Evaluation & Management
Coding and Documentation101 – the basicsStephanie Ann Call, MD MSPHVCU Internal Medicine Training
ProgramThe Practice of Medicine Series -
2009
Learning Objectives
At the end of this session, residents will be able to describe what medical documentation
facilitates identify three key components in
selecting the levels of E/M services select the appropriate level of an E&M
service for a new and established patient in either the outpatient or inpatient setting
identify resources for compliance
Evaluation and Management (E&M)
Documentation One of most commonly billed procedures May be billed for new or established
patients Includes office, hospital, nursing home
visits, consultations, phone and overall management, ICU care, discharge planning
1995/1997 Medicare guidelines – can use both
Medicare Physician Guide: A Resource for Residents, Practicing Physicians, and Other Health Care Professionals –http://www.cms.hhs.gov/MLNProducts/downloads/physicianguide.pdf Chapter 5 – E&M Documentation Great references and resource lists
Why document?
Medical /legal issues To tell the story of the patient –
communicate to others To have the opportunity for
reimbursement for the service provided “E&M documentation is the pathway
that translates a physician’s patient care work into the claims and reimbursement mechanism”
Medicare … “if it is not documented, it wasn’t done.”
What does documentation facilitate?
The ability to evaluate and plan the patient’s treatment
The ability to monitor patients health over time
Communication and continuity of care among healthcare professionals
Appropriate utilization review and quality of care evaluations
Collection of data for research and evaluation
General Principles of Documenting
Legibility – all documents MUST be legible Defined as easily read by peers (other
clinicians) Required information:
Patient name, MR, date of service on each page
Date AND time (for inpatient) Reason for encounter, relevant history,
PE findings Review of lab, x-ray data, other
ancillary services Assessment, clinical impression or
diagnosis Plan of care (including d/c plan if
appropriate) Legible identity of observer
(authenticated)
General Principles of Documenting
If not documented, rationale for ordering diagnostics or ancillary services should be easily inferred
Past and present diagnoses should be accessible to physician – can be in chart
Appropriate health risk factors should be identified
Patient progress, response to and changes in treatment should be documented
General Principles of Documenting
Documentation should support the intensity of the evaluation or treatment, including thought processes and complexity of medical decision making
All entries should be dated and authenticated by physician signature
CPT and ICD-9-CM codes reported should reflect documentaton in the medical records
Components of an E&M service
Seven components use to define level of E&M service (exceptions to rule if predominantly counseling or coordination of care) Key components
History Examination Medical Decision Making
Contributory components Counseling Coordination of Care Nature of Presenting Problem Time
Components of an E&M service
Seven components use to define level of E&M service (exceptions to rule if predominantly counseling or coordination of care) Key components
History Examination Medical Decision Making
Contributory components Counseling Coordination of Care Nature of Presenting Problem Time
Used in selecting level of E/M service (some exceptions)
Determining Level of Service
Table to determine appropriate level of service based on documentation (as a reflection of complexity of care provided) in three key component areas
Each key component has graded levels Different criteria for new patient vs
established Different criteria for inpatient vs
outpatient Procedure codes identified by tables –
determine the level of service and amount of reimbursement (99201, 99202, 99203, etc)
Key Components
History Physical Examination Decision Making
History – elements (4)
Chief complaint (CC) Required for ALL levels of E/M coding Reason for encounter If follow up … “follow up for …” NOT “routine f/u” Must be documented by resident, NP, PA
or attending History of Present Illness (HPI) Review of Systems (ROS) Past, Family, Social History (PFSH)
History HPI elements
Location Quality Severity Duration Timing Context Modifying Factors Associated Signs and Symptoms
Level of History Brief – status of 1-2 chronic conditions or 1-3
above Extended – status of 3 chronic conditions or
4+ above
History Review of Systems (ROS)
Do not have to write a notation for all systems Document the positive and pertinent negatives
“all other systems negative” – include number checked
Should have “usual” template Level for ROS based on number of
systems Problem pertinent – related to problem only +/- Extended – positive and pertinent responses for 2-9
systems Complete ROS is 10+
ROS Constitutional, eyes, ears, nose, throat, cv,
respiratory, gi, gu, musculoskeletal, skin, neuro, psych, endo, heme, lymph, allergic, immunological
History
Past, Family and Social (PFSH) Past History – review of patient’s past
illnesses, injuries, treatments Includes major illness, injury, operations,
prior hospitalizations, current meds, allergies
Social History – age appropriate review of past and current activities
May include marital status, living situation, employment and occupational hx, use of drugs/alcohol/tobacco, ed
Family History – review of medical events in family
History
PFSH Pertinent – review of history area
directly related to problem identified in HPI – at least one item from any of P, F, S
Complete – review of 2-3 PFSH areas if f/u visit, 3/3 areas if new patient
History – E/M levels
Problem Focused CC, 1-3 HPI elements
Expanded Problem Focused CC, 1-3 HPI, problem pertinent system
review (>1) Detailed
CC, 4+ HPI, problem pertinent ROS + 2-9 additional ROS, pertinent PFSH (1 element)
Comprehensive CC, 4+ HPI, complete ROS (10+),
complete PFSH
History
Type of History
HPI ROS PFSH
Problem Focused
Brief 1-3
N/A N/A
Expanded Problem Focused
Brief 1-3
Problem Pertinent
>1
N/A
Detailed Extended 4+
Extended 2-9
Pertinent 1
Comprehensive
Extended 4+
Compete (10+)
Complete 2/3 or 3/3*
Exam
Organ systems For a general multi-system exam
Body areas
Exam – Organ Systems
Vital Signs, General Symptoms Eyes ENT CV Respiratory GI
GU Musculoskeletal Skin Neurological Psychiatric Heme/Lymph/Immuno
Exam – Body Areas
Head/face Neck Breast/Axillary Abdomen Genitalia Back/spine Extremity
Exam
Document specific abnormal and relevant negative findings of affected or symptomatic area
Document abnormal or unexpected findings of unaffected or asymptomatic areas
“abnormal” is insufficient Templates ok Reference cards, review sheets
Exam – levels (see p81 guide)
Problem focused Limited to affected body area or organ system
(1-6 elements) Expanded Problem Focused
Affected system plus other symptomatic or related (6)
Detailed Extended exam of affected area and other
symptomatic or related organ system Comprehensive
Multisystem exam (8-12) or complete single system
Medical Decision Making
Medical Decision Making - tips
TELL THE STORY The medical record must clearly
support all diagnoses reported on the claim
Document impressions, diagnoses, tests ordered and/or reviewed AND the plan of care
What is the complexity of care for this patient AT THIS TIME?
Is the patient improved, resolved, unresponding?
Medical Decision Making
Complexity of establishing a diagnosis
Four types/levels – guided by … The number of diagnoses or
management options The amount or complexity of data
ordered or reviewed The risk of complications and
morbidity/mortality
Medical Decision Making
4 levels Straightforward Low Complexity Moderate Complexity High Complexity
3 subcomponents Diagnoses and Management Options Amount and Complexity of Data Risk of Complications
Decision Making
To qualify for a specific level of Decision Making, 2 of the 3 elements listed for that specific category must be met or exceeded
Diagnosed problems less complex than undiagnosed
Consider How many diagnostic tests ordered Did you request a consult
Diagnoses and Management Options
For established diagnosis Improved, resolved, unresponding
If diagnosis not established Possible, probable, rule out
Document treatment plan Include medication changes
Therapies Patient instructions, nursing
instructions
Amount and complexity of data
Review and/or order of clinical lab and XR tests
Review and/or order of diagnostic tests XR, scans, nuclear med, cardiac cath,
echo, ekg, eeg, non-invasive vasc, PFTs Document review of old records Document information from family
or caretaker Summarize relevant findings, if any
If not, document fact that reviews done
Risk of complication
Minimal Low Moderate High
Documenting Risk
See tables on “risk” Make sure to document
Co-morbidities Underlying diseases Other factors increasing risk
Medical Decision Making
MDM - Level
Dx/Mgmt Data Risk
Straight-forward
Minimal < 2
elements
Minimal/none
< 1 element
Minimal
Low Limited 3-4
elements
Limited 2
elements
Low
Moderate Multiple 5-6
elements
Multiple 3
elements
Moderate
High Extensive > 7
elements
Extensive > 4
elements
High
What code do I choose?
Step 1: Is the patient New or Established, Inpatient or Outpatient? New = 3 key components Established = 2 of 3 key components
Step 2: What level of History and Exam was performed? Use reference card for definitions
Step 3: Review the 3 subcomponents for Medical Decision Making ‘meets or exceeds’ is issue
What code do I choose?
Step 4: Compare your assessments against the requirements for a given level of service May not match exactly ‘meets or exceeds’ is key phrase
New and Established Patients
3 of 3 Key Components New patient office Initial Inpatient Admission Initial Consultation
2 of 3 Key Components Established Office Subsequent Inpatient care
Time
Choose code based on face-to-face time with the patient when OVER 50% of the visit was spent in counseling Document the total time spent with the
patient Document the total time spent in
counseling Document the content of the
counseling, and Choose the level of E/M by the total
amount of time
Other E&M Issues
Consultations Incident to
NPs, PAs, midwives, Clinical Nurse Specialists
Shared visits Involves physician and non-physician
practitioner Prolonged services Critical Care Teaching Physicians (including GE
exemption codes)
Learning Objectives
At the end of this session, residents will Be able to describe what medical
documentation facilitates Be able to identify three key
components in selecting the levels of E/M services
Be able to select the appropriate level of an E&M service for a new and established patient in either the outpatient or inpatient setting
Be able to identify resources for compliance