Coding and Billing 101: Getting Paid for What You Do

Transcription

1 American College of Physicians Internal Medicine 2014 Coding and Billing 101: Getting Paid for What You Do Faculty Director: Jeannine Z. Engel, MD, FACP Disclosure: Has no relationship with any proprietary entity producing health care goods or services consumed by or used on patients. Clinical questions to be addressed: 1.What are the basics of coding and documenting office visit and preventive services? 2.How can you best select the level of office visit service to maximize revenue and minimize audit risk? 3.How can you minimize coding problems that can lead to payment denials and delays? 4.What resources are available to help you navigate this nonclinical, yet essential, part of medical practice? Posted Date: March 10, American College of Physicians. All rights reserved. Reproduction of Internal Medicine 2014 presentations, or print or electronic material associated with presentations, is prohibited without written permission from the ACP.

2 Background Coding and Billing 101 The Basics of Outpatient Billing April 2014 Jeannine Z. P. Engel, MD, FACP Assistant Professor of Medicine Physician Advisor to Health Care Compliance Office University of Utah Medical Center HCFA, now CMS Center for Medicare and Medicaid Services issued guidelines for documentation of different service codes in They were revised in Either can be used, but not in combination. In general, the 1995 guidelines are more favorable for General Internists Medicaid and commercial payers may or may NOT follow CMS guidelines must check in your state Session Objectives Disclaimer This session will provide basic information regarding documentation and coding. Before applying this information at your institution or practice site, YOU MUST CHECK WITH YOUR COMPLIANCE OFFICE and/or local Medicare Carrier to be sure these general principles are appropriate for your practice situation. Review Documentation requirements for Basic Outpatient Office Visits Learn efficient documentation of Medical Decision Making Review time based coding for Counseling and Coordination of Care Review Transitional Care Management Codes Extra material if time Leave time for Questions Three Questions Basic Coding Rules and Regulations Is the patient new or established? What level of history, PE and Medical Decision Making MDM is will be recorded? Corollary: Is this a problem based or Annual Exam/Annual wellness visit What is the appropriate Service Code for the care documented? 1

3 New vs. Return A new patient has not received professional services from your group in the past 3 years Hospital clinic Residents Faculty Physician extenders If established patient has not been seen in 3 years, bill them as New CMS specialty Codes 01 General Practice 02 General Surgery 03 Allergy/Immunology 04 Otolaryngology 05 Anesthesiology 06 Cardiology 07 Dermatology 08 Family Practice 09 Interventional Pain Management 10 Gastroenterology 11 Internal Medicine 12 Osteopathic Manipulative Medicine 13 Neurology 14 Neurosurgery 15 Speech Language Pathologist in Private Practice 16 Obstetrics/Gynecology 17 Hospice and Palliative Care 18 Ophthalmology 19 Oral Surgery Dentists only 20 Orthopedic Surgery 21 Cardiac Electrophysiology 22 Pathology 23 Sports Medicine 24 Plastic and Reconstructive Surgery 25 Physical Medicine and Rehabilitation 26 Psychiatry 27 Geriatric Psychiatry 28 Colorectal Surgery 29 Pulmonary Disease 30 Diagnostic Radiology 31 Intensive Cardiac Rehabilitation ICR 32 Anesthesiologist Assistant 33 Thoracic Surgery 34 Urology 35 Chiropractic 36 Nuclear Medicine 37 Pediatric Medicine 38 Geriatric Medicine 39 Nephrology 40 Hand Surgery 41 Optometry 42 Certified Nurse Midwife 43 Certified Registered Nurse Anesthetist CRNA 44 Infectious Disease 46 Endocrinology 48 Podiatry 50 Nurse Practitioner New Patient outpatient visit 3/3 needed CPT HPI ROS PFSH 1 (PF) 1 (EPF) 1 4 (DET) (COMP) New Patient outpatient visit 3/3 needed NGS MAC CPT HPI ROS PFSH 1 (PF) 1 (EPF) 1 Exam 1 (PF) 2-7* (EPF) MDM Exam 1 (PF) 2 (EPF) 5 (DET) 8 (COMP) 8 MDM Straightforwarforward Straight- Low Moderate High Time Straightforward Straightforward 4 (DET) ** (DET) 4 (COMP) (COMP) 8 Low Moderate High Time *EPF exam: minimal detail; ** Det exam: expanded documentation of organ systems examined (NGS documentation tool) Coding New Patient Visits 3 of 3 elements must be documented history, exam, decision making MEDICAL NECESSITY SHOULD DRIVE CODING Return Patient outpatient visit 2/3 needed CPT HPI ROS 1 (PF) 1 (EPF) 1 4 (3 chronic) 2 (DET) 4 (3 chronic) 10(COMP) PFSH Reserved 1 2 Exam for nonhospitalbased 1 (PF) 2 (EPF) 5 (DET) 8 (COMP) MDM practice Straightforward Low Moderate High Time 10 min 15 min 25 min 40 min 2

4 Return Patient outpatient visit 2/3 needed NGS MAC CPT HPI ROS 1 (PF) 1 (EPF) 1 4 (3 chronic) 2 (DET) 4 (3 chronic) 10(COMP) PFSH Reserved 1 2 for non- Exam 1 (PF) (COMP) facility- based (EPF) (DET) MDM practice Straightforward Low Moderate High Time 10 min 15 min 25 min 40 min Coding Return pt visits Only need 2 of 3 elements documented to meet level of service coded History, PE, MDM MEDICAL NECESSITY SHOULD STILL DRIVE CODING Medical Necessity?? It s what you should do, not what CAN do What the patient needs today, no more and no less Standard Documentation CC History PE Assessment and Plan Generally, not always medical decision making matches medical necessity What you are really thinking Chief Complaint What s wrong with this patient? MDM Possible differential diagnosis #diagnoses or management options What information do I need to gather to figure this out? Amount and complexity of data How quickly do I need to do all of this? risk level to patient History PE Documenting Medical Decision Making The Real Meat of Internal Medicine 3

5 Medical Decision Making Number of diagnoses Self limited; established; new problem Stable, worsening, additional testing planned Amount/complexity of data reviewed Ordering tests, reviewing tests, obtaining record Overall risk of complications See chart Number of diagnoses Self limited or minor: 1 pt each 2 max Established problem, stable: 1 pt New England now limiting to 2!! Established problem, worsening: 2 pts New problem, no addt l w/u: 3 pts New problem, with further w/u: 4 pts Diagnosis Points Diagnosis MDM SF Low Moderate High Amount/complexity of data Review and/or order lab test: 1 pt Review and/or order radiology: 1 pt Review and/or order medical test: 1 pt Includes vaccines, ecg, echo, pfts Discussion of test w/performing MD: 1 pt Independent review of test: 2 pts Old records or hx from another person Decision to do this: 1 pt Doing it and summarizing: 2 pts Data points Data MDM SF Low Moderate High Overall Risk table Learn and Love the overall risk table 3 categories: presenting problem, dx procedures, management options Pearls: Dart Board Prescription drug management: moderate 2 stable chronic illness: moderate Abrupt MS change: high 1 chronic illness w/severe exacerbation: high Risk Level Presenting Problems Diagnostic Procedures Ordered Management Options Selected Minimal One self limited or minor problem, e.g., cold Laboratory tests requiring venipuncture Rest insect bite, tinea corporis Chest X rays Gargles EKG/ EEG Elastic bandages Urinalysis Superficial dressings Ultrasound, e.g., echo KOH prep Low Two or more self limited or minor problems Physiologic tests not under stress, e.g., Over the Counter drugs One stable chronic illness, e.g., well controlled pulmonary function tests Minor surgery with no identified risk factors hypertension or Noncardiovascular imaging studies with Physical therapy noninsulin dependent diabetes, cataract, BPH contrast, e.g., barium enema Occupational therapy Acute uncomplicated illness or injury, e.g., Superficial needle biopsies IV fluids without additives cystitis, allergic rhinitis, simple sprain Clinical laboratory tests requiring arterial puncture Skin biopsies Moderate One or more chronic illness with mild Physiologic tests under stress, e.g., cardiac Minor surgery with identified risk factors exacerbation, progression, or side effects of stress test, fetal contraction stress test Elective major surgery open, percutaneous treatment Diagnostic endoscopies with no identified or endoscopic with no identified risk factors Two or more stable chronic illnesses risk factors Prescription drug management continuation Undiagnosed new problem with uncertain Deep needle or incisional biopsy & new prescription prognosis, e.g., lump in breast Cardiovascular imaging studies with contrast Therapeutic nuclear medicine Acute illness with systemic symptoms, e.g., and no identified risk factors, e.g., arteriogram IV fluids with additives pyelonephritis, pneumonitis, colitis cardiac catheter Closed treatment of fracture or dislocation Acute complicated injury, e.g., head injury with Obtain fluid from body cavity, e.g., lumbar without manipulation brief loss of consciousness puncture, thoracentesis, culdocentesis High One or more chronic illnesses with severe Cardiovascular imaging studies with contrast Elective major surgery open, percutaneous exacerbation, progression, or side effects of with identified risk factors or endoscopic with identified risk factors treatment Cardiac electrophysiological tests Emergency major surgery open, Acute or chronic illnesses or injuries that may Diagnostic endoscopies with identified risk percutaneous or endoscopic pose a threat to life or bodily function, e.g., factors Parental controlled substances multiple trauma, acute MI, pulmonary embolus, Discography Drug therapy requiring intensive monitoring severe respiratory distress, progressive severe for toxicity rheumatoid arthritis, psychiatric illness with Decision not to resuscitate or to de escalate potential threat to self or others, peritonitis, acute care because of poor prognosis renal failure An abrupt change in neurologic status, e.g., seizure, TIA, weakness or sensory loss Overall Decision Making Table need 2 of 3 elements to qualify for given level Level of MDM Straightforward 99201/ Low Moderate High # dx Amt data 0 or Overall risk minimal low moderate high 4

6 Case #1:LBP, New pt IMP: Mechanical LBP; R/O HNP Plan: Taper off NSAIDs; tylenol prn; Xray of LS spine Work on Hamstring stretching Will call with xray results If xray neg, or symptoms persist, will consider MRI of spine to R/O HNP. Pt understands plan. Xray results noted personally reviewed?? Case #1: LBP PM&R Presenting Problems: 1 new with workup 4 points high Data: xray; 1points SF Risk: OTC meds; exercises: Low Level of MDM Straight-forward Low Moderate High # dx 1 minimal 2 limited 3 Moderate 4 Extensive Amt data 1 minimal 2 limited 3 Moderate 4 Extensive Risk minimal low moderate high Overall: From MDM perspective: Low; Case #2 Case #2 Presenting problems 2 new with w/u; 1 new: 11 pts HIGH Data Labs 1pt; x ray 1pt; hx from other 2pts; order old records 1pt: 5 pts HIGH Risk Prescription drugs MODERATE Overall MDM:HIGH Pearls for documenting MDM Diagnosis 1 new problem without w/u level 4 dx 1 new problem with w/u level 5 dx Risk: Moderate Risklevel 4 visit Prescription drugs 1 chronic illness w/ progression or side effect of tx 2 stable illnesses undiagnosed new problem Pearls for documenting MDM Data 7 labs count the same as 1 lab 1 point Document if you discuss test with performing MD 1 pt Document when you review test 2 pts EKG, x rays, Urine dip, rapid strept Document if history from others 2 pts Document data from old records 2 pts old records reviewed is NOT adequate 5

7 Elements for E&M visits For Acute or Chronic Patient History CC HPI bullets 8 Location Quality Severity Duration Timing Context Modifying Factors Associated signs and symptoms Duration Years/months/days/hours Severity 6/10 pain; BP 190/110; sugars over 250 at home/4 pads/hour bleeding/hgb 5.1/needs nebs Q2 hrs Modifying Factors PT treatments; medications taking; position changes; a good cry Associated Symptoms Anything you ask! 1997 revisited Elements for E&M visits 1997 guidelines: An extended HPI consists of at least four elements of the HPI or the status of at least three chronic or inactive conditions For level 4 of 5 return visit, can document, pt here to f/u HTN, DM, and rash works for 1995 and1997 guidelines as of September and Education/Medicare Learning Network MLN/MLNEdWebGuide/EMDOC.html 99214/ / HPI Status 3 chronic Status 3 chronic ROS 2 10 PFSH 1 2 History CC HPI ROS 14 Constitutional fever/wt Eyes Ears/nose/mouth/throat CV Respiratory GI GU Musculoskeletal Skin Neurologic Psychiatric Endocrine Heme/lymphatic Allergic/Immuneologic Elements for E&M visits Pearls for History History CC HPI ROS PFSH Past Medical History Family history Social history Can refer to previously documented elements: problem list updated as part of today s visit Complete ROS o/w negative Taking history from someone other than the pt increases level of MDM Single bullets satisfy PFSH requirements does not need to be exhaustive BUT don t forget about patient care 6

8 Elements for E&M visits Elements for E&M visits Exam # of organ systems 12 Constitutional VS, general appearance Eyes Ears, nose, mouth, throat CV edema, pulses Respiratory GI GU Musculoskeletal Skin Neurologic Psychiatric Heme/lymph/immunologic Exam # body parts Head includes face 2. Neck 3. Chest includes breasts and axilla 4. Abdomen 5. Genitalia, groin, buttock 6. Back including spine Each extremity Extremities? Edema? Neck? Thyroid? Physical Exam How many PE elements can you document before examining the patient? At least 7 General appearance Eyes sclera anicteric/injected HENT hearing intact hard of hearing MSK normal gait/limping Psych normal depressed/flat affect Skin no rash on face, arms Immunologic NKDA use for PMH or PE Pearls for Documenting Exam Notations such as negative or normal are sufficient to document normal findings related to unaffected body areas or asymptomatic organ systems HEENT Normal: only counts as 1 organ system, so: Eyes sclera anicteric ENMT OP clear/red/whatever 95 versus 97 Physical exam is the difference 1995 Organ systems Body part Loosy goosy 1997 General Various specialty exams Proscriptive 97 exam example: Respiratory Problem Foc: 1-5 bullets Exp Prob Focused: 6+ bullets Detailed: 12+ bullets Comprehensive: perform all bullets; DOCUMENT every element in shaded box AND 1+ element in other boxes 7

9 1997 PE guidelines(gen) Case #1:PM&R Problem Focused: 1 5 bullets in 1 or more systems 99201/99212 Expanded Problem Focused: 6 11 bullets in 1 or more systems 99202/99213 Detailed: 12 bullets in 2 or more organ systems or 6 systems w/2 bullets each 99203/99214 Comprehensive: 2 bullets from 9 organ systems 99204/5 and audit tool available as part of electronic handout HPI: Context (fallen in tub) Duration (1 month) Location (right leg) Alleviating (NSAIDs) 4+ ROS: 1; PMH: meds EPF (level 2 new) 39 yo male, no sig PMH evaluated in ED 1 month ago. He had fallen in the tub and experienced R leg pain. Was seen and given IM injection and Rx for NSAIDs. Pain is improving, x mild?flare up about 1 week ago, no back pain. R leg pain involving posterior aspect of thigh, popliteal fossa, not. Case #1 PM&R Case #1 PM&R PE: thin male in NAD; A&O X3; BUE full ROM; good ; normal strength BLE with Nl strength, tight hamstrings, full DF/PR Nl sensation, no atrophy; 2 DTRs; symmetric LS spine c Nl lordosis; no paraspinous spasm; L5 ; Nl gait. PE: Gen; Psych : MSK; Neuro Organ systems Detailed level 3 new Overall Code? History: EPF Level 2 new Exam: Detailed Level 3 new MDM: Low Level 3 new Need 3/3 for new patients, so: Physician billed Could get with 1 additional ROS: no leg weakness or numbness; no bowel or bladder incontinence, no fevers. Case #2 8

10 Case #2 HPI: Foot pain loc, duration, severity, context, mod factors 4 HPI ROS: negative then 7 CV, pulm, GI, const,, eyes, ENMT PFSH: 2 NO FH!! PE: 8 History: PE: 99204/05 MDM: HIGH Case #2 BILLED: DOCUMENTED: BUT Case #2 Add FH Add 10 organ ROS otherwise negative Now history is 99204/ wrvus Only have 1 opportunity to bill New patients. Maximize these as MDM and Medical Necessity allows!! Counseling Time Based Coding When time spent counseling 50% of total visit, then TIME becomes the deciding factor for coding Total billing provider residents don t count face to face time : 15 min 14: 25 min 15: 40 min Must document total time, time spent counseling and reason for counseling 9

11 Counseling is: a discussion with the pt and/or family concerning one or more of the following areas CPT book Recommended tests, diagnostic results, impressions Prognosis Risks/benefits of treatment management options Instructions for treatment management options and follow up Importance of compliance with treatment management options Risk factor reduction Patient and family education New(ish) and exciting TCM codes; new 2013 Non face to face services and days post hospital D/C care Contact patient/caregiver with 2 days FTF visit in 7/14 days Moderate/high complexity and MDM Non FTF services provided by clinical staff and physician related to coordination of care Medicine reconciliation prior to FTF visit Clinical Staff Contact with home health Patient/family education Medication management Assistance with services needed Provider Obtaining/reviewing discharge information Review of pending diagnostic tests Interaction with other healthcare providers Assistance scheduling other follow up TCM codes; new 2013 TCM codes: reimbursement Process complexities Communication with D/C facility Initial patient contact or attempt Coherent/cohesive documentation of a 30 day service Holding bill from FTF service until end of 30 day period Work RVU facility Total RVU facility MC payment $84.59 $ $ $ $61.20 $80.20 $ $ Work RVU nonfacility Total RVU nonfacility MC Payment $ $ $ $ $81.13 $ $ $ Conversion: $ ($ ) 10

12 Opportunities? Why should you care? ALL CODING TALKS, PARAPHRASED it s the EMR I don t have enough time so many patients each day Audit scrutiny NGS: National Govt Services; Jurisdiction K: includes NY, CT, MA, RI, VT, NH, ME Pre payment audit May June 2013 GIM services; error rates exceeded 70% majority recoded to lower E&M level due to lack of documentation in H; PE; or high comp MDM Pre pay audit for for Oncology June August services reviewed; error rates 75% initial hosp Gen Surg June August services reviewed; error rates80% 99233subs hosp Cardiology and Gastroenterology June August services reviewed; error rates 70% October 2013: All above expanding to all specialties THANK YOU!! Other material if time Prolonged Services Preventive services IPPE/AWV CMS you Prolonged services Add on code used when at least 30 minutes of time is spent beyond the usual time per E&M visit Requirements Medically necessary services beyond the usual time for the base services Must be face to face service provided by the billing provider. Can not count time spent by nursing staff first minutes each additional 30 minutes Prolonged services Prolonged services codes: First 60 minutes (min 30 min) Each Additional 30 minutes (min 15 min) Inpatient wrvus wrvus Outpatient wrvus wrvus 11

13 Prolonged services Time Based Coding Documentation requirements: Start and stop time of the visit; total time spent Usual documentation for the base code level of service ; Documentation of medical necessity for prolonged services, face to face services performed. Must spend time expected for the base LOS, plus minimum of 30 minutes. For Counseling/Coord of Care, must spend time for 99205/15 plus min of 30 minutes. Preventative Service Visits Preventive Services NO Chief complaint or HPI MUST HAVE Comprehensive ROS 10 organ systems Comprehensive or interval PMH, FH, SH Comp. assessment of RF appropriate to age Multi system PE appropriate to age and RF Assessment/Plan which includes counseling, anticipatory guidance and RF reduction Preventative Service Visits New vs. Return rules are the same Coding based on age of patient NO specific guidelines for what to include with each age group Documentation of anticipatory guidance/ RF reduction is the common missing element in my group residents are frequent culprits Can refer to previous ROS, PMH, FH, etc Medicare Preventive Services IPPE: Initial Preventive Physical Examination Introduction to Medicare exam G0402; one time benefit ONLY First 12 month of Medicare eligibility Initial AWV: Annual Wellness Visit new in 2011 G0438; one time benefit ONLY Patient no longer eligible for IPPE, and has not received IPPE or AWV in last 12 months Subsequent AWV G0439 Yearly, 12 months after G

14 Medicare IPPE: January 2009 Now have 12 months of eligibility to complete ECG and interpretation is OPTIONAL 1.34 wrvus 2.30 wrvus G0402 IPPE G0403 ECG G0404 facility charge for ECG G0405 ECG interpretation and report IPPE: Elements History PMH; Medications; FH; SH; Diet; Physical Activity RF for Depression Functional ability and level of safety: hearing; ADLs; fall risk; home safety Physical Exam Counseling/Other IPPE: Elements History Physical Exam Ht; wt; BP Visual acuity screen BMI Other factors deemed appropriate Counseling/Other IPPE: Elements History Physical Exam Counseling/Other End of life planning: required service upon beneficiaries consent Education/referral based on the previous components: Obesity, prevention of chronic illness, smoking cessation Complete a brief written plan for pt such as checklist for obtaining appropriate screening tests covered by Medicare Annual Wellness Visits Jan 2011 AWV Jan 2011 G0438 Initial AWV 2.43 wrvus G0439 subsequent AWV 1.50 wrvus AWV Components: To DOcument To PROVIDE/ESTABLISH for patient still document To DOcument PMH/FH includes medications Current Providers involved in patient s care PE: height, weight, BMI or waist circ, BP, other routine measurements as deemed appropriate Detection of cognitive impairments Direct observation, with family info as appropriate Potential RF for depression Current/past history and/or screening tool Functional level of safety based on direct observation OR screening tool hearing, ADLs, Fall risk, home safety 13

15 AWV Jan 2011 To DOcument To PROVIDE/ESTABLISH for patient still document Written 5 10 yr schedule of Medicare covered, USPSTF recommended preventive services List of RF or conditions for which 1, 2, or 3 interventions are recommended or underway Including Mental Health conditions Provide list of treatment options and risks/benefits Furnish personal health advice and referral as appropriate wt loss, exercise, nutrition, smoking cessation... IPPE and AWV: my opinion To provide these well AND get reimbursed: Make templates: EHR or typed Have nursing/support staff do as much as possible data gathering prior to/during visit Depression screening tool Beck or other Pre made sheets for diet; tobacco cessation; exercise; Checklist of Medicare covered preventive services that you can check and give to pt IPPE/AWV plus E/M same day? YES!!! Reporting a Medically Necessary E/M Service Furnished During the Same Encounter as an IPPE or AWV When the physician or qualified NPP, or for AWV the health professional, provides a significant, separately identifiable medically necessary E/M service in addition to the IPPE or an AWV, CPT codes may be reported depending on the clinical appropriateness of the circumstances. CPT Modifier 25 shall be appended to the medically necessary E/M service identifying this service as a significant, separately identifiable service from the IPPE or AWV code reported HCPCS code G0344 or G0402, whichever applies based on the date the IPPE is performed, or HCPCS code G0438 or G0439 whichever AWV code applies. HPI ROS PFSH Physical Exam AWV None Cognitive deficits, depression, ADLs, safety PMH, Allergies, Meds, FH Height, weight, BMI, BP, other routine measurements as deemed appropriate /3 needed Brief (2 4) Problem Pert (1) None Expanded Prob Foc (2 4) / 3 needed Extended (4+) Extended (2 9) Pertinent (1) Detailed (5 7) /3 needed Extended (4+) Complete (10) Complete Comprehensive (8+) MDM Low Complexity Moderate High OTHER Written 5 10 yr screening schedule based on USPSTF List RF/conditions & interventions needed including mental health Personalized health advice and referral for health education and screening List of current providers involved in pt s care The key to documentation of additional E/M service will be that it is MEDICALLY NECESSARY and SEPARATELY IDENTIFIABLE from AWV documentation Medicare Claims processing Manual Chapter 12 HPI ROS PFSH Physical Exam AWV None Cognitive deficits, depression, ADLs, safety PMH, Allergies, Meds, FH Height, weight, BMI, BP, other routine measurements as deemed appropriate /3 needed Extended (4+) Extended (2 9) Pertinent (1) Detailed (5 7) /3 needed Extended Complete Complete Comprehensive (8+) /3 needed Extended Complete Complete Comprehensive (8+) MDM Low Complexity Moderate High OTHER Written 5 10 yr screening schedule based on USPSTF List RF/conditions & interventions needed including mental health Personalized health advice and referral for health education and screening List of current providers involved in pt s care The key to documentation of additional E/M service will be that it is MEDICALLY NECESSARY and SEPARATELY IDENTIFIABLE from AWV documentation Helpful links AWV/IPPE Most recently updated transmittal from CMS regarding documentation requirements for AWV as of Feb 28, Update to Medicare claims processing manual. Details about billing IPPE/AWV in GE clinic AND billing these with on same day. Update to Medicare Benefit Policy Manual. Some more specific definitions about AWV here. Quick reference info, ABCs of providing the AWV. Very helpful 3 page document from CMS and Education/Medicare Learning Network MLN/MLNProducts/downloads/MPS_QRI_IPPE001a.pdf Same quick reference guide for IPPE E/M Documentation and Education/Medicare Learning Network MLN/MLNEdWebGuide/EMDOC.html CMS webpage with links to E/M Service Guide, and 1995 and 1997 documentation guidelines TCM Services and Education/Medicare Learning Network MLN/MLNProducts/Downloads/Transitional Care Management Services Fact Sheet ICN pdf Service guide. 14

16 1997 Physical Exam Audit Tool System Elements of exam total Constitutional Measurement of any three of the following seven vital signs: 1) sitting/standing BP 2) supine BP 3) pulse 4) resp5) temp 6) ht 7) wt (May be measured and recorded by staff) General appearance of patient Eyes Inspection of conjunctivae and lids Examination of pupils and irises (eg, reaction to light and accommodation, size and symmetry) **EOMI Ophthalmoscopic examination of optic discs and posterior segments Ears, Nose, Mouth External inspection of ears and nose (eg, overall appearance, scars, lesions, masses) and Throat Otoscopic exam of external auditory canals and tympanic membranes Assessment of hearing (eg, whispered voice, finger rub, tuning fork) Inspection of nasal mucosa, septum and turbinates Inspection of lips, teeth and gums Exam of oropharynx: oral mucosa, salivary glands, hard/soft palates, tongue, tonsils and posterior pharynx Neck Examination of neck (eg, masses, overall appearance, symmetry, tracheal position, crepitus) Examination of thyroid (eg, enlargement, tenderness, mass) Respiratory Assessment of respiratory effort (intercostal retractions, use of accessory muscles) Percussion of chest (eg, dullness, flatness, hyperresonance) Palpation of chest (eg, tactile fremitus) Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs) Cardiovascular Palpation of heart (eg, location, size, thrills) Auscultation of heart with notation of abnormal sounds and murmurs Examination of: carotid arteries (eg, pulse amplitude, bruits) abdominal aorta (eg, size, bruits) femoral arteries (eg, pulse amplitude, bruits) pedal pulses (eg, pulse amplitude) Exam of extremities for edema and/or varicosities Chest Inspection of breasts (eg, symmetry, nipple discharge) Palpation of breasts and axillae (eg, masses or lumps, tenderness) GI/Abd Examination of abdomen with notation of presence of masses or tenderness Examination of liver and spleen Examination for presence or absence of hernia Examination (when indicated) of anus, perineum and rectum, sphincter tone, hemorrhoids, rectal masses Obtain stool sample for occult blood test when indicated GU (Male) Examination of the scrotal contents (eg, hydrocele, spermatocele, tenderness of cord, testicular mass) Examination of the penis Digital rectal examination of prostate gland (eg, size, symmetry, nodularity, tenderness) GU (Female) Pelvic examination (with or without specimen collection for smears and cultures), including Exam of external genitalia (gen appearance, lesions) and vagina (gen appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele) Exam of urethra (eg, masses, tenderness, scarring) Exam of bladder (eg, fullness, masses, tenderness) Cervix (eg, general appearance, lesions, discharge) Uterus (eg, size, contour, position, mobility, tenderness, consistency, descent or support) Adnexa/parametria (eg, masses, tenderness, organomegaly, nodularity) Lymph Palpation of lymph nodes in two or more areas: Neck Axillae Groin Other MSK Skin Neurologic Psych Examination of gait and station Inspection and/or palpation of digits and nails (eg, clubbing, cyanosis) Exam of joints, bones and muscles of one + of the following six areas: 1) head/neck; 2) spine/ribs/pelvis; 3) right arm; 4) left arm; 5) right leg; and 6) left leg. The examination of a given area includes: Inspection and/or palpation; noting misalignment, asymmetry, defects, tenderness, masses, effusions Assessment of range of motion with notation of any pain, crepitation or contracture Assessment of stability with notation of any dislocation (luxation), subluxation or laxity Assessment of muscle strength and tone with notation of any atrophy or abnormal movements Inspection of skin and subcutaneous tissue (eg, rashes, lesions, ulcers) Palpation of skin and subcutaneous tissue (eg, induration, subcutaneous nodules, tightening) Test cranial nerves with notation of any deficits Examination of deep tendon reflexes with notation of pathological reflexes (eg, Babinski) Examination of sensation (eg, by touch, pin, vibration, proprioception) Description of patient s judgment and insight Brief assessment of mental status including: orientation to time, place and person recent and remote memory mood and affect (eg, depression, anxiety, agitation) Problem Focused: 1 5 bullets in 1 or more systems Expanded Problem Focused: 6 11 bullets in 1 or more systems Detailed: 12 bullets in 2 or more organ systems (or 6 systems w 2 bullets each) Comprehensive: 2 bullets from 9 + organ systems

17 Complexity of Medical Decision Making: I. Type and Number of Presenting Problems A x B = C single self-limited or minor problem: stable, improved or worsening max = 2 1 established problem (to examiner): stable, improved, resolving/resolved 1 established problem (to examiner): worsening, inadequately controlled 2 new problem (to examiner): no additional work-up planned max = 1 3 new problem (to examiner): with additional assessment, consult or diagnostic studies 4 Total II. Amount and Complexity of Data Points review and/or order of clinical tests 1 review and/or order of tests in CPT radiology section 1 review and/or order of tests in CPT medicine section 1 discussion of test results with performing physician 1 independent review of image, tracing or specimen 2 decision to obtain old records and/or obtain history from someone other than patient 1 review and summarization of old records &/or obtaining hx from someone other than patient 2 Total Level of Risk Presenting Problem (s) III. TABLE OF RISK Diagnostic Procedures Ordered Management Options Selected Minimal Low Moderate High One self-limited or minor problem (rash or oral ulcers, cold, insect bites) Lab tests requiring venipuncture Chest x-rays EKG/ECG UA Ultrasound Two or more self-limited or minor problems or symptoms MRI/CT, PFT s One stable chronic illness (well-controlled HTN or NIDDM, BPH) Superficial needle biopsies Acute uncomplicated illness (e.g., cystitis, allergic rhinitis,simple sprain) Clinical lab test requiring arterial puncture Skin biopsies One or more chronic illness w/ mild exacerbation, progression, or side Diagnostic endoscopies with no effect of treatment identified risk factors Acute illness with systemic symptoms, eg. pyelonephritis, pneumonitis, Cardiovascular imaging studies w/ colitis contrast, no risk factors (arteriogram) Two or more stable chronic illnesses Arthrocentesis, LP Acute complicated injury (vertebral compression fracture, head injury w/ Physiologic tests under stress test brief LOC) eg,(cardiac stress test) Undiagnosed new problem with uncertain prognosis, eg. lump in breast Deep needle or incisional biopsy One or more chronic illnesses w/ severe exacerbation, progression, or Cardiac EP tests side effects of tx Cardiovascular imaging studies Acute or chronic illness that may pose a threat to life or bodily function ( w/contrast, w/ identified risk factors eg. progressive severe RA, multiple trauma, acute MI, PE, severe Diagnostic endoscopies w/ identified respiratory distress, psych illness w/ threat to self or others, acute renal risk factors failure) Discography An abrupt change in neurological status, eg. Seizure, TIA, weakness, or sensory loss Rest Splints Superficial dressings OTC drugs Minor surgery w/ no identified risk factors PT/OT IV fluids w/o additives Prescription drug management Minor surgery w/ identified risk factors IV fluids w/ additives Therapeutic nuclear medicine Elective major surgery(open, percutaneous or endoscopic) w/ no identified risk factors Closed treatment of fx or dislocation without manipulation Elective major surgery w/ risk factors Emergency major surgery Administration of parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Decision not to resuscitate or to de-escalate care because of poor prognosis **The highest level of risk in any one category (presenting problem(s), diagnostic procedure(s) or management options determines the overall risk** To qualify for a given type of decision making, two of the three elements in the table must be either met or exceeded: Type of Decision Making: StrForward Low Moderate High I. Presenting Problems = 0 or (+) II. Amount of Data = 0 or (+) III. Overall risk = Minimal Low Moderate High