Rational Physician Coding for Emergency Department E/M Services and Critical Care

Transcription

1 Rational Physician Coding for Emergency Department E/M Services and Critical Care Peter R. Jensen, MD, CPC

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3 Rational Physician Coding for Emergency E/M Services Peter R. Jensen, MD, CPC For clinically driven E/M coding education, go to ER E/M Coding E/M = Evaluation and Management How patient encounters are translated into 5 digit numbers to facilitate billing For ED E/M services, there are five levels of care: 998 $ $ $ $ $ %

4 Goals Learn the documentation requirements for ED E/M services and critical care Ensure compliance Streamline the documentation process Identify the highest ethical level of care Maintain the focus on patient care ER E/M Documentation E/M Code Time 998 SF Comp Comp 3 out of 3 key components must qualify

5 E/M = Cognitive Labor = The E/M Guidelines Developed by the AMA and CMS First set released in 995 Second set released in 997 Based on three Key Components Physical Medical Decision-Making 3

6 Physical Problem Focused Expanded Problem Focused ailed Comprehensive Physical Straightforward Complexity erate We think Complexity of the key components as being random, but they re really not Complexity Problem Focused Expanded Problem Focused ailed Comprehensive Problem Focused Expanded Problem Focused ailed Comprehensive Physical Straightforward Complexity erate Complexity Complexity This is how auditors look at the E/M guidelines. They view the history, physical exam and medical decision-making in very concrete terms. 4

7 FH Physical PMH SH Bullets ROS Physical Risk HPI Organ Systems Data Reviewed Diagnoses Our challenge is to find some way to translate our cognitive labor into the abstruse language of the E/M guidelines without wasting time on overdocumentation or getting distracted from our real job of taking care of patients. Rational Physician Coding Target M DM E/M Code Physical Rational Physician Coding teaches you to consider the first in order to identify a target code for each encounter. Then you can perform and document the history and exam in a purpose-driven manner to ensure that these elements are congruent with the level of care selected. 5

8 Step Step Target E/M Code Step 3 The E/M Documentation Guidelines Physical Rational Physician Coding is a simple three step process:. Calculate the medical decision-making. Identify the target code 3. Perform and document the required elements of history/exam Primacy of Medical Decision-Making = Problems Data Risk 6

9 The Importance of Medical Necessity Medical Necessity Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate = to bill a higher level of E/M service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Correct Level of Care Problems Data Risk The quote above is taken directly from the Medicare carrier manual and it points out the fact that there must be sufficient medical necessity to support the intensity of the history and exam performed and documented. The key component of medical decision-making can act as an objective index of medical necessity and help us identify the highest ethical level of care based on the clinical circumstances of the patient. Cognitive Labor + Medical Necessity Correct Level of Care The Secret of True E/M Compliance If you can find the level of care which matches both the cognitive labor provided and the intrinsic medical necessity of the encounter, you can find the correct level of care. If you let the key component of lead the way, you can find this level of care each and every time. This is the secret of true E/M compliance because it allows you to avoid undercoding while ensuring that the level of care selected is congruent with the medical necessity of the encounter. 7

10 ermining the Number of Diagnoses Data Reviewed Risk Level of Minimal Minimal Minimal Straight- Forward Limited Limited Complexity Multiple erate erate erate Complexity Extensive Extensive Complexity Need out of 3 to qualify for given level of Given the importance of the, it is essential that we be able to quantify this key component in an objective and repeatable manner. Unfortunately, the official table of from both the 995 and 997 E/M guidelines (shown above) makes this a very difficult thing to do. The problem is that the terms used to stratify the dimensions of are too vague. Points Complexity Problems Data Risk Straight Forward Minimal erate 3 3 erate 4 4 Need out of 3 to qualify for given level of The framers of the E/M guidelines realized that the rules were to vague to be used by auditors, so they came up with a weighted point system which was eventually released to all Medicare carriers to used on a voluntary basis. 8

11 Problem Points Problems/DDx Self limited or minor (Max ) Established problem, stable Established problem, worsening New problem, no additional work-up planned New problem, additional work-up planned Points 3 4 The problem points are tabulated by referring to this table. You add up all the problems you are addressing during the encounter and come up with the final number of total problem points. New problems are defined relative to the physician, not the patient. Points for Data Reviewed Review/order clinical lab tests Review/order X-rays Data Reviewed Review/order tests in the medicine section (echo, EKG, LHC, Ts) Discussion of test results with performing MD Independent review of image, tracing, or specimen Decision to obtain old records Review and summation of old records Points The data points are calculated using this table. You only get one data point for reviewing and/or ordering labs and ordering or reviewing X-ray reports. If you personally review any primary data (such as an EKG, an X-ray or a blood smear, etc.), you get two data points, but you must record your findings in the chart. 9

12 Table of Risk Risk Presenting Problem(s) Diagnostic Procedures Management Options Selected Minimal One self-limited or minor problem, e.g., cold, insect bite, tinea corporis Laboratory tests Chest X-rays EKG/EEG Urinalysis Ultrasound/ Echocardiogram KOH prep Rest Gargles Elastic bandages Superficial dressings Two or more self-limited or minor problems One stable chronic illness, e.g., well controlled HTN, DM, cataract Acute uncomplicated injury or illness, e.g., cystitis, allergic rhinitis, sprain Physiologic tests not under stress, e.g., Ts Non-cardiovascular imaging studies with contrast, e.g., barium enema Superficial needle biopsy ABG Skin biopsies Over the counter drugs Minor surgery, with no identified risk factors Physical therapy Occupational therapy IV fluids, without additives erate One or more chronic illness, with mild exacerbation, progression, or side effects of treatment Two or more stable chronic illnesses Undiagnosed new problem, with uncertain prognosis, e.g., lump in breast Acute illness, with systemic symptoms, e.g., pyelonephritis, pleuritis, colitis Acute complicated injury, e.g., head injury, with brief loss of consciousness Physiologic tests under stress, e.g., cardiac stress test, fetal contraction stress test Diagnostic endoscopies, with no identified risk factors Deep needle, or incisional biopsies Cardiovascular imaging studies, with contrast, with no identified risk factors, e.g., arteriogram, cardiac catheterization Obtain fluid from body cavity, (e.g., LP or thoracentesis) Minor surgery, with identified risk factors Elective major surgery (open, percutaneous, or endoscopic), with no identified risk factors Prescription drug management Therapeutic nuclear medicine IV fluids, with additives Closed treatment of fracture or dislocation, without manipulation One or more chronic illness, with severe exacerbation, progression, or side effects of treatment Acute or chronic illness or injury, which poses a threat to life or bodily function, e.g., acute MI, pulmonary embolism, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness, with potential threat to self or others, peritonitis, ARF An abrupt change in neurological status, e.g., seizure, TIA, weakness, sensory loss Cardiovascular imaging, with contrast, with identified risk factors Cardiac EP studies Diagnostic endoscopies, with identified risk factors Discography Elective major surgery (open, percutaneous, endoscopic), with identified risk factors Emergency major surgery (open, percutaneous, endoscopic) Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Decision not to resuscitate, or to de-escalate care because of poor prognosis This is the official table of risk for both the 995 and 997 E/M guidelines. The rules explicitly state that it only takes one element in any of the categories above to qualify for any given level of risk. Use highest level of risk present to stratify the overall level of risk for any encounter. 0

13 Calculating the Overall Complexity Problems Data Risk Straight Forward Minimal erate 3 3 erate 4 4 Need out of 3 to qualify for given level of The overall level of is determined by referring to the table above. Only two out of three elements are needed to qualify for any given level of. The example above would qualify for moderate complexity based on the presence of three problem points and three data points, even though the level of risk is only low. Step Step Target E/M Code Step 3 The E/M Documentation Guidelines Physical

14 CC HPI ROS SH Problem Focused Expanded Problem Focused ailed Comprehensive Levels of HPI ROS SH Brief None None Brief None ailed Extended 9 out of 3 Comp Extended 0 3 out of 3 For ER E/M encounters, a comprehensive history requires only TWO out of THREE components of SH.

15 HPI A narrative of the patient s symptoms or illnesses since onset or since the previous encounter Every level of history requires and HPI, which may be referred to as an interval history for follow-up encounters The HPI is the only component of history which MUST be personally obtained and documented by the provider Elements of HPI Location Duration Timing Quality Severity Context ifying factors Associated signs or symptoms 3

16 Location HPI Elements Duration Location Quality Severity Duration Timing Context Context ifying Factors Associated Signs/Symptoms Patient complains of stabbing intermittent chest pain which began 8 hours ago while watching TV. The pain is rated as 8/0 in severity, is worse with exertion and is associated with SOB and nausea. Severity Quality Timing ifying Factors Associated Signs or Symptoms ple of an extended HPI using all eight of the HPI elements. Levels of HPI Brief HPI Requires only one to three HPI elements Extended HPI Requires four HPI elements or the status of three chronic or inactive problems 4

17 What if the patient has no complaints? Without a specific somatic complaint, it may be difficult or outright impossible to qualify for any level of HPI using the HPI elements. This problem was addressed in the 997 E/M guidelines. If there are no somatic complaints, the 997 E/M guidelines allow you to qualify for extended HPI by commenting on the status of three or more chronic or inactive problems. ROS Constitutional Eyes Ears, nose, mouth, throat Cardiovascular Respiratory GI GU Musculoskeletal Skin Neurological Psychiatric Endocrine Hem/Lymphatic Allergic/Immunologic The ROS may be completed by the physician, ancillary staff or by having the patient fill out a questionnaire. 5

18 SH Past Medical Previously existing illnesses, prior operations, current medications, allergies, immunizations Family Health status of parents/siblings/children including relevant or hereditary diseases Social Marital status, employment, DOA, education, sexual history The SH may be completed by the physician, ancillary staff or by having the patient fill out a questionnaire. Levels of HPI ROS SH Brief None None Brief None ailed Extended 9 out of 3 Comp Extended 0 3 out of 3 The documentation requirements for each level of history are very specific. Therefore, the history should be recorded in a purpose-driven manner to ensure compliance while avoiding time-wasting over-documentation. For ER E/M encounters, a comprehensive history requires only TWO out of THREE components of SH. 6

19 Tips and Shortcuts. You need a chief complaint for each and every encounter. It may be a symptom or it may be a statement such as follow-up HTN.. The physician must always complete the HPI. However, it is acceptable to have the patient or a member of your staff fill out a questionnaire for the past medical, family, and social history (SH). However, in order for this information to be counted in your history, you must initial the document and include any pertinent positive and negative information in the body of your note. You should also mention that you reviewed the form in its entirety. Finally, you must keep the questionnaire as a permanent part of the medical record. 3. You don t have to list out the ROS; it is acceptable to have the patient fill out a form and then initial it, but that form must remain in the chart and you must refer to it in the body of your note. For example, Complete 0 system ROS performed and documented, with pertinent findings included in the interval history. 4. A Complete ROS requires that at least 0 systems be documented. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least 0 systems must be individually documented. (This shortcut is NOT accepted by ALL Medicare carriers, so check before you use it.) 5. When doing a comprehensive history on a follow-up patient in the office, you do not need to redictate a previous PMFSH if it is already in the chart. It is acceptable to refer to the earlier PMFSH and make any additions as needed. For example: The comprehensive past medical, family, and social history obtained during our initial encounter was re-examined and reviewed with the patient. For details, please refer to my dictated note in this chart, dated September 3, 003. Nothing more to add at this time. 6. If the patient is too ill or confused to give a reliable history or ROS, you do not need to include this information in the documentation, but you must explain why the data is missing, e.g., Unable to obtain ROS or past medical, family and social history due to patient s mental status 7. At least one element from EACH of family, medical, and social history (SH) are required for a complete SH for the following categories: Office New Patient, Hospital Observation Care, Initial inpatient services, Consults, Comprehensive Nursing Facility Assessments (new patient), domiciliary care (new patient), and home care (new patient). 8. Only out of 3 elements of SH are required to qualify for Comprehensive for established office patients, ER visits, and established domiciliary or home patients. 9. SH Exemption: hospital progress notes require only an interval history. These encounters are officially exempt from the requirement for any elements of SH. Therefore a level 3 hospital progress note (9933)--which requires a ailed --does not require documentation of any elements of SH. 0. When using time as a determining factor, you must see the patient face to face for the entire time allotted for that particular level of care (for instance 5 minutes for a level 4 office follow-up visit.) You MUST document in the time spent AND the fact that OVER half of that time was devoted to counseling and/or coordination of care.. Prolonged services may be billed separately when a physician provides extended service involving direct (face-to-face) patient contact that is beyond the usual time allotted to a given encounter in either the inpatient or outpatient setting. This service is reported in addition to other physician services, including E/M services at any level. Report the total duration of face-to-face time spent by a physician on a given date, even if the time spent is not continuous. Prolonged services of less than 30 minutes are not reported separately. Code for the first 30 minutes to one hour of additional face-to-face service in the outpatient setting. This code is used in addition to the outpatient E/ M visit codes. Code for each additional 30 minutes beyond the first hour. Code for the first 30 minutes to one hour of prolonged services in the inpatient setting. Code for each additional 30 minutes beyond the first hour of prolonged services in the inpatient setting. These codes are used in addition to the inpatient E/M codes. 7

20 Physical 997 Physical 5 Organ Systems and 59 bullets ailed Comp Bullets Physical Organ Systems Constitutional Eyes Ears, nose, mouth and throat Neck Respiratory Cardiovascular Chest (breasts) Gastrointestinal GU (male, female) Musculoskeletal Lymphatic Skin Neurologic Psychiatric See individual bullets on next page. 8

21 The 997 Multi-System Bullets Constitutional Three vital signs General appearance Eyes Inspection of conjunctiva and lids ination of pupils and irises (PERRLA) Ophthalmoscopic discs and posterior segments Ears, Nose, Mouth, and Throat External appearance of the ears and nose Otoscopic examination of the external auditory canals and tympanic membranes Assessment of hearing Inspection of nasal mucosa, septum and turbinates Inspection of lips, teeth and gums ination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx Neck ination of neck (e.g., masses, overall appearance, symmetry, tracheal position, crepitus) ination of thyroid Respiratory Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic excursions) Percussion of chest Palpation of chest (e.g., tactile fremitus) Auscultation of the lungs Cardiovascular Palpation of the heart (PMI) Auscultation of the heart Assessment of lower extremity edema ination of the carotid arteries ination of abdominal aorta ination of the femoral pulses ination of the pedal pulses Chest (Breasts) Inspection of the breasts Palpation of the breasts and axillae Gastrointestinal (Abdomen) ination of the abdomen with notation of presence of masses or tenderness ination of the liver and spleen ination for the presence or absence of hernias ination of anus, perineum, and rectum, including sphincter tone, presence of hemorrhoids, rectal masses Obtain stool for occult blood testing Genitourinary (Male) ination of the scrotal contents (e.g., tenderness of cord) ination of the penis DRE of the prostate Genitourinary (Female) ination of the external genitalia ination of the urethra ination of the bladder (e.g., fullness, masses, tenderness) ination of the cervix ination of the uterus (e.g., size, contour, position, mobility) ination of the adnexa (e.g., masses, tenderness, nodularity) Musculoskeletal ination of gait and station Inspection and/or palpation of digits and nails (e.g., clubbing, cyanosis, ischemia) ination of the joints, bones, and muscles of one or more of the following six areas:. Head and neck. Spine, ribs, and pelvis 3. Right upper extremity 4. Left upper extremity 5. Right lower extremity 6. Left lower extremity The examination of a given area includes: Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses or effusions Assessment of range of motion with notation of any pain, crepitation or contracture Assessment of stability with notation of any dislocation, subluxation, or laxity Assessment of muscle strength and tone with notation of any atrophy or abnormal movements Lymphatic Palpation of lymph nodes two or more areas Neck Axillae Groin Other Skin Inspection of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers) Palpation of the skin and subcutaneous tissue (e.g., induration, subcutaneous nodules, tightening) Neurologic Test cranial nerves with notation of any deficits ination of DTRs with notation of any pathologic reflexes (e.g., Babinksi) ination of sensation (e.g., by touch, pin, vibration, proprioception) Psychiatric Description of patient s judgment and insight Brief assessment of mental status, which may include: Orientation to time, place, and person Recent and remote memory Mood and affect 9

22 995 Rules Body Areas Organ Systems Head/face Neck Chest/breast/axillae Abdomen Genitalia/groin/buttocks Back/spine Each extremity Constitutional Eyes ENMT Cardiovascular Respiratory GI GU Musculoskeletal Skin Neuro Psychiatric Hematologic-lymphatic Problem Focused: a limited exam of affected body area or organ system Expanded Problem Focused: a limited exam of the affected body area or organ system and other symptomatic or related organ systems ailed: an extended exam of the affected body area or organ system and other symptomatic or related organ systems Comprehensive: a general multi-system exam or complete exam of a single organ system The 995 exam rules are included here for the sake of completeness. We recommend using the 997 physical exam rules because they are less open to individual interpretation and therefore more likely to stand up against an audit. 0

23 Physical. What level of care is supported by the?. What documentation is required? 3. Is it reasonable to do what the documentation asks? ER E/M Services E/M Code Time 998 SF Comp Comp 3 out of 3 key components must qualify

24 998 E/M Code Time 998 SF 3 out of 3 key components must qualify By far the least frequently used code for these encounters Reimbursement is about $ % % % % % 998 E/M Code Time 998 SF 3 out of 3 key components must qualify Problem Focused Problem Focused SF/ Complexity Hx HPI ROS SH Bullets Prob Pts Data Pts Risk Brief None None 5 from any systems SF 0 - Min Brief None 6 from any systems Ext 9 /3 from any systems 3 3 Comp Ext 0 3/3 Comp from 9 systems 4 4 Requires two out of three

25 What Does a 998 Look Like? A 4 year old male presents for removal of sutures from a well-healed, uncomplicated laceration on the left arm You remove the sutures and clean and dress the wound The patient is discharged with no further follow-up required Points Problems/DDx Pts Data Reviewed Pts Self limited or minor (Max ) Review/order clinical lab tests Established problem, stable Review/order X-rays Established problem, worsening New problem, no additional work-up planned New problem, additional work-up planned 3 4 Total Points = Review/order medicine tests (echo, EKG, LHC, Ts) Discuss test results with MD Independent review of image, tracing, or specimen Decision to obtain old records Review of old records Total Points = 0 3

26 Risk Presenting Problems Diagnostic Procedures Management Options Minimal One self-limited or minor problem, e.g., cold, insect bite, tinea corporis. Laboratory tests Chest X-rays EKG/EEG, Echocardiogram Rest Gargles Superficial dressings Two or more self-limited or minor problems One stable chronic illness Acute uncomplicated injury or illness, e.g., cystitis, allergic rhinitis, sprain Physiologic tests not under stress, e.g., Ts Non-cardiovascular imaging studies with contrast ABG Skin biopsies Over the counter drugs Minor surgery, with no risk factors PT/OT IV fluids, without additives erate One chronic illness, with mild exacerbation, Two stable chronic illnesses Undiagnosed new problem, with uncertain prognosis Cardiac stress test Cardiovascular imaging studies, with contrast, with no identified risk factors Prescription drug management IV fluids, with additives One or more chronic illness, with severe exacerbation Acute or chronic illness or injury, which poses a threat to life or bodily function An abrupt change in neurological status Cardiovascular imaging, with contrast, with identified risk factors Cardiac EP studies Diagnostic endoscopies, with identified risk factors Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Obtain DNR or deescalate care Calculating the Overall Complexity Problems Data Risk SF 0 - Min erate Need out of 3 to qualify for given level of 4

27 Selecting the Target Code E/M Code Time 998 SF Comp Comp 3 out of 3 key components must qualify Plan Out the Documentation 998 Straightforward 3 out of 3 key components must qualify 5

28 HPI ROS SH Brief None None CC: Follow-up for suture removal HPI: The patient is here to have sutures removed from a left arm laceration. One HPI Element Location 3 out of 3 key components must qualify Target Code 998 E/M Insight: Problem Focused The requirements for a problem focused history are so minimal, it s difficult (but not impossible) not to qualify for this level of history. The only requirement is a brief HPI, which must contain one HPI element OR the status of one to three chronic or inactive problems. In the example above, we noted the location of the laceration, which counts as one HPI element. That s all you need. SF 6

29 Constitutional Eyes ENMT Neck Lungs Physical CV GI GU Chest/Breasts 4 cm well healed linear laceration; wound edges clean; no fluctuance Skin Musculoskeletal Requires only - 5 bullets from ANY organ systems Neurologic Psychiatric 3 out of 3 key components must qualify Target Code 998 SF E/M Insight: Problem Focused Similar to the problem focused history, the requirements for a problem focused history are so minimal, it s difficult (but not impossible) not to qualify for this level of exam. The only requirement is one to five bullets from any organ systems. In the example above, we included the following bullets: Inspection of skin Palpation of skin That s all you need. 7

30 Medical Decision-Making Assessment: Well-healed, uncomplicated laceration Plan: No further follow-up required Prob Pts Data Pts Risk SF 0 - Min Requires two out of three Target Code 998 SF E/M Insight: Straightforward It literally is impossible not to qualify for this level of complexity. All you need is two out of three: One problem point One data point Minimal risk The example above qualifies based on one problem point (for the selflimited problem of the laceration) and minimal risk. 8

31 998 CC: Follow-up for suture removal One HPI Element Location (qualifies as a problem focused history) HPI: The patient is here to have sutures removed from a left arm laceration. 4 cm well healed linear laceration; wound edges clean; no fluctuance Bullets Used Inspection of skin Palpation of skin (Qualifies as a problem focused exam) Assessment: Well-healed, uncomplicated laceration Plan: No further follow-up required Prob Pts Data Pts Risk SF Min This example qualifies as straightforward based on one problem point and minimal risk. Target 998 Requires three out of three qualifying key components SF 9

32 998 E/M Code Time out of 3 key components must qualify Second least frequently used code for these encounters Reimbursement is about $ % % % % % 998 E/M Code Time out of 3 key components must qualify Complexity Hx HPI ROS SH Bullets Prob Pts Data Pts Risk Brief None None 5 from any systems SF 0 - Min Brief None 6 from any systems Ext 9 /3 from any systems 3 3 Comp Ext 0 3/3 Comp from 9 systems 4 4 Requires two out of three 30

33 What Does a 998 Look Like? You see a 9 year old college student with a rash on both legs after hiking in the woods You diagnose Toxicodendron dermatitis You recommend Calamine lotion, PRN benadryl and Burrow's solution Points Problems/DDx Pts Data Reviewed Pts Self limited or minor (Max ) Review/order clinical lab tests Established problem, stable Review/order X-rays Established problem, worsening New problem, no additional work-up planned New problem, additional work-up planned 3 4 Total Points = 3 Review/order medicine tests (echo, EKG, LHC, Ts) Discuss test results with MD Independent review of image, tracing, or specimen Decision to obtain old records Review of old records Total Points = 0 3

34 Risk Presenting Problems Diagnostic Procedures Management Options Minimal One self-limited or minor problem, e.g., cold, insect bite, tinea corporis. Laboratory tests Chest X-rays EKG/EEG, Echocardiogram Rest Gargles Superficial dressings Two or more self-limited or minor problems One stable chronic illness Acute uncomplicated injury or illness, e.g., cystitis, allergic rhinitis, sprain Physiologic tests not under stress, e.g., Ts Non-cardiovascular imaging studies with contrast ABG Skin biopsies Over the counter drugs Minor surgery, with no risk factors PT/OT IV fluids, without additives erate One chronic illness, with mild exacerbation, Two stable chronic illnesses Undiagnosed new problem, with uncertain prognosis Cardiac stress test Cardiovascular imaging studies, with contrast, with no identified risk factors Prescription drug management IV fluids, with additives One or more chronic illness, with severe exacerbation Acute or chronic illness or injury, which poses a threat to life or bodily function An abrupt change in neurological status Cardiovascular imaging, with contrast, with identified risk factors Cardiac EP studies Diagnostic endoscopies, with identified risk factors Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Obtain DNR or deescalate care Calculating the Overall Complexity Problems Data Risk SF 0 - Min erate Need out of 3 to qualify for given level of 3

35 Selecting the Target Code E/M Code Time 998 SF Comp Comp 3 out of 3 key components must qualify Plan Out the Documentation 998 Complexity 3 out of 3 key components must qualify 33

36 HPI ROS SH Brief None CC: My legs are really itchy HPI: The patient is a 9 YOF who was out hiking yesterday and developed a painful and intensely pruritic rash on both legs this morning. ROS CV: Negative for palpitations, chest tightness Two HPI Elements Location, Duration Review of One System Cardiovascular 3 out of 3 key components must qualify Target Code 998 E/M Insight: Expanded Problem Focused The only difference between a problem focused history and an expanded problem focused history is one element of ROS. A problem focused history requires a brief HPI and review of one system. Brief HPI: Requires one to four HPI elements or the status of one to three problems. The above example qualifies with documentation of two HPI elements (Location, Duration). ROS: One ROS is required for this history. The example qualifies by reviewing the CV system. 34

37 Constitutional Eyes ENMT Neck 3 Lungs Physical CV 4 5 GI GU Chest/Breasts Vitals: 5/75, 8, 8, 98.6 General: D, conversant, well nourished WF looks stated age OP: Clear; no pharyngeal edema Lungs: No wheezes CV: RRR, no MRGs Skin: Warm and dry; normal turgor; multiple streak-like edematous papular lesions on an erythematous base located on both lower extremities below the knees Requires only 6 - bullets from ANY organ systems Skin 6 7 Musculoskeletal Neurologic Psychiatric 3 out of 3 key components must qualify Target Code 998 E/M Insight: Expanded Problem Focused An expanded problem focused exam requires six to bullets from any organ systems. The example above qualifies based on the following seven bullets: General appearance Three vital signs ination of the oropharynx Auscultation of the lungs Auscultation of the heart Inspection of the skin Palpation of the skin 35

38 Medical Decision-Making Assessment: Toxicodendron Dermatitis Plan:. Calamine lotion. PRN Benadryl Prob Pts Data Pts Risk 3. Burrow s solution for weeping blisters SF 0 - Min Requires two out of three 3 out of 3 key components must qualify Target Code 998 E/M Insight: Complexity The acuity of care required for this level of is very low. All you need is two out of three: Two problem points Two data points risk The example above qualifies based on three problem points (for the new problem with no additional w/u of poison ivy) and low risk (based on the use of OTC medications). 36

39 CC: My legs are really itchy 998 Two HPI Elements Location, Duration HPI: The patient is a 9 YOF who was out hiking yesterday and developed a painful and intensely pruritic rash on both legs this morning. ROS CV: Negative for palpitations/chest tightness One ROS Cardiovascular Physical D, conversant, well-nourished WF; looks stated age Vitals: 5/75, 8, 8, 98.6 OP: Clear; no pharyngeal edema Lungs: No wheezes CV: RRR, no MRGs Skin: Warm and dry; normal turgor; multiple streak-like, edematous popular lesions on an erythematous base on both lower extremities This exam includes seven bullets: General appearance Three vital signs of oropharynx Auscultation of lungs Auscultation of heart Inspection of skin Palpation of skin (Qualifies as a n exam) Assessment: Toxicodendron dermatitis Plan:. CALAMINE lotion. PRN BEDRYL 3. Borrow s solution for weeping blisters Prob Pts Data Pts Risk SF Min qualifies as being of low complexity based on three problem points and the presence of low risk. Target

40 9983 E/M Code Time out of 3 key components must qualify Third most frequently used code for these encounters Reimbursement is about $ % % % % % 9983 E/M Code Time out of 3 key components must qualify erate Complexity Hx HPI ROS SH Bullets Prob Pts Data Pts Risk Brief None None 5 from any systems SF 0 - Min Brief None 6 from any systems Ext 9 /3 from any systems 3 3 Comp Ext 0 3/3 Comp from 9 systems 4 4 Requires two out of three 38

41 What Does a 9983 Look Like? You see a 34 YOF who complains of one day of dysuria UA shows 0 WBCs The patient is afebrile, hemodynamically stable and otherwise healthy After diagnosing uncomplicated cystitis, you prescribe Bactrim DS BID for three days Points Problems/DDx Pts Data Reviewed Pts Self limited or minor (Max ) Review/order clinical lab tests Established problem, stable Review/order X-rays Established problem, worsening New problem, no additional work-up planned New problem, additional work-up planned 3 4 Total Points = 3 Review/order medicine tests (echo, EKG, LHC, Ts) Discuss test results with MD Independent review of image, tracing, or specimen Decision to obtain old records Review of old records Total Points = 39

42 Risk Presenting Problems Diagnostic Procedures Management Options Minimal One self-limited or minor problem, e.g., cold, insect bite, tinea corporis. Laboratory tests Chest X-rays EKG/EEG, Echocardiogram Rest Gargles Superficial dressings Two or more self-limited or minor problems One stable chronic illness Acute uncomplicated injury or illness, e.g., cystitis, allergic rhinitis, sprain Physiologic tests not under stress, e.g., Ts Non-cardiovascular imaging studies with contrast ABG Skin biopsies Over the counter drugs Minor surgery, with no risk factors PT/OT IV fluids, without additives erate One chronic illness, with mild exacerbation, Two stable chronic illnesses Undiagnosed new problem, with uncertain prognosis Cardiac stress test Cardiovascular imaging studies, with contrast, with no identified risk factors Prescription drug management IV fluids, with additives One or more chronic illness, with severe exacerbation Acute or chronic illness or injury, which poses a threat to life or bodily function An abrupt change in neurological status Cardiovascular imaging, with contrast, with identified risk factors Cardiac EP studies Diagnostic endoscopies, with identified risk factors Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Obtain DNR or deescalate care Calculating the Overall Complexity Problems Data Risk SF 0 - Min Need out of 3 to qualify for given level of 40

43 Selecting the Target Code E/M Code Time 998 SF Comp Comp erate complexity goes along with EITHER a 9983 or a Which of these is the correct target code? 9983 vs The Three Questions. What level of care is supported by the?. What documentation is required? 3. Is it medically necessary to do what the documentation asks? 4

44 9983 vs Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of E/M service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Medicare Carrier Manual 9983 vs E/M Code Time 998 SF Comp Comp ailed Requires 4 HPI elements or the status of three chronic or inactive problems, plus 9 ROS, plus at least one element of SH ailed Requires at least bullets from any organ systems Given the benignity of the presenting problem of cystitis, it is unlikely that we can justify performing and documenting EITHER a detailed history or a detailed exam. The medical necessity of this encounter simply does not support this level of history and physical. When this happens, you should dial it down a notch and re-test the documentation. 4

45 Target Code: 9983 E/M Code Time 998 SF Comp Comp 3 out of 3 key components must qualify Plan Out the Documentation 9983 erate 3 out of 3 key components must qualify 43

46 HPI ROS SH Brief None CC: Burning with urination HPI: The patient complains of burning with urination since yesterday. ROS Constitutional: Negative for fevers/chills/anorexia GU: Negative for flank pain, hematuria One HPI Element Duration Review of Two Systems Constitutional GU Target Code out of 3 key components must qualify E/M Insight: Expanded Problem Focused Requires a brief HPI (using one to three HPI elements or the status of one to three problems), plus one ROS. No elements of SH are required. This example qualifies as follows: HPI: One HPI element (Duration) ROS: Two systems reviewed (constitutional, genitourinary) 44

47 Constitutional Eyes ENMT Neck Lungs Physical 3 CV GI 4 5 GU Chest/Breasts Vitals: 0/65, 8, 77, 98.7 General: D, conversant, well nourished WF looks stated age Lungs: CTA CV: RRR, no MRGs Abd: Soft, non-tender; no CVAT Skin: Warm and dry, well-perfused 6 Skin Musculoskeletal Requires only 6 - bullets from ANY organ systems 3 out of 3 key components must qualify Target Code 9983 Neurologic Psychiatric E/M Insight: Expanded Problem Focused An expanded problem focused exam requires six to bullets from any organ systems. The example above qualifies based on the following six bullets: General appearance Three vital signs Auscultation of the lungs Auscultation of the heart Brief abdominal exam Palpation of the skin 45

48 Medical Decision-Making UA shows 0 WBCs Assessment: Uncomplicated acute cystitis Plan:. Bactrim DS BID X 3 days. Push PO fluids 3. RTC if flank pain or high fever Prob Pts Data Pts Risk SF 0 - Min Requires two out of three 3 out of 3 key components must qualify Target Code 9983 E/M Insight: erate Complexity Requires two out of three: Three problem points Three data points erate risk The example above qualifies based on three problem points (for the new problem with no additional w/u of cystitis) and the presence of moderate risk (based on the use of prescription medications). 46

49 9983 Chief Complaint: Burning with urination. One HPI Element Duration HPI: The patient complains of burning with urination since yesterday. ROS Constitutional: Negative for fevers/chills/anorexia GU: Negative for flank pain or hematuria Two ROS Constitutional, GU Physical Vitals: 0/65, 8, 77, 98.7 Gen: D, well-nourished WF; looks stated age Lungs: CTA CV: RRR, no MRGs Abd: Soft, non-tender; no CVAT Skin: Warm and dry; well-perfused This exam includes six bullets: General appearance Three vital signs Auscultation of lungs Auscultation of heart Abdominal exam Palpation of skin (Qualifies as a n exam) UA shows 0 WBCs Assessment: Uncomplicated acute cystitis Plan:. Bactrim DS times three days. Push PO fluids 3. RTC if flank pain or high fever Prob Pts Data Pts Risk SF Min qualifies as being of moderate complexity based on three problem points and the presence of moderate risk. Target

50 9984 E/M Code Time out of 3 key components must qualify Second most frequently used code for these encounters Reimbursement is about $ % % % % % 9984 E/M Code Time out of 3 key components must qualify erate Complexity Hx HPI ROS SH Bullets Prob Pts Data Pts Risk Brief None None 5 from any systems SF 0 - Min Brief None 6 from any systems Ext 9 /3 from any systems 3 3 Comp Ext 0 3/3 Comp from 9 systems 4 4 Requires two out of three 48

51 What Does a 9984 Look Like? You see a 58 YOM who complains of abdominal/flank pain and hematuria The pain responds to IV Ketorolac CT renal colic shows a mm nonobstructing stone in the distal left ureter UA shows RBCs, but all other labs are WNL You prescribe Lortab and fluids and discharge the patient with a strainer Points Problems/DDx Pts Data Reviewed Pts Self limited or minor (Max ) Review/order clinical lab tests Established problem, stable Review/order X-rays Established problem, worsening New problem, no additional work-up planned New problem, additional work-up planned 3 4 Total Points = 3 Review/order medicine tests (echo, EKG, LHC, Ts) Discuss test results with MD Independent review of image, tracing, or specimen Decision to obtain old records Review of old records Total Points = 4 49

52 Risk Presenting Problems Diagnostic Procedures Management Options Minimal One self-limited or minor problem, e.g., cold, insect bite, tinea corporis. Laboratory tests Chest X-rays EKG/EEG, Echocardiogram Rest Gargles Superficial dressings Two or more self-limited or minor problems One stable chronic illness Acute uncomplicated injury or illness, e.g., cystitis, allergic rhinitis, sprain Physiologic tests not under stress, e.g., Ts Non-cardiovascular imaging studies with contrast ABG Skin biopsies Over the counter drugs Minor surgery, with no risk factors PT/OT IV fluids, without additives erate One chronic illness, with mild exacerbation, Two stable chronic illnesses Undiagnosed new problem, with uncertain prognosis Cardiac stress test Cardiovascular imaging studies, with contrast, with no identified risk factors Prescription drug management IV fluids, with additives One or more chronic illness, with severe exacerbation Acute or chronic illness or injury, which poses a threat to life or bodily function An abrupt change in neurological status Cardiovascular imaging, with contrast, with identified risk factors Cardiac EP studies Diagnostic endoscopies, with identified risk factors Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Obtain DNR or deescalate care Calculating the Overall Complexity Problems Data Risk SF 0 - Min Need out of 3 to qualify for given level of 50

53 Target Code: 9984 E/M Code Time 998 SF Comp Comp 3 out of 3 key components must qualify Plan Out the Documentation 9984 ailed ailed erate 3 out of 3 key components must qualify 5

54 HPI ROS SH ailed Extended 9 /3 CC: Abdominal pain HPI: The patient is a pleasant a 58 YOWM who presents with intermittent left flank and abdominal pain associated with blood in the urine, which began this morning at 000. The pain is described as 8/0 in severity. Pertinent SH: Positive for ongoing tobacco abuse; negative ETOH ROS CV: Negative for SSCP/orthopnea/PND GU: Negative for obstructive sx, dysuria, urgency, nocturia GI: Negative for N/V/D, melena, hematemesis 3 out of 3 key components must qualify Target Code 9984 E/M Insight: ailed Requires an extended HPI (using four HPI elements or the status of three problems), plus -9 ROS and one out of three components of SH. This example qualifies as follows: HPI: Five HPI elements (timing, location, associated signs/symptoms, duration, severity) ROS: Three systems reviewed (CV, GU, GI) SH: An item from the social history is documented. 5

55 Physical Constitutional Eyes ENMT Neck Lungs: Clear to auscultation and percussion bilaterally Lungs Vitals: 48/90, 8, 96, 98.6 General: Somewhat agitated non-toxic WM; looks stated age Eyes: Anicteric sclerae CV: RRR, no MRGs Abd: Soft, non-tender; BS; no HSM, masses, hernias or bruits Rectal: Normal tone; no masses; heme - Ext: No peripheral edema CV Requires AT LEAST bullets from ANY organ systems 8 GI9 0GU Chest/Breasts Skin Musculoskeletal Neurologic Psychiatric 3 out of 3 key components must qualify Target Code 9984 E/M Insight: ailed An detailed exam requires bullets from any organ systems. The example above qualifies based on the following bullets: General appearance Three vital signs of sclerae Auscultation of the lungs Percussion of lungs Auscultation of the heart Brief abdominal exam of liver/spleen for hernias Rectal exam Obtain stool for occult blood Assessment of peripheral edema 53

56 Medical Decision-Making UA: No WBCs; RBCs TNTC CT renal colic was reviewed and showed a mm non-obstructing stone in the distal left ureter Assessment: Acute non-obstructing left ureteral nephrolithiasis Plan:. D/C patient home with a strainer. Push PO fluids at home 3. Lortab 7.5/500 PO Q 4 hrs, PRN for pain Prob Pts Data Pts Risk SF 0 - Min Requires two out of three Target Code out of 3 key components must qualify E/M Insight: erate Complexity Requires two out of three: Three problem points Three data points erate risk In the example above, there are three problem points, four data points and moderate risk. Since two out of three dimensions are needed, this adds up to moderate complexity. 54

57 Chief Complaint: Abdominal pain HPI: The patient is a pleasant 58 YOWM who presents with intermittent left flank and abdominal pain associated with blood in the urine, which began this morning at 000. The pain is described as 8/0 in severity. Five HPI Elements Timing Location Assoc. Signs/Sx Duration Severity Pertinent SH is remarkable for ongoing tobacco abuse; negative ETOH. ROS CV: Negative for SSCP/orthopnea/PND GU: Negative for obstructive sx/dysuria/nocturia GI: Negative for N/V/melena/hematemesis /3 SH SH Three ROS CV, GU, GI Vitals: 48/90, 8, 96, 98.6 Gen: Somewhat agitated, non-toxic WM Eyes: Anicteric sclerae Lungs: CTA and percussion CV: RRR, no MRGs Abd: Soft, BS, no HSM, hernias, masses or bruits Rectal: Normal tone; no masses; heme - Ext: No peripheral edema UA: No WBCs; RBCs TNTC Bullets General appearance Three vital signs of slcerae Auscultation of lungs Percussion of lungs Auscultation of heart Abdominal exam of liver/spleen for hernias Rectal exam Obtain stool for occult blood Assessment of extremity edema Assessment: Acute non-obstructing left ureteral nephrolithiasis Plan:. D/C patient to home with a strainer. Push PO fluids at home 3. Lortab 7.5/500 PO Q 4H, PRN Prob Pts Data Pts Risk SF Min qualifies as being of moderate complexity based on all three dimensions of medical decision-making Target

58 9985 E/M Code Time 9985 Comp* Comp 3 out of 3 key components must qualify Most frequently used code for these encounters Reimbursement is about $ % % % % % 9985 E/M Code Time 9985 Comp* Comp 3 out of 3 key components must qualify Comprehensive* Comprehensive Complexity Hx HPI ROS SH Bullets Prob Pts Data Pts Risk Brief None None 5 from any systems SF 0 - Min Brief None 6 from any systems Ext 9 /3 from any systems 3 3 Comp* Ext 0 3/3 Comp from 9 systems 4 4 Requires two out of three *For ER E/M services, only two out of three components of SH are needed to qualify for a comprehensive history. 56

59 What Does a 9985 Look Like? You see an elderly NH resident brought to the ER for confusion The patient is obtunded and cannot give any history, but there is an old chart available, which you review After reviewing the labs and the CXR, you make the diagnosis of RML pneumonia. You send sputum and blood cultures, start IV fluids and empiric ATBs. You also arrange for the patient to be admitted. Points Problems/DDx Self limited or minor (Max ) Established problem, stable Established problem, worsening New problem, no additional work-up planned New problem, additional work-up planned Pts 3 4 Total Points = 7 Data Reviewed Review/order clinical lab tests Review/order X-rays Review/order medicine tests (echo, EKG, LHC, Ts) Discuss test results with MD Independent review of image, tracing, or specimen Decision to obtain old records Review of old records Pts Total Points = 6 57

60 Risk Presenting Problems Diagnostic Procedures Management Options Minimal One self-limited or minor problem, e.g., cold, insect bite, tinea corporis. Laboratory tests Chest X-rays EKG/EEG, Echocardiogram Rest Gargles Superficial dressings Two or more self-limited or minor problems One stable chronic illness Acute uncomplicated injury or illness, e.g., cystitis, allergic rhinitis, sprain Physiologic tests not under stress, e.g., Ts Non-cardiovascular imaging studies with contrast ABG Skin biopsies Over the counter drugs Minor surgery, with no risk factors PT/OT IV fluids, without additives erate One chronic illness, with mild exacerbation, Two stable chronic illnesses Undiagnosed new problem, with uncertain prognosis Cardiac stress test Cardiovascular imaging studies, with contrast, with no identified risk factors Prescription drug management IV fluids, with additives One or more chronic illness, with severe exacerbation Acute or chronic illness or injury, which poses a threat to life or bodily function An abrupt change in neurological status Cardiovascular imaging, with contrast, with identified risk factors Cardiac EP studies Diagnostic endoscopies, with identified risk factors Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Obtain DNR or deescalate care Calculating the Overall Complexity Problems Data Risk SF 0 - Min Need out of 3 to qualify for given level of 58