Section 5 Evaluation & Management Codes (E/M) 129 Modified For 04-10-14 031214 10:15-11:15, Section 5 Carl R Bogardus, Jr MD

Section 5Section 5

Evaluation & Evaluation & Management Codes Management Codes

(E/M)(E/M)

129 Modified For 04-10-14

03121410:15-11:15, Section 5

Carl R Bogardus, Jr MD

This Guide is intended to be This Guide is intended to be a brief supplement rather a brief supplement rather than a replacement for the than a replacement for the

American Medical American Medical Association’s Physician’s Association’s Physician’s

Current Procedural Current Procedural Terminology (CPT).Terminology (CPT).

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The E/M Section is divided into:

office visits hospital visits consultations

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These codes are available for use by radiation oncologists while seeing new patients.

It is very important however, that the correct codes be designated for the proper location of service rendered.

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DOCUMENTATION DOCUMENTATION GUIDELINES FORGUIDELINES FOREVALUATION & EVALUATION & MANAGEMENT MANAGEMENT

SERVICESSERVICES

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1.1. Medical record Medical record documentation is required to documentation is required to record record all of theall of the facts, facts, findings, and observations findings, and observations about an individual's healthabout an individual's health history.history.

2.2. The medical record is the only The medical record is the only reliable source of information reliable source of information regarding a patient’s diagnosis, regarding a patient’s diagnosis, evaluation, treatment, clinical evaluation, treatment, clinical management, and final resultsmanagement, and final results

Why is Documentation Why is Documentation Important?Important?

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Quality Documentation

Quality documentation must include keeping carefully prepared comprehensive, accurate, legible and timely medical records.

This is a basic component of sound medical practice as well as a legal obligation externally imposed on all healthcare providers.

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Outside Documentation

A proper medical record may also include information from outside sources.

This information may be scanned into an electronic medical record and becomes part of your documentation.

Never maintain your own “personal patient information” outside of the office or hospital medical record.

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IMPROPER DOCUMENTATION

Claims may go out before the Claims may go out before the documentation is created.documentation is created.

The documentation may be The documentation may be incomplete, or even non existent.incomplete, or even non existent.

Generally the longer it takes to Generally the longer it takes to create a document, the less create a document, the less accurate it becomes.accurate it becomes.

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• Quality decreases with timeQuality decreases with time

• Eventually the document may Eventually the document may fail to satisfy the requirements fail to satisfy the requirements of the clinical service level of the clinical service level originally provided by the originally provided by the physician.physician.

• Any of these can place the Any of these can place the practice in danger of non practice in danger of non compliance and Medicare compliance and Medicare fraud.fraud.

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DOCUMENTATION DOCUMENTED AND MEDICALLY DOCUMENTED AND MEDICALLY

NECESSARY--- NECESSARY--- BILL FOR PROCEDUREBILL FOR PROCEDURE

NOT DOCUMENTED, BUT MEDICALLY NOT DOCUMENTED, BUT MEDICALLY NECESSARY--- NECESSARY--- DO NOT BILL FOR DO NOT BILL FOR PROCEDUREPROCEDURE

DOCUMENTED BUT NOT MEDICALLY DOCUMENTED BUT NOT MEDICALLY NECESSARY--- NECESSARY--- DO NOT BILL FOR DO NOT BILL FOR PROCEDUREPROCEDURE

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Reason for the encounter and Reason for the encounter and relevant historyrelevant history

Physical examination findings Physical examination findings Prior diagnostic test resultsPrior diagnostic test results Clinical impression by the physicianClinical impression by the physician Plan for carePlan for care Date and legible identity of the Date and legible identity of the

physicianphysician

GGeneraleneral PrinciplesPrinciples

The medical record should be The medical record should be complete and legiblecomplete and legible

The E/M documentation should The E/M documentation should includeinclude::

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IDEALLY, 3 DATES SHOULD IDEALLY, 3 DATES SHOULD MATCHMATCH When the procedure wasWhen the procedure was performed ( PC)performed ( PC)

When the physicianWhen the physician signssigns the document (PC)the document (PC)

TheThe date of occurrencedate of occurrence on the submitted on the submitted billingbilling

THIS RULE APPLIES TO ALL THIS RULE APPLIES TO ALL PROCEDURE BILLINGPROCEDURE BILLING

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When Dates When Dates ConflictConflict Either the date of physician Either the date of physician signaturesignature, or the , or the

printed date of performance must match the date printed date of performance must match the date of occurrence on the submitted professional bill.of occurrence on the submitted professional bill.

There is so much variability between carriers and There is so much variability between carriers and hospital practices, that we are non committal on hospital practices, that we are non committal on the issue of DOS for the TC of the procedure. the issue of DOS for the TC of the procedure. Dosimetry being the largest source of conflicting Dosimetry being the largest source of conflicting dates.dates.

Be consistent and always use one Be consistent and always use one system or the other for billingsystem or the other for billing

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•NEW PATIENTNEW PATIENT is one who has not received any is one who has not received any professional services from the physician or group professional services from the physician or group within the last three years.within the last three years.

•ESTABLISHED PATIENTESTABLISHED PATIENT is one who has is one who has received professional services from the physician received professional services from the physician or group within the last three years.or group within the last three years.

•CONSULTATIONCONSULTATION is an evaluation and is an evaluation and management service rendered by a physician management service rendered by a physician whose opinion or advice is requested by another whose opinion or advice is requested by another physician. physician. THIS CODE IS RAPIDLY THIS CODE IS RAPIDLY DISAPPEARING FROM ALL PAYERSDISAPPEARING FROM ALL PAYERS

The following definitions apply

to the 99,000 series E/M codes

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CMS ELIMINATED THE CMS ELIMINATED THE CONSULTATION CODES IN 2010CONSULTATION CODES IN 2010

Most private carriers have Most private carriers have followed Medicare’s lead on followed Medicare’s lead on consultations, and the consultations, and the consultation codes have consultation codes have essentially disappearedessentially disappeared..

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CCI Edits In 2010 CMS modified the CCI editsIn 2010 CMS modified the CCI edits to allow 99,000 codes to be billed same date of service with 77,000 codes

A modifier -25 was needed (separate and identifiable service).

Today carriers no longer recognize this edit correction.

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Bundling Edits

Starting in 2014, all carriers started bundling all procedures done on the day of an initial evaluation or follow-up examination into the value of the E/M procedure.

See, set, start, and treat is no longer possible without considerable loss of revenue.

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Best Possible solution On the day of the initial encounter

generate a “clinical care plan” document.

There is no requirement that the initial evaluation must be done on the first day you see the patient, remember this is an office visit.

A clinical care plan is not a billable event, therefore there will be no conflicts with doing 77,000 procedures on this date.

Many of the elements of the clinical care plan will transfer to the initial evaluation and other document to be done a few days later.

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Elements that may be part of a Clinical Care Plan Document

Diagnoses and staging. Histology of tumor. Brief history of case. Multidisciplinary clinic recommendations. Tumor board recommendation. Intent of therapy: curative, consolidative,

temporizing, or palliative. A plan for continued care.

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Elements that may be part of a Clinical Care Plan

Document Surgical treatment status, pre

operative, post operative. Use of chemotherapy. Proposed course of external beam

radiation. Proposed course of Brachytherapy. Diagnostic procedures reviewed. Diagnostic procedures needed.

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This is a segment of the clinical care plan tentatively establishing the intended course of radiation therapy. This is not a clinical treatment plan, or an initial evaluation, but only an intent of treatment.

Please note, the use of a clinical care plan document to bypass same date CCI edits has neither been approved or denied by Medicare.

This is our best solution to another complex government generated problem where the consequences of rulemaking interfere significantly with patient care.

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Rate of Reporting E/M Rate of Reporting E/M CodesCodes

The 99000 series of codes make up

about 10% of the total codes billed in Radiation Oncology

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An initial procedure that the physician will An initial procedure that the physician will carry out for every case is to evaluate the carry out for every case is to evaluate the patient to determine his/her suitability to patient to determine his/her suitability to receive radiation therapy.receive radiation therapy.

This can be a consultation, new case This can be a consultation, new case visit, or an established patient visit.visit, or an established patient visit.

If an E/M service is rendered by If an E/M service is rendered by the physician, then this is a the physician, then this is a billable procedure, even if the billable procedure, even if the case is not treated.case is not treated.

Evaluation & Management Codes

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NEW PATIENT EVALUATION AND THE NEW PATIENT EVALUATION AND THE OFFICE OF THE INSPECTOR GENERALOFFICE OF THE INSPECTOR GENERAL

The OIG recently reported that upcoding and The OIG recently reported that upcoding and documentation errors cost $1.1 billion in fines and documentation errors cost $1.1 billion in fines and paybackpayback

Physicians billed approximately 2 million services Physicians billed approximately 2 million services at a level 5, and only 5% of these were coded at a level 5, and only 5% of these were coded correctly.correctly.

The Initial Evaluation service, The Initial Evaluation service, regardless of the level of code regardless of the level of code used, is the most commonly used, is the most commonly audited procedure, and we audited procedure, and we

anticipate this will increase.anticipate this will increase.

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Simple or Minimal Cases, Level 1Problem focused (Medicare)

Expanded or Minor Cases, Level 2Expanded problem focused

(Medicare) Detailed or Low Severity, Level 3

Detailed (Medicare) Comprehensive or Moderate Severity,

Level 4 Comprehensive (Medicare) High Complexity or High Severity,

Level 5 Comprehensive high complexity (Medicare)

Five Levels of Complexity Five Levels of Complexity of E/Mof E/M

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Informal format for consultation acknowledgement to requesting physician.

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Chief complaint and present Chief complaint and present illnessillness

The patient's historyThe patient's history Physical examinationPhysical examination Medical decision makingMedical decision making Counseling of the patient and Counseling of the patient and

familyfamily Coordination of careCoordination of care Impression and Impression and

recommendations forrecommendations for treatmenttreatment

The CPT descriptors recognize

seven components of a new patient office visit; these

are:

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This document is the source of the basic information needed to prepare a proper Initial evaluation.

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CMS modifies CMS modifies these these documents documents yearly, follow yearly, follow the current the current guidelinesguidelines

The Initial Evaluation must always The Initial Evaluation must always start with a chief complaintstart with a chief complaint. .

This is a required element.This is a required element.

The chief complaint is a concise The chief complaint is a concise statement describing the statement describing the presenting symptomspresenting symptoms..

Chief Complaint14

The HPI is a chronological

description of the development of the patient's present

illness.

History of Present Illness14

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HPI Elements and Quantification of Severity

NIB

ONCOCHART

NEEDED FOR COMPLETE HPI (HISTORY OF PRESENT ILLNESS)

Location (of the problem)Location (of the problem)Quality (what is the problem)Quality (what is the problem)Severity (how bad is it)Severity (how bad is it)Duration (how long has the patient had it)Duration (how long has the patient had it)Timing (how often does it occur)Timing (how often does it occur)Context (how bad is it)Context (how bad is it)Modifying Factors (does anything help)Modifying Factors (does anything help)Associated Signs and Symptoms (what else)Associated Signs and Symptoms (what else) ( (

Each of these elements needs to Each of these elements needs to be covered related to the be covered related to the

patient’s illnesspatient’s illness

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Example of HPI for Bone Example of HPI for Bone MetastasisMetastasis

Narrative; This patient is experiencing extreme pain, which is almost continuous. The pain is intense, at a level 7. The pain has been present for many months. The pain is caused by the tumor, and is relieved only by prescription medication.

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HPI SCORING

The HPI is scored at two levels of intensity for Medicare

For most of what we treat we usually include much more than what is required.

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1)1)Extended; document 4 or Extended; document 4 or moremore elements of the HPIelements of the HPI

2)2)Brief; document 1-3 Brief; document 1-3 elements of HPIelements of HPI

CMS E/M guidelines 2013

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A review of all significant medical occurrences is covered under these five general categories:

Add pastAdd past radiation radiation exposure exposure historyhistoryAdd past or present use of Add past or present use of chemotherapychemotherapypastpast surgicalsurgical history historypast serious medical past serious medical illnessesillnessespast serious past serious injuriesinjuries

Past History 16

A review and summary of the pertinent facts relating to present and past family members.

A cancer history should be part of this statement.

Family History

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This covers many significant This covers many significant factors such as:factors such as:- Add tobacco use-Add alcohol use or abuse-Add hazardous occupational exposure- work history- education- exercise

Social History16

SMOKING CPT CODES 99406; Smoking cessation counseling,

smoking and smokeless tobacco, 3-10 min. Payment $12.13

99407; Smoking cessation counseling, smoking and smokeless tobacco, over 10 min.

Payment $23.12 Bill with a -25 modifier , must be reported

with another E/M code Payable up to 8 times per year. Most private insurance may not recognize

these codes, and usually no payment is expected

Not disease specific.

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This is an inventory of the This is an inventory of the general health status of the general health status of the body systemsbody systems.

14 items make up the review of systems.

Review Of Systems

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Constitutional SymptomsConstitutional Symptoms Integumentary Integumentary (skin & breasts)(skin & breasts) EyesEyes Musculoskeletal Musculoskeletal Ears, nose, mouth, and throatEars, nose, mouth, and throat Neurological Neurological CardiovascularCardiovascular Psychiatric Psychiatric RespiratoryRespiratory Endocrine Endocrine GastrointestinalGastrointestinal Hematologic/LymphaticHematologic/Lymphatic GenitourinaryGenitourinary Allergic/ImmunologicAllergic/Immunologic

The following 14 systems may be covered in some detail

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BMSi recommends separation BMSi recommends separation of breast and skin as two of breast and skin as two

topics.topics.

PainPain Quality of lifeQuality of life Nutritional Nutritional statusstatus

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BMSi also recommends adding BMSi also recommends adding the following ROS topics for the following ROS topics for radiation Oncology patientsradiation Oncology patients

The History Section of the E/M The History Section of the E/M Must Include Coverage of all Must Include Coverage of all componentscomponents

Chief Complaint History of Present Illness Past History Family History Social History Review Of Systems

NIB

97 Guide line requirements

Note the “Bullet” Note the “Bullet” requirementsrequirements, these are specific questions that must be answered under each organ system.At least 2 or At least 2 or more are more are required per required per organ system organ system for an extended for an extended general multi-general multi-system work system work up.up.

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12 organ systems are recognized. The level 12 organ systems are recognized. The level of the physical examination will be based of the physical examination will be based upon the number of these organ systems upon the number of these organ systems evaluated.evaluated.

1. Constitutional - vital signsConstitutional - vital signs 7. Genitourinary including pelvic & 7. Genitourinary including pelvic & rectal examsrectal exams

2. Eyes2. Eyes 8. Musculoskeletal 8. Musculoskeletal 3. Ears, nose, mouth, throat, neck3. Ears, nose, mouth, throat, neck 9. 9. Skin and BreastsSkin and Breasts4. Cardiovascular4. Cardiovascular 10. Neurologic 10. Neurologic5. Respiratory and Chest5. Respiratory and Chest 11. Psychiatric 11. Psychiatric6. Gastrointestinal and Abdomen6. Gastrointestinal and Abdomen 12. 12.

Hematologic/Lymphatic/ImmunologicHematologic/Lymphatic/Immunologic

18Physical examination

BMSi recommends separation of breast and BMSi recommends separation of breast and skin as two topics.skin as two topics.

The extent of the examination and documentation is dependent upon clinical judgment and the nature of the presenting problem.

The examination may range from a The examination may range from a limited examination of a single limited examination of a single body area to a general multi-body area to a general multi-system examination.system examination.

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Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by three specific categories:

This is the most difficult section to produce a high score in radiation oncology because of the nature of our specialty

Medical Decision MakingMedical Decision Making 20

Medical decision making format


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#1#1 The number of possible diagnoses and/or The number of possible diagnoses and/or management\management\

options to be consideredoptions to be considered. In radiation oncology there . In radiation oncology there is usuallyis usually

only one management option (radiation therapy only one management option (radiation therapy treatment) andtreatment) and

only one diagnosis (malignancy).only one diagnosis (malignancy).

#2#2 The risk of significant complications, morbidity, The risk of significant complications, morbidity, and/orand/or

mortality,.mortality,. In radiation oncology, the risk of In radiation oncology, the risk of complications iscomplications is

almost always high and morbidity and mortality almost always high and morbidity and mortality continuouslycontinuously

play a significant role in the management of these play a significant role in the management of these patients.patients.

#3#3 The amount and/or complexity of medical records, The amount and/or complexity of medical records, diagnostic tests, and other information that must be diagnostic tests, and other information that must be obtained, reviewed, andobtained, reviewed, and analyzed.

Medical Decision MakingMedical Decision Making 21

1) DIAGNOSIS OR MANAGEMENT DIAGNOSIS OR MANAGEMENT OPTIONSOPTIONS

Diagnosis listed as ICD-9 (ICD-10) with description of disease

Assessment or clinical impression of case

Recommendations of therapy (Management Options, not your clinical treatment plan)

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2) RISK OF COMPLICATIONS/ MORBIDITY/MORTALITYRisk of local areaRisk of local area complications resulting from complications resulting from

treatmenttreatmentRisk of Morbidity or severe complications from Risk of Morbidity or severe complications from treatmenttreatmentRisk of Mortality (Death) from treatmentRisk of Mortality (Death) from treatmentRisk of Mortality (Death) from the diseaseRisk of Mortality (Death) from the diseaseRisk of Mortality (Death) from other causesRisk of Mortality (Death) from other causes

1) Minimal1) Minimal 2) Low2) Low 3) Moderate3) Moderate 4) 4) HighHigh

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Medical Decision Making Narratives22

3) DATA TO REVIEW

Clinical laboratory tests to reviewClinical laboratory tests to review Radiology exams to reviewRadiology exams to review Pathology reports to reviewPathology reports to review Old medical records to reviewOld medical records to review History from family to reviewHistory from family to review New tests ordered to reviewNew tests ordered to review Discussion of any results with performing Discussion of any results with performing

personnelpersonnel

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DATA TO REVIEW22

•Scoring MDM requires Scoring MDM requires independently independently scoring scoring each of the three components each of the three components of MDM.of MDM. •The evaluation for The evaluation for two most complete two most complete of the three of the three components is then components is then incorporated into the final overall incorporated into the final overall MDM level score. MDM level score. High complexity High complexity requires all 3 to be covered.requires all 3 to be covered.

• This score is then integrated with This score is then integrated with the other key components of the the other key components of the evaluation to develop the final overall evaluation to develop the final overall CPT code for the E/M service. CPT code for the E/M service.

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Medical Decision Making – scoring

DiagnosisManagement

Data Risk

Straightforward

Minimal Minimal Minimal

Low Complexity

Limited Limited Low

Moderate Complexity

Multiple Moderate Moderate

High Complexity

Extensive Extensive High

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The element of counseling the patient and family is The element of counseling the patient and family is extremely important.extremely important.

The risks and benefits of the proposed course of The risks and benefits of the proposed course of treatment must be explained in great detail to the treatment must be explained in great detail to the patient and family.patient and family.

It is important to note that they understand and accept It is important to note that they understand and accept the course of treatment as outlined and accept the the course of treatment as outlined and accept the risks of treatment.risks of treatment.

The risk of complications and a complete explanation The risk of complications and a complete explanation of the risks and benefits of the course of treatment of the risks and benefits of the course of treatment must be indicated in your work-up.must be indicated in your work-up.

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Counseling & Coordination of Counseling & Coordination of CareCare

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Counseling Is ImportantCounseling Is Important

This does not take This does not take the place of a signed the place of a signed consent to treat consent to treat formform.

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PATIENT CONSENT FORMSPATIENT CONSENT FORMS It is generally accepted that the It is generally accepted that the

“standard” generic consent form is of “standard” generic consent form is of little value in a court of law, or in the eyes little value in a court of law, or in the eyes of CMS of CMS

Consent forms should be customized for Consent forms should be customized for the case being treated to cover a variety the case being treated to cover a variety of topics. of topics.

Few patients read, understand, or recall Few patients read, understand, or recall the form.the form.

Presenting and securing an informed Presenting and securing an informed consent is a skill.consent is a skill.

NIB

Radiation oncology physicians should familiarize themselves with

the time general guidelines as noted in CPT

The overall work is very similar, and the questions to be documented may be the same, only the time requirement is different.

Note the differences between the time recommendations for the four types of patient evaluations.

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Medicare and Time

Time is not a required element. In fact, it only comes into play for coding purposes when less than half of the visit is used for key component work, and over 50% is required for meaningful face to face physician counseling and coordination. Note, the time is physician time, not staff time.

All of this must be documented and the counseling/coordination must be of a nature that the physician’s skill was required. .

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Fill in the minutes of time spent:More than 50% face to face if time is the chief factor in scoring the work up. Less than 50% if the work up is scored on key component elements and Physician work

25

Face to face time often requires considerable physician time to fully answer all the questions that can be asked by concerned patients and their family members.Documentation of Documentation of this component of this component of the encounter is the encounter is part of informed part of informed consent.consent.

This can be very time intensiveThis can be very time intensive

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The final REQUIRED elements of a complete work-up are the concluding statements of:

A clinical impression of the problem to be treated and;

Recommendations by the physician for continuing care.

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Impression, Recommendation, TimeImpression, Recommendation, Time

ONCOCHART

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Code Time Problem

CC – HPI ROS

History PFSH

Exam Med. Dec. Making

99201 10 min

(Brief)

NA NA Problem Found

Straight Forward

99202 20 min

(Brief)

Problem Pertinent

Problem focused

Expanded Problem Found

Straight Forward

99203 30 min

(Brief)

Extended

Extended

Detailed

Low complexity

99204 45 min

(Extended)

Extended

Comprehensive

Comprehensive

Moderate complexity

99205 60

min

(Extended)

Complete

Comprehensive

Comprehensive

High Complexity

SUMMARY OF ALL ELEMENTS TO PRODUCE THE CORRECT INITIAL EVALUATION E/M CODES

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THESE ARE THE VARIABLE ELEMENTS FOR MEDICARETHESE ARE THE VARIABLE ELEMENTS FOR MEDICARE

This is for an initial office visit, the most common encounter for a new patient in radiation oncology

Code Time Problem

CC – HPI

ROS

History PFSH


99201 10 min

Brief

NA NA Problem Found

Straight Forward

99202 20 min

Brief

Problem Pertinent

Problem Focused


Straight Forward

99203 30 min

Brief

Extended

Extended

Detailed

Low complexity

99204 45 min

Extended Extended

Comprehensive

Comprehensive

Moderate complexity

99205 60

min Extended Complete

Comprehensive

Comprehensive

High Complexity

SUMMARY OF ALL ELEMENTS TO PRODUCE THE CORRECT INITIAL EVALUATION E/M CODESRelated to the summary chart on page 28

Problem focused workup, missing ROS, PFSH, Med Dec Making

Scoring of the work up is always driven by the lowest scoring elementScoring of the work up is always driven by the lowest scoring element


Code Time Problem

CC – HPI ROS

History PFSH


99201 10 min Brief

NA NA Problem Found

Straight Forward

99202 20 min Brief

Problem Pertinent

Problem focused


Straight Forward

99203 30 min Brief

Extended

Extended

Detailed

Low complexity

99204 45 min Extended Extended

Comprehensive

Comprehensive

Moderate complexity

99205 60 min Extended Complete

Comprehensive

Comprehensive

High Complexity

Remains Problem focused workup, missing Key elements

Related to the summary chart on page 28

Code Time Problem

CC – HPI ROS

History PFSH


99201 10 min Brief

NA NA Problem Found

Straight Forward

99202 20 min Brief

Problem Pertinent

Problem Focused


Straight Forward

99203 30 min Brief

Extended

Extended

Detailed

Low complexity


Comprehensive

Comprehensive

Moderate complexity


Comprehensive

Comprehensive

High Complexity



Detailed workup, missing key elements to advance to a higher level

Code Time Problem

CC – HPI ROS

History PFSH


99201 10 min Brief

NA NA Problem Found Straight Forward

99202 20 min Brief

Problem Pertinent

Problem Focused


Straight Forward

99203 30 min Brief

Extended

Extended

Detailed

Low complexity


Comprehensive

Comprehensive

Moderate complexity


Comprehensive

Comprehensive

High Complexity



Comprehensive or high complexity work up all elements complete

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ONCOCHART

Time is used as a scoring factor in this work up

Assignment of the level of complexity of the workup

THIS IS NOT TO BE UTILIZED THIS IS NOT TO BE UTILIZED TO ENHANCE THE VALUE OF TO ENHANCE THE VALUE OF YOUR WORK-UP, RATHER, IT YOUR WORK-UP, RATHER, IT IS A TOOL TO ASSIST AND IS A TOOL TO ASSIST AND GUIDE YOU TO THE GUIDE YOU TO THE APPROPRIATE LEVEL OF APPROPRIATE LEVEL OF EVALUATIONEVALUATION

The greatest use for this scoring tool is to prevent you accidentally leaving out a key portion of the workup

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Electronic Health Records

Much tighter scrutiny by Medicare of EHR.

Family practice, internal medicine, emergency room medicine are the chief targets at the moment.

17,000 physicians were paid over $100 million more in 2010, than in the previous year.

One mouse click could elevate you to the next level, but did you really do that procedure?

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•A macro can be executed by one A macro can be executed by one computer key stroke and can be computer key stroke and can be found just as easily by an found just as easily by an automated computer auditor.automated computer auditor.

•Electronic medical records are Electronic medical records are very powerful tools allowing the very powerful tools allowing the physician to easily enhance his physician to easily enhance his records with simple commands, records with simple commands,

•BUT THEY MUST CORRECT.BUT THEY MUST CORRECT.

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Medicare contractors have Medicare contractors have noted an noted an increasedincreased frequency frequency of medical records with of medical records with identical documentation across identical documentation across cases and even across cases and even across services.services. They (RAC) will review They (RAC) will review multiple E&M services for the multiple E&M services for the same providers and same providers and beneficiaries to identify beneficiaries to identify electronic health records (EHR) electronic health records (EHR) documentation practices documentation practices associated with associated with potentially potentially improper paymentsimproper payments..

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ELECTRONIC MEDICAL RECORDS ELECTRONIC MEDICAL RECORDS LEGALITY ISSUESLEGALITY ISSUES

Templates with only one choice of Templates with only one choice of narrative are very hazardous.narrative are very hazardous.

Multiple questions should be asked, Multiple questions should be asked, each with a variety of choices for each with a variety of choices for answers.answers.

Narrations should be specific to the Narrations should be specific to the questions asked, and the answers questions asked, and the answers given must make clinical sense.given must make clinical sense.

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Cloned Note TrapsCloned Note Traps If the template choice is not there, don’t

just get “close”, either don’t use the question or generate a correct answer.

Do not fill the report with “fluff” just because the question is available. Use only pertinent items that add to the workup.

Read every auto filled answer, some may no longer be correct.

Avoid documentation that is identical over multiple records, or from one patient to the next.

Dictate or type the HPI, and use the EHR to fill out only items that relate to the actual patient and the condition being treated.

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AVOID SLOPPY CUT AND PASTE Make every effort to avoid having

identical notes appearing on successive records.

These are easily found by pattern recognition programs.

When any section of a record cascades, it should always be reviewed by the physician for completeness, modified, or deleted.

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Pitfalls to avoid Be certain that all required elements are

present to reach the reported level of the code being billed.

Make certain that the record justifys medical necessity for this level.

Avoid the use of cloned statements that elevate the value of the procedure.

Watch for conflicting or contradictory statements.

NIB

Slow Down when using Slow Down when using EHREHR Moving too quickly can result in cut and pasting improper information.

Beware of cloned or template data sets unless they are very specific to the case at hand.

Always carefully read what you produced either through cloning, cascading, or voice-recognition software. Spelling corrections can end up with some strange words.

Beware of deferential diagnosis programs, they may not always be complete or correct.

Always review what you just wrote.

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Legal Risks of Legal Risks of EHREHR

Electronic health records save time and money, but they can create huge liability issues if improperly used.

Encryption of data is the number one priority.

Security of the data file is number two.

NIB

Correction of a previously saved document Never under any circumstances un

record and correct a document. This could result in 2 separate

documents related to the same procedure.

If a correction must be made always make it as an addendum to the original document.

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DOCUMENTATIONDOCUMENTATION

I often say “if it is not documented, it did

not happen”

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OFTEN, EVEN IF IT IS WELL DOCUMENTED,

IT STILL MAY NOT HAVE IT STILL MAY NOT HAVE HAPPENEDHAPPENED

Electronic medical records make Electronic medical records make documentation very easy, but accurate, documentation very easy, but accurate,

compliant documents are more difficult to compliant documents are more difficult to achieve.achieve.

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CPT Codes New Patient Office visit

99201 - Office Visit; 99202 - Office Visit; 99203 - Office Visit; 99204 - Office Visit; 99205 - Office Visit;

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OFFICE VISIT, NEW OFFICE VISIT, NEW PATIENTPATIENT

•These codes cover all new patient who These codes cover all new patient who comes to your office the first time. comes to your office the first time. (Consultations or new patients) including (Consultations or new patients) including those patients sent to you as a direct those patients sent to you as a direct referral for treatment.referral for treatment.

•99201-99205 are covered on pages 28-99201-99205 are covered on pages 28-2929

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Routine follow-up visits may be Routine follow-up visits may be carried out after a course of radiation carried out after a course of radiation therapy has been completed. therapy has been completed. The follow-up patient, who was The follow-up patient, who was treated previously, and returns with treated previously, and returns with a new problem, and requires a new a new problem, and requires a new evaluation by the radiation evaluation by the radiation oncologist, oncologist, continues to be billed continues to be billed under theunder the established patient codes established patient codes 99211-99215.99211-99215.

These codes are covered on pages These codes are covered on pages 34-3534-35

OUTPATIENT ESTABLISHED PATIENT (FOLLOW-UP) VISIT

34

Occurrence Rate of Follow up Occurrence Rate of Follow up only and established patient only and established patient (New problem) Evaluations (New problem) Evaluations

20132013

99211 .04 .01 99212 .26 .08 99213 .56 .18

99214 .13 .26 99215 .01 .47

NIB

FU EP

OCCURENCE OF USE 2013 NEW PATIENT ESTABLISHED 99201 .02 99211 .01 99202 .02 99212 .08 99203 .05 99213 .18 99204 .19 99214 .26 99205 .73 99215 .47

NIB

Shift in reporting

Billing is shifting from the lower 3 codes to the upper 2 higher codes.

Level 4 and 5 reporting increased 17%. Medicare believes that electronic health

records are driving this shift. A conscious move by the physician to

raise the value of the procedure? Cloning and cascading makes it easier?

NIB

Values for office visits Decreasing

Code $ 2013 $2014 % Difference

99203 $107.90 $102.75 -5%

99204 $164.74 $157.87 -4%

99205 $203.89 $196.65 -4%

99213 $72.50 $69.41 -4%

99214 $102.54 $102.41 00%

99215 $142.96 $137.11 -4%

NIB

None of these None of these codes can be codes can be billed during an billed during an active course of active course of treatment.treatment.

NIB

HOSPITAL INPATIENT HOSPITAL INPATIENT CONSULTATION NEW CONSULTATION NEW PATIENT, OR PATIENT, OR ESTABLISHED ESTABLISHED PATIENTPATIENT

NIB

The recommended codes for Initial evaluation for Medicare hospital inpatients are 99221, 99222, 99223 (Equivalent to 99201-99205), use for a new case consultation for an inpatient. For a follow up Medicare inpatient consultation, use 99231, 99232, 99233, (equivalent to 99211-99215). Use for follow up or new problem on an established case who is an inpatient.

38-40INITIAL EVALUATION

99221-99223 was, and still is, originally intended for hospital admission work up.99231-99233 was, and still is, intended for daily hospital care by the admitting physician.

These codes do not fit well for this new intended use, but Medicare did not think this through when they changed the rules and abolished 99251-99255.

38-40HOSPITAL ADMISSION AND CARE

The radiation oncologist may be required to admit a patient to the hospital for care.

If the patient is currently If the patient is currently receiving radiation therapy, receiving radiation therapy,

no additional hospital no additional hospital charges are allowed.charges are allowed.

44

ExclusionsExclusions

The radiation oncologist is The radiation oncologist is specifically excluded from specifically excluded from billing any of the 99000 series billing any of the 99000 series codes while services are being codes while services are being provided to the patient under provided to the patient under the treatment management the treatment management codes, 77427 through 77432.codes, 77427 through 77432.

44

Brachytherapy Brachytherapy AdmissionsAdmissions

The physician’s professional component for the brachytherapy procedure includes any necessary hospital admission and hospital care during the time that the patient is undergoing the brachytherapy procedure.

Admission, subsequent hospital care and discharge day summary is included in the global “fee for Brachytherapy procedure.”

Since most of the Brachytherapy procedures require Since most of the Brachytherapy procedures require the assistance of a surgeon, this physician should be the assistance of a surgeon, this physician should be encouraged to admit the patient.encouraged to admit the patient.

This fosters good will with the surgeon while keeping the radiation oncologist out of conflict with Medicare regulations.

44

WHO IS REALLY RESPONSIBLE?

This issue is still under serious review by many intermediaries and CMS.

““I have reviewed the CC, and HPI and I have reviewed the CC, and HPI and agree with above” is not acceptable.agree with above” is not acceptable.

The physician should make every effort to be directly involved either performing or reviewing all areas of the E/M

45

Non Physician Practitioners Non Physician Practitioners (NPP)(NPP)

Will be paid 85% of the physician fee schedule. No upper limit of complexity that can be billed,

Level 1 through Level 5. NP (Nurse Practitioner), CNS (Clinical Nurse

Specialist), PA (Physician Assistant) all have provider number that they can use for their private care cases.

In the same group only one E/M may be billed.

46

The E/M procedures may be billed according to the appropriate level of 99,000

series codes complexity by the physician, using the NPI, and does not require any modifiers or other explanatory remarks.

46

SP100/108

Responsibility For The History Data Of Responsibility For The History Data Of The E/MThe E/M

Many of the sections of the E/M covering the Many of the sections of the E/M covering the routine questions, answers and evaluations do routine questions, answers and evaluations do not require the specialized skill of the not require the specialized skill of the radiation oncologist.radiation oncologist.

The PA, NP, or RN can directly interrogate and The PA, NP, or RN can directly interrogate and examine the patient as a source of examine the patient as a source of information to generate a very credible information to generate a very credible history & physical, but understand the history & physical, but understand the Medicare rules of “Incident To”.Medicare rules of “Incident To”.

The physician is obligated to utilize and The physician is obligated to utilize and

validate validate all of the information all of the information contained in this work-up.contained in this work-up.

46

PHYSICIAN EXTENDERS PA, NP, RN

•Service must be medically necessary

•Typically performed in a physician’s office

•Within scope of physician’s practice

•Must be an employee of physician

•Physician must be present when service is performed

•Non physician provider paid at 85% of medicare rate

•“Incident to” pays at 100% of medicare rate when physician is present and involved in care of case.

ONCOCHART

NIB

DOCUMENTATION OF WORKDOCUMENTATION OF WORK

NEW HOSPITAL COMPLIANCE RULES MAY STATE THAT EVERY PERSON WHO MODIFIES A DOCUMENT, IN ANY FASHION, MUST HAVE THEIR SIGNATURE DATE AND TIME STAMPED AS HAVING MADE SOME CHANGE IN THE DOCUMENT

47

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47

SIGNATURE REQUIREMENTS

1.1. Legible original full signature Legible original full signature (readable first and last name)(readable first and last name)

2.2. Original illegible signature over Original illegible signature over a typed or printed first and last a typed or printed first and last name.name.

3.3. Original illegible signature on Original illegible signature on letterhead with multiple names, letterhead with multiple names, identity circledidentity circled

48


Electronic signatures are Electronic signatures are acceptable as long as secure acceptable as long as secure log in/out procedures are log in/out procedures are rigorously followed, and an rigorously followed, and an original signature is available original signature is available on file in a signature log or on file in a signature log or attestation statement.attestation statement.

48

This Physician Signature is a key This Physician Signature is a key investigative component of any investigative component of any

RAC auditRAC audit

Initials with each new entry on a running progress note , full name printed on document with E signature when securely logged in

NIB


WHAT NOT TO DOWHAT NOT TO DO Never use a signature stamp.Never use a signature stamp. Never use “signature on file”Never use “signature on file” Don’t forget to sign all typed notesDon’t forget to sign all typed notes Don’t use only initials without a Don’t use only initials without a

typed name.typed name. Never leave a “live” EMR terminal Never leave a “live” EMR terminal

unattended, maintain rigorous unattended, maintain rigorous security of your computer at all timessecurity of your computer at all times

48

E/M Visits (Global) Who should normally document/bill/captures these

codes?Physicians and Nurses

When are these codes normally billed?On the date of service indicated by the documentation as charted. Report Upfront

What Documentation is suggested for these codes? Use the Physician’s work up as documentation What is the most common documentation error

identified with these codes?Up coding or down coding due to lack of knowledge

about codes and what makes up the requirements for complexity

48-49

END

PRINCIPLES OF PRINCIPLES OF BILLING, CODING AND BILLING, CODING AND

COMPLIANCE IN COMPLIANCE IN RADIATION RADIATION ONCOLOGYONCOLOGYBMSi 2014

END EM

END SECTION 5

CPT Codes CPT Codes Established Patient Established Patient

Office visitsOffice visits 99211 - Office Visit: Simple99212 - Office Visit: Expanded99213 - Office Visit: Detailed99214 - Office Visit: Comprehensive99215 - Office Visit: High Complexity

31

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34

CPT Codes Hospital CPT Codes Hospital ConsultationConsultation

99251 - Inpatient Consultation; Simple99252 - Inpatient Consultation; Expanded99253 - Inpatient Consultation; Detailed99254 - Inpatient Consultation; Comprehensive99255 - Inpatient Consultation; High Complexity

38

THESE HOSPITAL CONSULTATION THESE HOSPITAL CONSULTATION CODES HAVE GENERALLY BEEN CODES HAVE GENERALLY BEEN

ELEMINATED.ELEMINATED.

90/108

Hospital E/M Visit Hospital E/M Visit CodeCode

New code for 2014 representing any clinic visit under OPPS.

HCPCS G code, G0463. Value $92.53. Covered under APC 0634

37

These are some comical example of errors that Dragon or any speech recognition program can make, be aware of what you sign into the record.

The patient’s skin exam shows evidence of long term Sonics hosiery but no significant lesions.

The patient’s skin exam shows evidence of long term sun exposure but no significant lesions.

NIB

In truck have a Terry Brachytherapy, should read Intracavitary Brachytherapy.

Voice Recognition software makes dictation and transcription a single function, faster and more efficient, allowing custom answers at any point in your workup

NIB

28

NOTICE! when the workup is for an established patient, one who we have seen in the last 3 years, the requirements are far less stringent, yet we are often answering the same level of questions, making the scoring much easier to achieve a high level work up

34

End Section 5

End Section 5

Section 5Section 5

Evaluation & Management Evaluation & Management Codes (E/M)Codes (E/M)

Covered by pages 1-44

108 Modified For 09-13-12

090412

1:30-3:00, Section 5

PRINCIPLES OF PRINCIPLES OF BILLING, CODING AND BILLING, CODING AND

COMPLIANCE IN COMPLIANCE IN RADIATION RADIATION ONCOLOGYONCOLOGYBMSi 2013

END EM

Coffee Break, Next Session #9 at Coffee Break, Next Session #9 at 3:15 PM3:15 PM

There will be 3 There will be 3 afternoon afternoon sessions sessions covering covering

sections sections 6, 6, 55, , andand 99

Dr BogardusDr Bogardus

Dr BogardusDr BogardusScott SimmonsScott Simmons

Susan VannoniSusan Vannoni

THIS SCHEDULE MAY BE MODIFIED THIS SCHEDULE MAY BE MODIFIED DEPENDING UPON SPEAKER DEPENDING UPON SPEAKER

AVAILABILITYAVAILABILITY

There will be 4 morning sessions

covering sections 1,2, 3, 4, and 5

Dr Bogardus

Dr Bogardus

Susan Vannoni

Dr Bogardus/ Susan Vannoni

Scott Simmons

THIS SCHEDULE

MAY BE MODIFIED

There will be 4 morning sessions

covering sections 1,2, 3, 4, and 5

Dr Bogardus

Dr Bogardus

Susan Vannoni

Dr Bogardus/ Susan Vannoni

Scott Simmons

THIS SCHEDULE

MAY BE MODIFIED

Time is not used as a scoring factor in this work up, but it still remains a level 4, based on MDM

27

Assignment of the level of complexity of the workup

RESPONSIBILITY FOR THE EVALUATION REQUEST

A proper record must be maintained that A proper record must be maintained that tracks the initial request to see the tracks the initial request to see the patient.patient.

We recommend using a Radiation Oncology We recommend using a Radiation Oncology request form from all clinics originating request form from all clinics originating patients for Radiation Therapy . This form patients for Radiation Therapy . This form may originate in the requesting physicians may originate in the requesting physicians office or may be a part of your intake office or may be a part of your intake documentation of the request to see the documentation of the request to see the patient. patient.

11

Required Components of the History/Decision making format

14

RADIATION ONCOLOGY REQUEST FORM FOR INITIAL EVALUATION OF PATIENT

COPY OR ADAPT FORYOUR PRACTICE

12

Telephone, Internet Telephone, Internet ConsultationConsultation

Telephone evaluation, 5-10 min, code 99441



Internet evaluation, code 99444

40

Telephone evaluation of this patient’s medical Telephone evaluation of this patient’s medical condition and recommendations of care was condition and recommendations of care was provided to the patient and/or the local provided to the patient and/or the local caregivers. Orders for care and any appropriate caregivers. Orders for care and any appropriate prescriptions were generated as needed. prescriptions were generated as needed. I have I have not seen this case within 7 days, nor will I see not seen this case within 7 days, nor will I see this patient within the next 24 hours.this patient within the next 24 hours.

Evaluation of this patient’s medical condition Evaluation of this patient’s medical condition was provided by Electronic internet was provided by Electronic internet communication, and recommendations of care communication, and recommendations of care were provided to the patient and/or the local were provided to the patient and/or the local caregivers. Adequate time was utilized to caregivers. Adequate time was utilized to develop recommendations and orders for care develop recommendations and orders for care and appropriate prescriptions were generated as and appropriate prescriptions were generated as needed. needed. I have not provided an identifiable E/M I have not provided an identifiable E/M service for this case within 7 days.service for this case within 7 days.

40

DON’T TOTALLY GIVE UP ON THE CONSULTATION

A few Commercial carriers may still A few Commercial carriers may still recognize the old consultation codes in recognize the old consultation codes in 2012,2012, check each carriercheck each carrier..

Non government insurance or under Non government insurance or under age 65 and not on Medicare may still age 65 and not on Medicare may still recognize the consultation. recognize the consultation.

The selection of the proper code to use The selection of the proper code to use can be based on age or Insurance data can be based on age or Insurance data

This can be automated or done This can be automated or done manuallymanually

5

The 3 Year Rule

The The 3 year rule3 year rule now comes into play now comes into play Same group, same physician, same specialtySame group, same physician, same specialty In the past we could code a consultation on an In the past we could code a consultation on an

established patient if the diagnosis changed established patient if the diagnosis changed and a consultation was requested (primary lung and a consultation was requested (primary lung 162.4 develops brain metastasis, 198.3.162.4 develops brain metastasis, 198.3.

Now this is considered an established patient Now this is considered an established patient and a new patient encounter cannot be billedand a new patient encounter cannot be billed

The case must be coded as a follow up 99211-The case must be coded as a follow up 99211-215215

5

WRITTEN DOCUMENTATION OF REFERRALS

This is an old CMS enforcement regulation, (RAC, 2010)

The rule has been on the books for years You must have a written (EMR is OK) of the request

for referral, and your response, on file and available for audit.

Failure to produce the documentation could Failure to produce the documentation could result in a one year suspension from Medicare.result in a one year suspension from Medicare.

If you don’t have this information you are at risk from the RAC

The physicians must sign all orders and The physicians must sign all orders and requests with full documentation of referrals requests with full documentation of referrals from the original request to the final report.from the original request to the final report.

11

THIS STATEMENT IS STILL THIS STATEMENT IS STILL RECOMMENDED ON ALL NEW RECOMMENDED ON ALL NEW

PATIENT VISITSPATIENT VISITS

This evaluation has been personally requested by Doctor “_____” to determine the possible use of radiation therapy to treat “PATIENT NAME”. A copy of this medical record has been made available to the requesting physician to aid in the decision making process for the care of this patient.

10

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OCCURENCE OF USE OF ALL CONSULTATION CODES

992X1 .10------------------------.065 992X2 .12------------------------.115992X3 .19------------------------.22992X4 .27------------------------.38 992X5 .32-------------------------.22

NIB

2010 2010 2008 2008

The 3 Month Rule The The 3 month rule3 month rule is also a problem. is also a problem. 99211-99215 cannot be reported until 99211-99215 cannot be reported until

90 days have elapsed following a course 90 days have elapsed following a course of radiation therapy.of radiation therapy.

This is a problem for cases returning This is a problem for cases returning with recurring bone or other metastatic with recurring bone or other metastatic disease.disease.

We have been told that -24 may We have been told that -24 may circumvent this problem.circumvent this problem.

Under questioning with CMS at this Under questioning with CMS at this time.time.

5

Medicare contractors have Medicare contractors have noted an noted an increasedincreased frequency frequency of medical records with of medical records with identical documentation across identical documentation across services.services. They (RAC) will review They (RAC) will review multiple E&M services for the multiple E&M services for the same providers and same providers and beneficiaries to identify beneficiaries to identify electronic health records (EHR) electronic health records (EHR) documentation practices documentation practices associated with associated with potentially potentially improper paymentsimproper payments..

5 sec 3

MAC Examination Requirement

CIGNA, a Mac contractor is now requiring an examination on all E/M services

CMS has a track record of allowing the Mac to do what they want to do

All denials should be appealed at this time. This rule does not exist in either Medicare or CPT.

NIB

Transmittal 1823 (Dated October 2, 2009

CMS’ transmittal 1823 had the goal of trying to provide guidance on the date of service

Interpretations and procedures are often performed on dates that are different from when the technical component of the exam or procedure is delivered. For many reasons, interpretations and final reporting often appropriately occur on dates different from the exam or procedure itself .

NIB

•When determining the level of ANY examination, When determining the level of ANY examination, consider the clinical circumstances of the encounter. consider the clinical circumstances of the encounter.

•Do not select the level of examination based on Do not select the level of examination based on excessive and unnecessary information recorded excessive and unnecessary information recorded solely to meet the requirements of a higher-level solely to meet the requirements of a higher-level service.service.

•The physician is ultimately responsible The physician is ultimately responsible for Validating the level of complexity for for Validating the level of complexity for coding all E&M procedures.coding all E&M procedures.

Previously covered in Section 3, page 5, but worth repeatingPreviously covered in Section 3, page 5, but worth repeating

27

This proposal would have required reporting in medical record systems of both the dates of the TC and the PC in order to demonstrate compliance.Some carriers are still enforcing the

requirement of splitting the dates of TC and PC if the report was on a different date from the procedure. If a ‘global’ exam is performed – and the technical portion and professional portion is performed on two different dates– they are to split the charge and report the two different DOS. This proposal was rescinded to define the DOS of the professional component (DOS-PC) as the date the technical component of the exam was performed

NIB

Transmittal 1823 (Dated October 2, 2009

CMS’ transmittal 1823 had the goal of trying to provide guidance on the date of service

Interpretations and procedures are often performed on dates that are different from when the technical component of the exam or procedure is delivered. For many reasons, interpretations and final reporting often appropriately occur on dates different from the exam or procedure itself .

NIB

This proposal would have required reporting in medical record systems of both the dates of the TC and the PC in order to demonstrate compliance.Some carriers are still enforcing the

requirement of splitting the dates of TC and PC if the report was on a different date from the procedure. If a ‘global’ exam is performed – and the technical portion and professional portion is performed on two different dates– they are to split the charge and report the two different DOS. This proposal was rescinded to define the DOS of the professional component (DOS-PC) as the date the technical component of the exam was performed

NIB

VALUE COMPARISON 99201-VALUE COMPARISON 99201-0505

99241 $48.6999241 $48.69 99201 $44.9899201 $44.98 -$3.71-$3.71 99242 $90.8999242 $90.89 99202 $77.0699202 $77.06 -$13.83-$13.83 99243 $124.7999243 $124.79 99203 $112.0999203 $112.09 -$12.70-$12.70 99244 $184.3099244 $184.30 99204 $172.2099204 $172.20 -$12.10-$12.10 99245 $226.5099245 $226.50 99205 $214.2399205 $214.23 -$12.27-$12.27

2009 2011*** DIFFERENCEDIFFERENCE

7

This is a minor loss, which may not have a great impact on your practice*** These values may not be totally correct for you

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VALUE COMPARISON 99211-VALUE COMPARISON 99211-1515

99241 $48.6999241 $48.69 99211 $21.3999211 $21.39 --$27.30$27.30

99242 $90.8999242 $90.89 99212 $44.9899212 $44.98 --$45.91$45.91

99243 $124.7999243 $124.79 99213 $74.8599213 $74.85 -$49.94-$49.94 99244 $184.3099244 $184.30 99214 $111.3699214 $111.36 -$72.94-$72.94 99245 $226.5099245 $226.50 99215 $149.7099215 $149.70 -$76.80-$76.80

2009 2011*** DIFFERENCEDIFFERENCE

7

THESE REDUCTIONS ARE THESE REDUCTIONS ARE NOW MORE SIGNIFICANTNOW MORE SIGNIFICANT

*** These values may not be totally correct

Without a correspondingly

complex MDM there may be no

justification for payment of a high-level E/M service.

20

•This is true of each component This is true of each component of the medical record for an E/M of the medical record for an E/M service, not just the MDM. service, not just the MDM. •Overlooking the documentation Overlooking the documentation of your thoughts can sabotage an of your thoughts can sabotage an otherwise good clinical record,otherwise good clinical record, Because the physician failed to Because the physician failed to adequately address the issues of adequately address the issues of the MDM process.the MDM process.

20

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Time RequiredTime Required

The inclusion of time as an explicit factor started in CPT ‘92 and was done to assist physicians in selecting the most appropriate level of E/M services.

Times are averages and therefore represent Times are averages and therefore represent a range of times centered on a specific time a range of times centered on a specific time value, and should be documented in your value, and should be documented in your workup. workup.

24

Time is no longer considered a scoring element in your usual

workup. Time is scored only for those workups

using time only.

.Coordination of care is an essential Coordination of care is an essential element of medical decision making, element of medical decision making, and requires complete and requires complete documentationdocumentation..

•Discussion of contradictory or Discussion of contradictory or unexpected test results with the unexpected test results with the physician who performed or physician who performed or interpreted the test, and the interpreted the test, and the requesting physician is important.requesting physician is important.

•Your consultation report must be Your consultation report must be available to all physicians involved available to all physicians involved on the primary care of the patient, on the primary care of the patient, indicated by “copy to”indicated by “copy to”

22

A basic pocket guide demonstrating the various elements that make up a proper E/M service, and the codes to be used to report these services

13

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This is a CMS guide available through your local carrier

Physical examination decision making format

17

Medical decision making format

19


Physical examination decision making formatNIB

New vs. Established New vs. Established casecase

If the case is a new patient, 99201-99205, and both the physician and a non-physician provider are involved, only the NPP may bill the procedure, because no clinical care plan has been established.

If the case is an established patient, 99211-99215, with a clinical care plan in the record, the NPP or the physician may bill the entire procedure as a shared services. In this case either provider may bill for the services.

Page 5, also covered on page 42

Documents

Section 5 Evaluation & Management Codes (E/M) 129 Modified For 04-10-14 031214 10:15-11:15, Section 5 Carl R Bogardus, Jr MD