2014 E&M Oncology Documentation & Coding Basics Working Smarter, Not Harder!
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1 2014 E&M Oncology Documentation & Coding Basics Working Smarter, Not Harder! West Virginia Oncology Society October 2, 2014
2 This presentation is offered as an educational tool. E&M Consulting Inc. does not bear any responsibility or liability for the results or consequences of using the tools found in this presentation. This presentation was current as of the date presented; nevertheless, we encourage readers to review the specific laws, regulations and rulings for up-to-date detailed information. Providers are responsible for the correct submission of claims and response to any remittance advice in accordance with current laws, regulations and standards.
3 Off-Label Use Disclosure(s) I do not intend to discuss an off-label use of a product during this activity
4 Financial Disclosure(s) I have not had any relevant financial relations during the past 12 months to disclose
5 2012 Medicare National Oncology E&M Benchmarks New Patient Codes 99201: 0.26% 99202: 1.12% 99203: 7.91% 99204: 31.61% 99205: 59.10% Initial Hospital Visit 99221: 8.09% 99222: 29.99% 99223: 61.91% Return Visits 99211: 2.92% 99212: 3.52% 99213: 31.60% 99214: 49.48% 99215: 12.47% Subsequent Care Visits 99231: 16.29% 99232: 51.41% 99233: 32.30%
6 Topics The E&M Philosophy History HPI ROS PMFSH Physical Exam: 95 vs. 97 Medical Decision Making Documentation Time Same Day Visit/Chemo
7 History Physical Exam Med Decision Making HPI DIAGNOSES Consult/New Patient: Count all 3 COLUMNS Return Visit: 2 out of 3 COLUMNS ROS 95 or 97 Physical Examination DATA Subsequent Care Visit: 2 out of 3 COLUMNS History Level: 3 out of 3 BOXES PFSH RISK Medical Decision Making: 2 out of 3 BOXES
8 The E&M Philosophy HISTORY HPI ROS PFSH P.E Multi- System MDM Number of Problems/ Diagnosis Data Risk
9 The E&M Philosophy MDM Number of Problems/ Diagnosis Data Medical Necessity Risk
10 E & M Key Components History Physical Medical Decision Making
11 History (Hx) Chief Complaint (CC) History of Present Illness (HPI) Review of Systems (ROS) Past Medical, Family and/or Social History (PFSH)
12 Chief Complaint Must Be In Documentation or Service Code Does Not Exist (cannot bill) Diagnosis IS NOT a chief complaint Follow-Up for or E&M of
13 History of Present Illness Cover Each: Location Quality Severity Duration Timing Context Modifying Factors Associated Signs & Symptoms Level 5 = 4 (Consults/New Patients/Return Visits)
14 Review of Systems Systems Constitutional Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Allergic/Immunologic Genitourinary Musculoskeletal Integumentary Neurological Psychiatric Endocrine Hematological/ Lymphatic Level 5 = 10 (Consults/New Patients/Return Visits)
15 Review of Systems For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented.
16 PFSH Family History Patient Medical &/Or Surgical History Social History Level 5 = 3 (Consults) 2 (Return Visit)
17 Family History Non-contributory Negative
18 History Capturing Information Collect From Any Source Patient information form Update Old History (ROS/PFSH only) Review history Note date, location Note any changes
19 E & M Key Components History Physical Medical Decision Making
20 Physical Single System Exam General Multi-System 1995 Exam 1997 Exam
21 1995 or 1997 Guidelines CMS has made clear that we cannot replace content found in the 1995 Documentation Guidelines for Evaluation and Management Services and the 1997 Documentation Guidelines for Evaluation and Management Services. During the review process, WPS Medicare will continue to apply whichever guideline is most advantageous to providers.
22 Physical 1995 General Multi-System Exam* Comprehensive (Level 5/3 Admit): 8 systems Detailed (Level 3): 5-7 systems Expanded Problem Focused (Level 2): 2-4 systems Problem Focused (Level 1): 1 system *Return Visit: Only what is medically necessary
23 Documentation of Physical Exam the use of examination templates/checklists is acceptable documentation. A notation of "abnormal" without elaboration is insufficient. A brief statement or notation indicating "negative" or "normal" is sufficient.
24 History Physical Exam Med Decision Making HPI 4 DIAGNOSES Consult/New Patient: Count all 3 COLUMNS Return Visit: 2 out of 3 COLUMNS ROS 10 PFSH 3/2 95 or 97 Physical Examination 8 DATA RISK Subsequent Care Visit: 2 out of 3 COLUMNS History Level: 3 out of 3 BOXES Medical Decision Making: 2 out of 3 BOXES
25 E & M Key Components History Physical Medical Decision Making
26 Medical Decision Making Diagnosis Data 2 out of 3 Risk
27 A Medical Decision Making: Diagnosis B Diagnosis Number Point Value Result Self-limiting or minor problem (2 max) 1 Established problem, stable or improving 1 Established problem, worsening 2 New problem, no additional workup (1 max) 3 New problem, with additional workup 4 TOTAL POINTS (B X C) = X C = D Hospital Level Office Level Total Points Minimum Limited Multiple Extensive 3 5 4
28 Medical Decision Making: Data A B C Categories # Points Review (max 1)/Order clinical lab tests (per puncture) Bloodwork 1 Review (max 1)/Order radiology tests [X-ray, imaging (except echocardiography & 1 cardiac cath)] Reports Review(max 1)/Order medical tests (EEG, echocardiography, cardiac cath., non-invasive 1 vascular studies, psychological tests, endoscopy) Reports Independent visualization of image, tracing, or specimen interpreted by another 2 physician X Discussion of test results with performing physician 1 Decision to obtain old records and/or history from someone other than patient. 1 Review & summarize old records 2 Obtain history from someone other than patient. 2 = D Extensive discussion with another physician or outside provider 2 Personal involvement of physician in testing (i.e. Bone Marrow Biopsy) 2 TOTAL POINTS (B X C) Hospital Level Office Level Total Points Minimum Limited Multiple Extensive 3 5 4
29 Key Medical Decision Making Documentation Required NUMBER OF PROBLEMS/DIAGNOSIS Document all primary AND secondary problems being addressed by you and status of each. DATA All Tests Reviewed All Tests Ordered All Discussions w/ Other Physicians All Tests Requiring Physician Personal Involvement (Bone Marrow Biopsy) All Independent Viewing of Films/Specimens
30 Medical Decision Making Table of Risk Risk Columns Presenting Problem Diagnostic Procedure(s) Ordered Management Options Selected Highest Leveled Column Determines Risk
31 Risk Level Level of Risk Presenting Problem(s) Diagnostic Procedure(s) Ordered Management Options Selected 2 Insect Bite Bloodwork Chest x-rays Rest Gargle 3 1 Stable Disease Barium Enema Hydration Therapy Stable Diseases Bone Marrow Biopsy Prescription Drug Lump In Breast Thoracentesis Radiation Therapy Disease w/ Major Progression Life Threatening Event Cardiovascular imaging studies w/ contrast w/ risk factors Diagnostic Endoscopies w/ risk factors Morphine Chemotherapy Hospice
32 Time Documentation Requirements Total time of visit (determines level) More than 50% of visit spent counseling/coordinating care Content of discussion TIME OVERRIDES COMPONENTS
33 Time How to determine the level Established Office Visit (total time) Level 1 (99211): 5 minutes Level 2 (99212): 10 minutes Level 3 (99213): minutes Level 4 (99214): minutes Level 5 (99215): 35+ minutes
34 Same Day Visit/Chemo Chemo/Visit on Same Day (-25 modifier) Georgia Cancer Specialists (Atlanta) $4.1 million settlement (False Claims Act) Chief Complaint Here for chemo vs. Here for reevaluation & chemo Chief Complaint drives what you can bill Visit note pertains to chemo, not disease. Data Medicare Manual: Chapter 12, Section 30.5, Subsection C.
35 James Leach, MBS E&M Consulting Inc
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