysiciansResidents

• Attending physicians must attest that they have reviewed a residents history and physical examination, assessment, and plan, and, if they concur with those findings based on their own history and physical examination, document their agreement.

• An attending physician can add additional history and physical findings as appropriate.

• An attending physician can document their own findings where they disagree with what was documented by the resident.

Rules for Teaching PhysiciansStudents

• Any contribution and participation of a student must be performed in the physical presence of a teaching physician or resident except for the review of systems, past medical history, family, and/or social history.

• The teaching physician may only refer to a student’s documentation of ROS and/or PFSH.

• The teaching physician may not refer to a student’s documentation of physical examination findings or medical decision making in his or her personal note.

• If a student documents other aspects of an E and M service, the teaching physician must – verify and redocument the history of present illness – perform and redocument the physical examination – Redocument the medical decision making activities of the service

Short Version

• What residents document counts.

• What students document doesn’t count (except for the Past Medical History, Social History, Family History, and Review of Systems)

Are there modifiers used

for E and M codes?

Commonly used modifiers applied to for E and M

codes by surgeons• 24 Modifier: Unrelated evaluation and

management service by the same physician during a postoperative period.

• 25 Modifier: Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other services

• 57 Modifier: Decision for Surgery

Summary• E and M coding is complex but can be

deciphered using simple, readily available tools.

• Document all of your findings, both positive and negative.

• Special rules apply to documentation performed by residents and students.

• There are modifiers that can be employed to clarify coding.

Why should you care about this?

• Surgeons deserve to be paid for the work they do, including the work that is not procedural.

• E and M codes can provide a significant source of revenue when you enter practice.

• As residents, the attendings are asked to evaluate you on your knowledge of billing and coding every time an evaluation is completed in e value.

Documents

Physician Coding II Evaluation and Management Codes