ELEVATING YOUR DOCUMENTATION FOR OB/GYN E/M SERVICES

Transcription

1 ELEVATING YOUR DOCUMENTATION FOR OB/GYN E/M SERVICES Brad Hart, MBA, MS, CMPE, CPC, COGBC ACOG District II 2014 CONFLICT OF INTEREST DISCLOSURE STATEMENT I have no significant financial interest with any commercial or corporate enterprise. I shall not discuss any off-label usage of any FDA-approved medications or other products. Learning Objectives At the conclusion of this session, attendees should be able to Describe the key documentation requirements that support particular E/M service levels. Promote excellence in E/M documentation by differentiating between high quality and substandard documentation. Contribute to the construction of documentation systems that facilitate the highest quality documentation and proper code selection in their practice Disclaimer Medicare OB/GYN E/M Distribution Outpt. Services - New Medicare OB/GYN E/M Distribution Outpt. Services - Established ICD-10 codes included in this presentation are not valid prior to the implementation date ICD-10 codes included in this presentation may be revised prior to implementation ICD-9 codes should continue to be used until transition date to ICD Coding Principles Coding Principles Document what was done Document why it was done Physicians and staff must stay current and involved Physicians are responsible for the coding information on claims! Code for what you document

2 Medically Necessary Services AMA s Model Managed Care Contract definition: Health care services or procedures that a prudent physician would provide to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease or it s symptoms in a manner that is: Medically Necessary Services In accordance with generally accepted standards for medical practice; Clinically appropriate in terms of type, frequency, extent, site, and duration; and Not primarily for the economic benefit of the health plans and purchasers or for the convenience of the patient, physician, or other health care provider. CODING FOR E/M SERVICES Diagnosis Coding and E/M Services Understanding E/M Services Selecting E/M Services Physicians are paid for medical services they provide Clinical need for each service must be justified by a code from ICD ICD-9/ICD-10-CM code must support level of service reported All clinically relevant diagnoses should be reported Developed in 1992 to accommodate RBRVS Describes outpatient and inpatient visits Divided into categories, subcategories, and levels of service Identify Category and Subcategory Type of service and/or Place of service Categories/Subcategories Selecting E/M Services How Do You Choose Levels of E/M Services? Office or Other Outpatient Services New Patient Established Patient Consultations Office or Other Outpatient Inpatient Review CPT instructions Information both at beginning of section and preceding some code families Select the Level of Service CPT definitions Documentation Guidelines History Exam Medical Decision Making Counseling Coordination of Care Nature of Problem Time

3 Key Components Contributing Components Reference History Exam Medical Decision Making Counseling Coordination of Care Nature of presenting problem Time RVU Comparison Summary of E/M Codes New Patient Level Estab. New Consult Not all E/M services selected using key components Time not always an option Not all distinguish between new and established patients Professional services defined as face-to-face services reported by a specific CPT code (s) Patients are: Self-referred, referred by friend Sent by a health care provider for treatment New Patient Subcategory New vs. Established New vs. Established In covering situations, the patient s encounter is reported as if the unavailable physician/qhp had seen the patient APN and PAs are considered as working in the exact same specialty/subspecialty as physician with whom they are working Classification applies only to: Office or Other Outpatient Services Preventive Services Mary is seen in the emergency department by Dr. Phillips. Dr. Phillips asks her to come to his office for follow-up. In the office, Mary is seen by Dr. Phillip s partner, Dr. Wickham. Mary is Dr. Wickham s established patient. Lydia has been seeing Dr. Bennett for years. Dr. Bennett leaves the Longbourne Medical Group and joins the Pemberley Medical Group. Lydia comes to the new practice to see Dr. Bennett within three years of her last visit. Lydia is Dr. Bennett s established patient

4 New vs. Established Kitty has been seeing Dr. Darcy for years. Dr. Darcy leaves the Longbourne Medical Group. Kitty then sees Dr. Gardiner, another general gyn at the Longbourne Medical Group. Kitty is Dr. Gardiner s established patient New vs. Established Dr. Hurst and Dr. Collins are both in solo practice. Dr. Hurst goes on vacation and asks Dr. Collins to cover for her. During that time, Dr. Hurst s patient, Jane, sees Dr. Collins. Jane is Dr. Collins established patient. New vs. Established Elizabeth, who recently moved to the local area, was seen in the ED for pelvic pain. An ultrasound was performed and was normal. The ED physician telephones Dr. Bingley, the on-call gynecologist, to discuss Elizabeth s care New vs. Established Key Components Dr. Bingley does not come in to see Elizabeth, but suggests she be seen in her office the following day. When Elizabeth sees Dr. Bingley, she is considered a new patient since Dr. Bingley did not provide a face-to-face service. SELECTING AND DOCUMENTING LEVELS OF E/M SERVICES History Exam Medical Decision Making Contributing Components Reference Category Requirements Counseling Coordination of Care Nature of presenting problem Time Visits requiring 3 of 3 key components New Outpatient Consultations Initial Inpatient Initial Observation care ED services Visits requiring 2 of 3 key components Established Outpatient Subsequent inpatient Subsequent observation care

5 Time Factors Physician may perform PE, obtain history BUT may spend most of the encounter providing counseling, OR All of the visit involves counseling with patient/family Using Time To Determine Levels Time may be the key factor for the selection of the level of service when counseling and/or coordination of care dominates the encounter (more than 50%) Counseling Discussion with patient and/or family Test results Prognosis Risks/benefits of management options Instructions Compliance issues Risk factor reduction Education Documentation Measuring Time Typical Times for Outpatient E/M Services Document description of the counseling/ coordination activities Document total time and time spent counseling with the patient Outpatient: Time spent by the provider face-to-face with the patient and/or family Inpatient: Time spent both with the patient and on the patient s unit or floor Report using the code with the closest actual time Verify Medicare contractor policy as may vary from CPT Outpatient - New Codes Times 10 min. 20 min. 30 min. 45 min. 60 min. Outpatient - Established Codes Times 5 min. 10 min. 15 min. 25 min. 40 min. Outpatient - Consultations Codes Times 15 min. 30 min. 40 min. 60 min. 80 min Time Factors: Hester Hester Dr. Dimmesdale Hester Hester is a 55 year-old new patient referred to Dr. Dimmesdale by her friend to discuss treatment options for menorrhagia. Another physician has suggested a vaginal hysterectomy and Hester would like to discuss other options including alternative surgical approaches. She refuses a physical exam today. 43 Dr. Dimmesdale spends 40 minutes discussing the risks and benefits of various treatment options with Hester. She will make a return appointment once she has determined her preferred course of treatment DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by line) 1. N92.6 Irregular menstruation, unspecified A. DATE(S) OF SERVICE From To MM DD YY MM DD YY B. POS D. PROCEDURES, SERVICES/SUPPLIES (Explain Unusual Circumstances) CPT/HCPCS MODIFIER E. DX POINTER 22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 23. PRIOR AUTHORIZATION NUMBER F. $ CHARGES G. DAYS OR UNITS I. ID. QUAL NPI Typical times for E/M codes are included in the CPT-4 code descriptors. Code lists 30 minutes as its typical time. Code lists 45 minutes as its typical time. NPI J. RENDERING PROVIDER ID. # 45 5

6 ICD-10-CM ICD-10-CM ICD-10-CM Index for Menorrhagia directs coder to: N92 (Excessive, frequent and irregular menstruation) and N95 (Menopausal and other perimenopausal disorders N92.0 Excessive and frequent menstruation with regular cycle N92.1 Excessive and frequent menstruation with irregular cycle N92.2 Excessive menstruation at puberty N92.3 Ovulation bleeding N92.4 Excessive bleeding in the premenopausal period N92.5 Other specified irregular menstruation N92.6 Irregular menstruation, unspecified Documentation for case was insufficient to select a specific ICD code Other specified means there was specific clinical documentation but not a code to describe the condition Reminders Time vs. Key Components Times in CPT are typical times only Time requirements do not have to be met when selecting codes based on key components Key component requirements do not have to be met when selecting codes based on time Time requirements must be met and documented when determining factor for level of service Time cannot be used when service was extended because: History was extensive Patient was a poor historian Physical exam was lengthy Key components must be used in these instances DOCUMENTATION IS CRITICAL! In the old days Today It gets worse This was billed as It was a follow up pap smear There was an abnormal pap 3 months earlier

7 Importance of Documentation 1992 Documentation Guidelines Principles of Documentation The medical record facilitates: Evaluation and planning of treatment Communication among providers Accurate claims review and payment Utilization review and quality of care activities Collection of data E/M codes restructured for RBRVS AMA released Principles of Documentation Developed by representatives from insurance industry, payers and providers Continue to be part of Medicare s Documentation Guidelines Complete and legible Documentation should include: Reason for encounter Relevant history and exam Assessment, impression, diagnosis Plan of care Date and legibility of observer Principles of Documentation 1995 and 1997 Documentation Guidelines Gynecologists and The DGs Documentation should include (cont d): Rationale for ordering tests and ancillary services Past and present diagnosis accessible Risk factors identified Progress and response to treatment Documentation should support CPT and ICD codes reported on claim 1995 Exam based on number of organ systems/body areas examined Criticized for not reflecting work of specialists 1997 Created single-organ system exams to reflect work of specialists Criticized for complexity of system Comprehensive Exam 1995 guidelines less restrictive 8 organ systems vs. 9 systems in 1997 DGs Less than comprehensive exams 1997 DGs recognizes work of single organ system exam Pelvic exam has 9 specific elements under 1997 vs. representing only 1 organ system in 1995 DGs Documenting Services in 2014 Documenting Services in 2014 Electronic Health Records (EHR) present both opportunities and challenges Increased efficiency/ improvements in quality of care Concern about accuracy and specificity of clinical information Medicare Carrier Manual: The volume of documentation should not be the primary influence upon which a specific level of service is billed Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code

8 Documenting Services in 2014 Medicare has noted increase frequency of identical information across services (copy/paste) Providers must select codes based on content of service and support selection with documentation Documenting Services in 2014 OIG Work Plans have focused on E/M codes suggested or determined by EHRs and templated notes Review of multiple E/M services for the same provider and same patient to identify improper payments Documenting Services in 2014 Other government and non-government payers initiating similar reviews Must consider the integrity of the medical record Information that is not customized to the individual patient may jeopardize patient care Selecting Levels of Service Selecting Levels of Service History CC HPI ROS PFSH Exam 1995 vs Medical Decision Making Diagnoses Data Risk History of Present Illness: is a 28-year-old G -0 referred for consultation by Dr. Thyme for evaluation of irregular uterine bleeding. She states that she has had vaginal bleeding for the past three months on a daily basis requiring the use of one to ten pads/day. She also reports the passage of large clots. She had irregular cycles after the onset of menarche at the age of 14. These were initially controlled with OCP. She stopped the OCP 18 months ago because she wanted a break from the pill. After stopping the OCP, she had cycles days apart, then began to bleed continuously 3 months ago. She has noted increased acne and some hair growth on her chin. Past Medical History: Negative for HTN, DM, CA, and TB Social History: She does not smoke or drink alcohol. No history of drug abuse Family History: Negative for HTN, DM, CA, and TB. Her mother had a hysterectomy for irregular uterine bleeding at the age of 35. ROS: No fatigue or weakness. No heart or lung symptoms. No GI problems. No neurologic complaints

9 Physical Exam: BP 120/80; P 80; Ht 68; Wt. 225#; BMI 34 General: WDWNF in NAD. A & O x 3. Neck: Supple without thyromegaly or lymphadenopathy. Chest: clear CV: RRR Breasts: No masses, galactorrhea, or retraction. No axillary lymphadenopathy Abdomen: BS+. Soft and non-tender without masses or organomegaly. Skin: Increased hair on chin and cheeks and below umbilicus Pelvic: External genitalia normal. Urethral meatus and urethra normal. Bladder no tenderness or fullness. Cervix and vagina normal. Copious, clear cervical mucous. Uterus normal size, shape, and consistency. Adnexa neg. RV: confirms Laboratory: Urine pregnancy test negative Ultrasound: Transvaginal ultrasound performed. Findings revealed a normal uterus with a thin endometrium. Ovaries are enlarged with multiple subcapsular cysts typical of PCOS Assessment: Menometrorrhagia secondary to chronic anovulation Hirsutism Obesity Probable PCOS but will confirm with hormonal data Plan: 1. Provera 10 mg/day for 10 days. 2. Restart OCP 3. Will check testosterone, LH, FSH, TSH, DHEA- S, prolactin, fasting comprehensive metabolic profile, insulin, and lipids 4. Return in 2 weeks to discuss findings of test results and determine further testing and/or management options. Consider the level of service for Dr. Thyme s consultation with All 3 key components must be met or exceeded Next, consider the level of service if was Dr. Thyme s established patient Only 2 of 3 key components required New Patients/Consultations Consultations Office or Other Outpatient Services Established Pt Selecting E/M Services CC Required Required Required Required Required CC N/A Required Required Required Required 1-3 elements 1-3 elements > 4 elements OR > 4 elements OR > 4 elements OR HPI > 3 chronic or > 3 chronic or > 3 chronic or Inactive conditions Inactive conditions Inactive conditions ROS N/A 1 system 2-9 systems systems systems PFSH N/A N/A 1 element 3 elements 3 elements Level PF Expanded PF Detailed Comprehensive Comprehensive systems 5-7 systems system 2-4 > 8 systems > 8 systems elements 6-11 elements > 12 elements Comprehensive Comprehensive Level PF Expanded PF Detailed Comprehensive Comprehensive Dx Mgmt Options Minimal Minimal Limited Multiple Extensive Minimal or Minimal or Limited Moderate Extensive Data Reviewed None None Risk Minimal Minimal Low Moderate High Level SF SF Low Moderate High 79 Face-to-face 10/15 min. 20/30 min. 30/40 min. 45/60 min. 60/80 min. N/A 1-3 elements 1-3 elements OR > 4 elements OR > 4 elements OR HPI > 3 chronic or > 3 chronic or > 3 chronic or Inactive conditions Inactive conditions Inactive conditions ROS N/A N/A 1 system 2-9 systems systems PFSH N/A N/A N/A 1 element 2 elements Level N/A PF Expanded PF Detailed Comprehensive 1995 N/A 1 system 2-4 systems 5-7 systems > 8 systems 1997 N/A 1-5 elements 6-11 elements > 12 elements Comprehensive Level N/A PF Expanded PF Detailed Comprehensive Dx Mgmt Options N/A Minimal Limited Multiple Extensive N/A Minimal or Limited Moderate Extensive Data Reviewed None Risk N/A Minimal Low Moderate High Level N/A SF Low Moderate High 80 5 min. 10 min. 15 min. 25 min. 40 min. Face-to-face supervision Proper coding and reimbursement means: Selecting code from proper category Selecting appropriate level of service Supporting selection with documentation CPT definitions CMS Documentation Guidelines 81 9

10 Selecting E/M Services Medical Decision Making Selecting the Level of MDM Based on physician work History, Exam, MDM, or time Includes services medically necessary to evaluate/tx the patient Code selection must be supported by work and medical necessity Level determined by: Number of diagnosis or management options Amount and/or complexity of data Risk to the patient Based on 2 of 3 areas Level of Medical Decision Making Number of diagnoses or management options Amount and/or complexity of data to be reviewed Straightforward Minimal Minimal or None Minimal (99241, 99242, 99201, 99202, 99212) Low complexity Limited Limited Low (99243, 99203, 99213) Moderate complexity Multiple Moderate Moderate (99244, 99204, 99214) High complexity Extensive Extensive High (99245, 99205, 99215) Risk of complications and/or morbidity or mortality MDM is the overarching criterion Level 1 Level 2 Level 3 Level 4 Level 5 New Patients/Consultations Outpatient CC * Required Required Required Required Required elements 4 + elements 4 + elements HPI * elements elements Office or Other Outpatient Services Est Patient CC * N/A Required Required Required Required HPI * N/A 1-3 elements 1-3 elements 4 + elements 4 + elements BP Check Injection with no physician on site Yeast Infection Brief discussion of birth control Pregnancy diagnosis Recurrent yeast infection Irregular periods, weight gain, hirsutism Recurrent yeast infection with systemic condition Empty uterus, rising beta Heavy bleeding, known anemia 85 ROS * N/A Pertinent 2-9 systems systems systems PFSH * N/A N/A 1 of 3 elements 3 of 3 elements 3 of 3 elements or > Comprehensive Comprehensive 1997 elements elements elements System of systems 8 or > systems 8 or > systems 1995 Complaint systems SF SF Low Moderate High Face-toface min. 10/15 min. 20/30 30/40 min. 45/60 min. 60/80 min. 86 ROS * N/A N/A Pertinent 2-9 systems systems PFSH * N/A N/A N/A 1 of 3 elements 2 of 3 elements elements 6-11 elements 12 or 1997 N/A 1-5 > elements Comprehensive N/A System of 2-4 systems 5-7 systems 8 or > systems 1995 Complaint Low Moderate N/A SF High Faceto-face 5 min. 10 min. 15 min. 25 min. 40 min. supervision 87 History Components of History Key Documentation Guidelines Four Types: Problem-focused Expanded problem-focused Detailed Comprehensive Chief Complaint (CC) History of Present Illness (HPI) Review of Systems (ROS) Past, Family, and/or Social History (PFSH) CC required for all levels Extent dependent on clinical judgment No specific format requirements Describe circumstances which preclude obtaining history

11 Key Documentation Guidelines History of Present Illness Documenting the HPI ROS/PFSH may be recorded by pt. or staff Provider must supplement/confirm info ROS/PFSH updated by: New information or noting change Noting date/location of previous information Note all positive and pertinent negatives in ROS Eight elements: Location Quality Severity Duration Timing Context Modifying factors Associated signs/symptoms Brief 1-3 elements Extended (99243+, , ) 4+ elements, OR Comments on 3 or more chronic or inactive conditions Review of Systems Documenting the ROS Past, Family, Social History 14 systems: Constitutional Eyes ENT, mouth Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary (skin and/or breasts) Neurological Psychiatric Endocrine Hematologic/Lymp. Allergic/Immun. Problem Pertinent (99242, 99202, 99213) System of complaint Extended (99243, 99203, 99214) 2-9 systems Complete (99244, 99245, 99204, 99205, 99215) 10 individual systems *Pertinent pos/neg. plus all other systems neg Comment on hx. form PFSH consists of 3 areas Past History-Patient s past Family History-Family medical events Social History-Age appropriate review of activities Documenting the PFSH Pertinent (99243, 99203, 99214) 1 of 3 areas Complete (99244, 99245, 99204, 99205, 99215) 3 of 3 for new and comprehensive assessments 2 of 3 for established outpatient and ED 97 Choosing the Level of History PF EPF Detailed Comp. Type HPI ROS PFSH Brief (1-3) Brief (1-3) Extended (4+) Extended (4+) None Problem Pertinent Extended (2-9) Complete (10+) None None Pertinent (1 of 3) Complete (2 of 3 or 3 of 3) Chief complaint required for all types. Requirements for all components must be met for a given type. 98 New Patients/Consultations Outpatient CC * Required Required Required Required Required HPI * elements 4 + elements 4 + elements elements elements ROS * N/A Pertinent 2-9 systems systems systems PFSH N/A N/A 1 of 3 elements 3 of 3 elements 3 of 3 elements * or > Comprehensive Comprehensive elements elements elements 5-7 systems 1995 System of or > systems 8 or > systems Complaint systems SF Low Moderate SF High Face-toface 10/15 min. 20/30 30/40 min. 45/60 min. 60/80 min. min

12 Office or Other Outpatient Services Est Patient CC * N/A Required Required Required Required HPI * N/A 1-3 elements 1-3 elements 4 + elements 4 + elements ROS * N/A N/A Pertinent 2-9 systems systems PFSH * N/A N/A N/A 1 of 3 elements 2 of 3 elements elements 6-11 elements 12 or 1997 N/A 1-5 > elements Comprehensive 1995 N/A System of 2-4 systems 5-7 systems 8 or > systems Complaint Ms. Rafferty was unable to keep her appointment, but she faxed her symptoms Examination Four Types Problem-focused Expanded problemfocused Detailed Comprehensive N/A SF Low Moderate High Faceto-face supervision 5 min. 10 min. 15 min. 25 min. 40 min Choosing the Level of Exam TYPE OF EXAM 1995 REQUIREMENTS 1997 REQUIREMENTS Problem Focused Expanded Problem Focused Detailed Comprehensive 1 body area or organ system 1-5 elements 2-4 organ systems 6-11 elements including affected area 5-7 organ systems 12 or more elements including affected area 8 or more organ systems Not defined Multi-System Not defined 2 elements from at least 9 areas/systems Single Organ System Not defined All elements in shaded boxes Face-toface 1 element in all unshaded boxes 103 New Patients/Consultations Outpatient CC * Required Required Required Required Required HPI * 1-3 elements 1-3 elements 4 + elements 4 + elements 4 + elements ROS * N/A Pertinent 2-9 systems systems systems PFSH * N/A N/A 1 of 3 elements 3 of 3 elements 3 of 3 elements elements System of Complaint 6-11 elements 2-4 systems 12 or > elements Comprehensive Comprehensive 5-7 systems 8 or > systems 8 or > systems SF SF Low Moderate High 10/15 min. 20/30 min. 30/40 min. 45/60 min. 60/80 min. 104 Dr. Thyme 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by line) 1. N92.1 Excessive and frequent menstruation with irregular cycle 2. L68.0 Hirsutism 3. Z68.34 BMI between , adult 24. A. DATE(S) OF SERVICE From To MM DD YY MM DD YY B. POS D. PROCEDURES, SERVICES/SUPPLIES (Explain Unusual Circumstances) CPT/HCPCS MODIFIER E. DX POINTER 22. MEDICAID RESUBMISSION CODE 23. PRIOR AUTHORIZATION NUMBER F. $ CHARGES G. DAYS OR UNITS I. ID. QUAL NPI NPI NPI CPT Codes CPT Description Level III Outpatient consultation Urine pregnancy test Transvaginal ultrasound ORIGINAL REF. NO. J. RENDERING PROVIDER ID. # 105 Office or Other Outpatient Services Est Patient CC * N/A Required Required Required Required HPI * N/A 1-3 elements 1-3 elements 4 + elements 4 + elements ROS * N/A N/A Pertinent 2-9 systems systems PFSH * N/A N/A N/A 1 of 3 elements 2 of 3 elements elements 6-11 elements 12 or 1997 N/A 1-5 > elements Comprehensive Dr. Thyme 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by line) 1. N92.1 Excessive and frequent menstruation with irregular cycle 2. L68.0 Hirsutism 3. Z68.34 BMI between , adult 24. A. DATE(S) OF SERVICE From To MM DD YY MM DD YY B. POS D. PROCEDURES, SERVICES/SUPPLIES (Explain Unusual Circumstances) CPT/HCPCS MODIFIER E. DX POINTER 22. MEDICAID RESUBMISSION CODE 23. PRIOR AUTHORIZATION NUMBER F. $ CHARGES G. DAYS OR UNITS I. ID. QUAL NPI ORIGINAL REF. NO. J. RENDERING PROVIDER ID. # USING E/M SERVICES N/A System of 2-4 systems 5-7 systems 8 or > systems 1995 Complaint N/A SF Low Moderate High Faceto-face supervision 5 min. 10 min. 15 min. 25 min. 40 min NPI NPI CPT Codes CPT Description Level IV Established Outpatient Urine pregnancy test Transvaginal ultrasound

13 New Patients/Consultations Office or Other Outpatient Services Outpatient CC * Required Required Required Required Required elements 4 + elements 4 + elements HPI * elements elements ROS * N/A Pertinent 2-9 systems systems systems PFSH N/A N/A 1 of 3 elements 3 of 3 elements 3 of 3 elements * or > Comprehensive Comprehensive 1997 elements elements elements System of systems 8 or > systems 8 or > systems 1995 Complaint systems SF Low SF Moderate High Face-toface 10/15 min. 20/30 30/40 min. 45/60 min. 60/80 min. min. 109 Est Patient CC * N/A Required Required Required Required HPI * N/A 1-3 elements 1-3 elements 4 + elements 4 + elements ROS * N/A N/A Pertinent 2-9 systems systems PFSH * N/A N/A N/A 1 of 3 elements 2 of 3 elements elements 6-11 elements 12 or 1997 N/A 1-5 > elements Comprehensive N/A System of 2-4 systems 5-7 systems 8 or > systems 1995 Complaint Low Moderate N/A SF High Faceto-face 5 min. 10 min. 15 min. 25 min. 40 min. supervision 110 Hope CC/HPI: Hope is a 22-year-old established patient with complaints of mild vaginal itching and irritation for the last 3-4 days. 111 Hope Exam: Pelvic: External genitalia: mild redness. Vagina: thick, white, curdy discharge. Wet mount: positive for candida. Hope Assessment: Vaginal candidiasis Plan: 1. Clotrimazole cream and vaginal inserts X 7 days 2. RTO prn. Office or Other Outpatient Services Code History Exam Medical Decision Making Face to Face Time Requires physician s supervision only 5 min Problem-focused Problem-focused Straightforward 10 min Expanded problem-focused Established Patient Expanded Low problem-focused 15 min Detailed Detailed Moderate 25 min Comprehensive Comprehensive High 40 min Charity Charity Charity CC/HPI: Charity is a 25-year-old established patient with complaints of vaginal discharge and discomfort for the last 1-2 weeks. The discharge is described as a thin greenish discharge that recently has become quite profuse. 115 ROS: She complains of mild dysuria and dyspareunia. Past history: She is sexually active and is on oral contraceptives. She does not use condoms. She has no history of previous STIs. Her last pap smear was 6 months ago and normal. 116 Exam Constitutional: BP 120/80; Wt.125; Ht. 64 inches Pelvic: External genitalia: Vulva is inflamed, Vagina: Large amount of greenish-yellow discharge in vaginal fornix. Vaginal mucosa: red and inflamed. Cervix: Punctate, red strawberry spots. Bimanual: Slight discomfort on palpation. No localization. Wet mount: Suggestive of trichomonas. Cultures taken

14 Charity Assessment: Probable trichomonas. She was counseled regarding STIs and the use of condoms. Plan: 1. Will screen for STI s 2. Metronidazole 500mg. bid X 7 days 3. Will call with test results and schedule appointment as necessary Office or Other Outpatient Services Code History Exam Medical Decision Making Face to Face Time Requires physician s supervision only 5 min Problem-focused Problem-focused Straightforward 10 min Expanded problem-focused Established Patient Expanded Low problem-focused 15 min Detailed Detailed Moderate 25 min Comprehensive Comprehensive High 40 min. Patience CC/HPI: Patience is a 48-year-old established patient with complaints of recurrent vaginitis. She has had 3 episodes of yeast in the last 6 months. The last episode, which was 4 weeks ago, required 2 courses of therapy. The discharge is again thick and white. She has significant external irritation and itching Patience Patience Patience ROS: She is also complaining of dysuria, frequency, and urgency. She denies polydipsia or polyphagia. She has had a weight gain of 10 lbs. over the last 6-8 months. Menses have been irregular for the last 18 months, occurring about 6-8 weeks apart. She has no menopausal symptoms. 121 Past history: She is married and sexually active. She has had no recent illness or oral antibiotic use. She has no history of STIs. Her last pap smear was 10 months ago and normal. Family history: Mother developed Type II DM at about age Constitutional: BP 130/86; Wt. 160 lbs.; Ht.65 Pelvic: External genitalia: Mild erythema Vagina: Moderate amount of thick, white, discharge Cervix: Significant area of patchy white discharge Bladder: Tender to palpation Uterus: Normal size, shape Adnexa: Non-tender without masses 123 Patience Wet mount: Positive for candida. U/A: Positive for increased WBC s. Both urine and vaginal cultures taken. Assessment: 1. Recurrent candidiasis. 2. Need to rule out diabetes and consider reinfection by partner. 3. Probable UTI. Will wait for culture results prior to initiating therapy. 124 Patience Plan: 1. Fluconazole 150 mg. X 1 dose 2. FBS and 2 hour pp in the AM. Will call with test results 3. RTO in 7-10 days for follow-up. 125 Office or Other Outpatient Services Code History Exam Medical Decision Making Face to Face Time Requires physician s supervision only 5 min Problem-focused Problem-focused Straightforward 10 min Expanded problem-focused Established Patient Expanded Low problem-focused 15 min Detailed Detailed Moderate 25 min Comprehensive Comprehensive High 40 min

15 QUESTIONS? Brad Hart, MBA, MS, CMPE, CPC, COBGC (862)