Provider Evaluation & Management Training

Christi Wesson, Assistant Director Misty Skelton, Assistant DirectorVMG Coding and Charge Entry

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NP Billing

There are separate rules for billing Nurse Practitioner’s and nonbilling Nurse Practitioners. Non Billing Nurse Practitioners can not bill for any

services. The attending can only reference their ROS, Past, Family and Social history in order to bill.

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Non Billing Acknowledgement

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NP BILLINGNP billing for the admission service (this includes

admission H&P’s) According to the Vanderbilt Bylaws NP’s can not bill

without the attending provider seeing the patient(except for CNM). Prior to billing the attending will need to document his own

note or countersign stating that he saw the patient and agrees with the NP’s note.

The preceptor will also need to review 20% of NP charts.

See next slides for appropriate Countersignature.

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NP Countersignature

• For Reviewing 20% of the NP’s notes.

• For billing a shared visit and then documenting Key findings.

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NP Billing cont.Nurse Practitioners can bill and see patients for

consults and consulting subsequent visits. The attending does not have to attest or document a note

prior to billing for these services. These services are not shared visits.

If the attending and NP both document a note these can not be combined in order to bill.

Billing Nurse Practitioners can bill for procedures if it is within their scope of practice.

Critical Care cannot be a shared service.

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Evaluation & Management Coding 3 Key Components in an E&M service

History Exam Medical Decision Making

The level of service selected is based on the extent of the history &/or exam, and the complexity of the medical decision making required and documented by the provider.

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Elements of HistoryChief Complaint (CC) History of present illness (HPI) Review of systems (ROS) Past medical, family, social history (PFSH)

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History of Present Illness Location – Where is the pain/problem? Quality – What type of pain? (throbbing, constant, improving, worsening, acute,

chronic) Severity – How bad is the pain? (scale of 1-10, functional status, compared to

other types of pain) Timing – When did you first experience the problem? Specific time of day?

Nocturnal? Duration – How long do the symptoms last? (Onset 3 days ago, since last Monday,

yesterday) Context – What are you doing when the problems occurs? Associated with meals,

exercise, or stress? Modifying factors – What have you tried to alleviate the problem?

Medications? What changes/alters the complaint? Associated signs and symptoms – What else is bothering you when this

occurs? (Fever w/ chills, headache w/ blurry visions, diaphoresis w/ chest pain)

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History of Present Illness cont.

Tip – 4 HPI needed for admits & consults levels 3-5

Tip – If any part of the history is unobtainable, you can document history unobtainable due to ______ (state the reason) Ex: pt intubated & sedated

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Review of Systems (ROS)An inventory of body systems obtained through questions seeking to identify signs and/or symptoms which the patient has or has had.

Constitutional symptoms (e.g. fever, weight loss)

Eyes

Ears, Nose, Mouth, Throat

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Musculoskeletal

Integumentary (including breasts)

Neurological

Psychiatric

Endocrine

Hematologic/Lymphatic

Allergic/Immunologic

May be recorded by ancillary staff or on a form completed by the patient

Provider must document that he/she reviewed and confirmed information recorded by others.

If unable to obtain, document why

Pertinent positives and negatives must be referred to in the notes

Review of Systems (ROS)

Unacceptable (ROS) statements

Review of system: negative Review of system: None Review of system Non-contributory Review of system: unremarkable Review of system: Full ROS was notable only for the findings

listed in the HPI 10 point review of systems was completed and is negative

unless otherwise stated Review of systems per HPI otherwise negative

Acceptable (ROS) statements Review of systems are obtained based on medical

necessity. Systems with pertinent positive or negative responses must be individually documented.

Example: Review of (# of systems reviewed) system is negative except

for: MSK: chronic back pain that is flaring, no HSM Review of (# of systems reviewed) system is negative except

as discussed per HPI Document all pertinent positive and negative findings

and document “All other systems reviewed and negative”

Past, Family & Social History

Past (past illness, injuries, operations, treatments, current medications, allergies)

Family (medical events of patient’s family, hereditary disease)

Social (living arrangements, level of education)

Tip: DON’T use “noncontributory”Can use negative, but must document negative for

what

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Physical Exam FindingsBody Areas (7)

Head including face

Neck

Chest, including breast

Abdomen

Genitalia, groin

Back including spine

Each extremity

Organ Systems (12)

Constitutional

Eyes

ENMT

Cardiovascular

Respiratory

GI

GU

Musculoskeletal

Skin

Neuro

Psych

Hem/Lymph/Immo

Examples of Organ system exam:

Constitutional: Vital signs and general appearance

Eyes: Pupils: size, shape, equality, reaction to light & accommodation

ENMT: Sinus tenderness, pharynx, tonsils

Cardiovascular: Thrill, Rhythm, Sounds, Murmur, Edema

Respiratory: Breath Sounds, Wheeze, Spoken or Whispered voice. GI: Hepatomegaly, Splenomegaly, Bowel sounds, bruits, rubs GU: Examination of Bladder, Palpation of kidney -enlargement,

CVAtenderness

Physical Exam Findings

Physical Exam Findings

Examples of Organ system exam:

Musculoskeletal: ROM (range of motion), Strength, Stability, Gait Skin: Color, texture, lesions, moles, birthmarks, rashes, dermatitis,

dermatoses, hyperhidrosis, actinic damage, ulcers Neuro: Sensory examination, Reflex Examination Psych: hallucinations, delusions, obsessions, compulsions, Time, place,

person Hem/Lymph/Immo: Palpable cervical, axillary, inguinal nodes

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Medical Decision Making

2 of the 3 elements must be met or exceeded Number of Diagnoses/Treatment Options Amount & Complexity of Data Level of Risk

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Number of Diagnoses/Treatment Options

Each encounter should have an assessment/plan and diagnosis that is documented Self limited/minor = 1Est problem: stable/improved = 1Est problem: worsening = 2New problem: no work-up = 3New problem: add work-up = 4

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Amount & Complexity of Data If a diagnostic service is ordered, planned, reviewed, or performed at the

time of the E/M encounter, the type of service should be documented Lab Test (80000 series) = 1 X-Ray (70000 series) = 1 Medical Test (90000 series) = 1 Discuss test with performing physician = 1 Independent review of images, testing or specimen = 2 Decision to obtain old records and/or hx from someone other than patient =1 Review/summarize old records and/or obtain hx from someone other

than patient = 2

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Table of RiskHighest level of risk in any category

determines the level of risk Presenting Problem Diagnostic Procedure Management Options

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Score Sheet – Table of Risk

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Score Sheet – Type of Decision Making

To qualify for a given type of decision making, 2 ofthe 3 elements in the table must be either met or exceeded.

Type of Decision Making

Str. Forward Low Moderate High

# of Dx or Mgmt Options

0 or 1 2 3 4+

Amount & Complexity of

Data

0 or 1 2 3 4+

Overall Risk Minimal Low Moderate High

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Evaluation & Management Services

Inpatient Consultation (3 out of 3)Level HX PE MDM Time

99251 Problem Focused Problem Focused Straightforward 2099252 Expanded PF Expanded PF Straightforward 4099253 Detailed Detailed Low 5599254 Comprehensive Comprehensive Moderate 8099255 Comprehensive Comprehensive High 110

Initial Hospital Care (3 out of 3)99221 Detailed/

ComprehensiveDetailed/ Comprehensive

Straightforward/ Low

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99222 Comprehensive Comprehensive Moderate 5099223 Comprehensive Comprehensive High 70

Subsequent Hospital Care (2 out of 3)99231 Problem Focused Problem Focused Straightforward/

Low15

99232 Expanded PF Expanded PF Moderate 2599233 Detailed Detailed High 35

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Questions

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