Assigning Evaluation and Management Code Levels Practical Tools for Seminar Learning

Transcription

1 Assigning Evaluation and Management Code Levels Practical Tools for Seminar Learning Copyright 2006 American Health Information Management Association. All rights reserved.

2 Disclaimer The American Health Information Management Association makes no representation or guarantee with respect to the contents herein and specifically disclaims any implied guarantee of suitability for any specific purpose. AHIMA has no liability or responsibility to any person or entity with respect to any loss or damage caused by the use of this audio seminar, including but not limited to any loss of revenue, interruption of service, loss of business, or indirect damages resulting from the use of this program. AHIMA makes no guarantee that the use of this program will prevent differences of opinion or disputes with Medicare or other third party payers as to the amount that will be paid to providers of service. How to earn one (1) CEU for participation To earn one (1) continuing education unit, each participant must do the following: Step 1: Step 2: Step 3: Step 4: Listen to the seminar, via Webcast link, audio CD, or MP3. Complete the assessment quiz contained in this resource book. Use the included answer key. Do not return the quiz to AHIMA. Save it for your records. Fax or mail us the completed sign-in form from this resource book. The fax number and address are located at the bottom of the form. Print the certificate of attendance for each listener. The certificate must be retained by each participant as a record of their participation, along with a copy of their completed quiz. After listening to the seminar, please let us know what you think, by completing our online evaluation survey at i

3 Faculty Susan M. Hull, MPH, RHIA, CCS, CCS-P Susan M. Hull, MPH, RHIA, CCS, CCS-P is a professional practice resources manager for the American Health Information Management Association (AHIMA). In her role as manager, Susan provides professional expertise to AHIMA members, the media, and outside organizations on coding practice issues, and develops written products aimed at furthering the art and science of coding. Susan has over 20 years experience in the HIM field. Before joining AHIMA in 2002, she served as Senior Executive Director for HMI Corporation where she oversaw coding reviews; chargemaster maintenance and development; and presented seminars in outpatient, inpatient, and physician documentation and coding. Prior to this, she worked in numerous HIM roles, including consultant, HIM department director, and HIM software developer and manager. In addition to AHIMA, Susan is actively involved as a volunteer in the HIM profession. She has presented on timely HIM topics to the Health Information Management Associations of California, Tennessee, and Southern Illinois, as well as the Southern Illinois Healthcare Financial Management Association. Susan received a bachelor of arts degree and a master of public health in Health Services and Hospital Administration from the University of California, Los Angeles. ii

4 Table of Contents Disclaimer... i How to earn one (1) CEU for participation... i Faculty...ii Basis for E&M level coding... 1 New vs. established patients... 1 History... 2 Review of systems... 2 PFSH... 3 Time as a determining factor Who may document... 5 Physical examination Physical examination (1995 guidelines)... 7 Physical examination (1997 guidelines)... 8 Medical decision making... 8 Categories of problems... 9 Categories of data reviewed... 9 Management options...10 Summary...11 AHIMA Audio Seminars...12 About assessment quiz...12 Thank you for attending (with link for evaluation survey)...13 Appendix...14 Assessment Quiz Continuing Education Credit and Compliance Sign-in Form Certificate of Attendance and Quiz Completion Quiz Answer Key

5 Basis for E&M level coding Evaluation and management levels are assigned based upon documentation of: History Physical examination Medical decision making In specific cases, time is the determining factor 1 New vs. established patients A New patient has not received face-to-face professional services from the provider or another provider of the same specialty who belongs to the same group with in the past 3 years. An Established patient has received face-to-face professional services from the provider or another provider of the same specialty who belongs to the same group with in the past 3 years. 2 1

6 History History of present illness Seven parameters: Location where it is Duration how long you have had it Timing when it occurs Context what you are doing when it occurs Severity how bad is it Modifying factors what makes it better or worse Associated signs and symptoms what else do you feel at the same time 3 History Review of systems Constitutional Eyes ENT Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary Neurological Psychiatric Endocrine Hematologic/lymphatic Allergic/immunologic 4 2

7 History PFSH Past history Prior major illnesses, injuries, hospitalizations and operations Current medications Allergies Immunization status (age appropriate) Feeding/dietary status (age appropriate) Continued 5 History PFSH (Continued) Family history Significant inherited conditions Anything that might place the patient at risk Social history Marital status/living arrangements Occupational history Use of drugs, alcohol, tobacco Educational history Sexual history 6 3

8 Time as a determining factor When counseling accounts for more than half the total visit time Document both the time in counseling and the total visit time Document what was discussed in the counseling Assign the appropriate evaluation and management code for the total time, not the time spend in counseling Continued 7 Time as a determining factor (Continued) Counseling may include: Advice re lifestyle modifications Treatment/management options Prognosis Medication administration and side-effects Educational resources Risk factor reduction Continued 8 4

9 Time as a determining factor (Continued) Time is the determining factor for: Pediatric critical care patient transport Critical care services Assuming that the criteria for critical care have been met Critical injury or illness that acutely impairs one or more vital organ systems High complexity medical decision making Both illness and treatment must meet criteria 9 Who may document History of present illness, PFSH, ROS may be documented by: Physician Historian Nurse Patient or patient advocate Physician should document that he or she reviewed the information Physical examination must be documented by physician or other practitioner (PA, RNP, etc.) 10 5

10 Physical examination Two sets of documentation guidelines for physical examination 1995 guidelines better for general examination 1997 guidelines better for specialty examination May use either, but must be consistent within a patient encounter 11 Physical examination (Continued) 1995 and 1997 guidelines are available on the CMS web site at: Basically the only thing that is different is the documentation guidelines for physical examination 12 6

11 Physical examination (Continued) 1995 guidelines based on either body areas or organ systems For purposes of examination, the following body areas are recognized: Head, including the face Neck Chest, including breasts and axillae Abdomen Genitalia, groin, buttocks Back, including spine Each extremity 13 Physical examination organ systems Constitutional (e.g., vital signs, general appearance) Eyes Ears, nose, mouth and throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic/lymphatic /immunologic 14 7

12 Physical examination (Continued) 1997 guidelines General multisystem examination Single system (specialty) examination Cardiovascular Ears, Nose, Mouth and Throat Eyes Genitourinary (Female) Genitourinary (Male) Hematologic/Lymphatic/Immunologic Musculoskeletal Neurological Psychiatric Respiratory Skin 15 Medical decision making The most difficult to quantify Based upon nature of the presenting problem, amount and complexity of information that must be analyzed Nature of the diagnosis and treatment plans Risk of significant disability or impairment if an error is made 16 8

13 Medical decision making (Continued) Categories of problems Minor or self-limited, stable, improving or worsening 1 point Established problem, stable 1 point Established problem, worsening 2 points New problem, no additional workup 3 points New problem, workup planned 4 points 17 Medical decision making (Continued) Categories of data reviewed Order/review clinical laboratory tests 1 point Order/review radiology tests 1 point Order/review medicine tests 1 point Discuss test results with performer 1 point Obtain old records/obtain history from third party/discuss case with provider 2 points Independent review of images, tracing or report 2 points 18 9

14 Medical decision making (Continued) Management options Minimal rest, superficial dressings or none Low OTC medications, minor surgery without risk factors, PT/OT, IV fluids without additives Moderate Minor surgery with risk, major surgery (elective) without risk, prescription drug management, IV fluids with additives, closed treatment of skeletal injury Continued 19 Medical decision making (Continued) Management options (Continued) High Elective major surgery with risk, emergency major surgery, parenteral/controlled substances, drug therapy requiring intensive monitoring, DNR decision 20 10

15 Summary Assignment of evaluation and management codes is based upon documentation of history, physical examination and medical decision making in most cases Guidelines apply to most evaluation and management code sets Time is determinant is select cases 21 Summary (Continued) All criteria applied must be documented in the medical record and readily available Established patients require that two of three components meet the level to be assigned; new patients and ED patients require that all be met 22 11

16 AHIMA Audio Seminars Visit our Web site for updated information on the current seminar schedule. While online, you can also register for live seminars or order CDs and Webcasts of past seminars American Health Information Management Association Assessment To access the assessment quiz that follows this seminar, download the seminar s resource book at Your sign-in form and certificate of completion are also found in the resource book. 12

17 Thank you for attending! Please visit the AHIMA Audio Seminars Web site to complete your evaluation form online at: 13

18 Appendix Assessment Quiz Continuing Education Credit and Compliance Sign-in Form Certificate of Attendance and Quiz Completion Quiz Answer Key

19 Assessment Quiz Assigning Evaluation and Management Code Levels To earn continuing education credit of one (1) AHIMA CEU, Fast Facts Audio Seminar listeners must also complete this 10-question quiz. This CE credit is for attending the audio seminar AND completing this quiz. Please keep a copy of the completed quiz with your certificate of attendance. Do not send a copy to AHIMA. 1. For purposes of assigning evaluation and management codes, an established patient is one who. a. has been seen by the provider before b. has received face-to-face professional services from the provider or other member of the same specialty in the same group within the past three years c. has received professional services from the provider or other member of the same specialty in the same group within the past three years d. has received face-to-face professional services from the provider or other member of the same specialty in the same group within the past year 2. Time is the determining factor in assigning evaluation and management codes when. a. counseling consumes more than half the time of the visit b. the visit takes longer than usual c. any time that the provider feels that it is appropriate d. coding visits to patients in skilled nursing facilities 3. For purposes of assigning evaluation and management codes, which of the following is not considered counseling? a. Advice re life style modification in combating effects of disease b. Interactive psychotherapy c. Discussion of medication administration and side-effects d. Provision of educational resources 4. True or false? Only the physician may document history, physical examination and medical decision making. a. True b. False 5. Which of the following statements re selection of 1995 vs documentation guidelines is false? (answer choices are in next column) a. Either may be chosen for a specific patient. b. The physician must use the same set of guidelines for all patients. c. The 1995 guidelines are better to use for general examinations. d. The guidelines are available for download on the CMS website. 6. A description of what you are doing when a symptom occurs is considered to be documentation of the of the complaint. a. context b. timing c. location d. None of the above 7. True or false? Medical decision making is the most difficult of the three components of evaluation and management coding to quantity as it can be somewhat subjective. a. True b. False 8. An established problem that is worsening is worth how many points in the medical decision making process? a. 1 point b. 2 points c. 3 points d. 4 points 9. Elective major surgery without identified significant risk is considered to be a level management option. a. low b. minimal c. moderate d. high 10. True or false? In assigning risk, pick the lowest level in any of the three sections of data review, management options and nature of presenting problem. a. True b. False Do not send a copy of completed quizzes to AHIMA. Please keep them with your certificate of attendance, for your records. Be sure to complete and send the seminar sign-in sheet found on the next page of this resource book. ANSWERS to this quiz are found on the last page of the seminar resource book, Practical Tools for Seminar Learning.

20 Continuing Education Credit and Compliance Sign-in Form Fast Facts Audio Seminar Assigning Evaluation and Management Code Levels Please duplicate this form so that everyone in attendance may sign-in. Those wishing to receive AHIMA continuing education credit must supply their AHIMA ID number. Those individuals will receive a total of 1 continuing education (CE) clock hour, for attending the seminar AND completing the assessment quiz. The CE certificate is located on the last page of the seminar resource book, Practical Tools for Seminar Learning. Each participant should keep a copy of the CE certificate AND the completed quiz on file as proof of training. Sign below to certify that you have listened to this audio seminar and completed the assessment quiz, to receive a total of 1 AHIMA CEU. Name: Title: Organization: Address: City, State, ZIP: AHIMA ID number: Address: Date: Signature: Name: Title: Organization: Address: City, State, ZIP: AHIMA ID number: Address: Date: Signature: Name: Title: Organization: Address: City, State, ZIP: AHIMA ID number: Address: Date: Signature: Name: Title: Organization: Address: City, State, ZIP: AHIMA ID number: Address: Date: Signature: Name: Title: Organization: Address: City, State, ZIP: AHIMA ID number: Address: Date: Signature: Name: Title: Organization: Address: City, State, ZIP: AHIMA ID number: Address: Date: Signature: Please visit the AHIMA Audio Seminars Web site to complete the evaluation form online at Return this form to: Distance Education, AHIMA, 233 N. Michigan, Ste 2150, Chicago, IL Fax 312/ Do not send completed Fast Facts Audio Seminar quizzes keep them for your records

21 Certificate of Attendance Fast Facts Audio Seminar Assigning Evaluation and Management Code Levels Name AHIMA ID Number Date Attended Anne M. Willmore Project Manager Distance Education The American Health Information Management Association has approved this program for one (1) continuing education unit. Participant certifies that he or she has attended this audio seminar and completed the accompanying quiz. Retain this certificate as evidence of participation. No record will be kept at AHIMA of your participation.

22 Quiz Answer Key Fast Facts Audio Seminar: Assigning Evaluation and Management Code Levels 1: b; 2: a; 3: b; 4: false; 5: b; 6: b; 7: true; 8: b; 9: c; 10: false Do not send a copy of your completed Fast Facts Audio Seminar quiz to AHIMA. Please keep it with your certificate of attendance, for your records.