Evaluation & Management Documentation and Coding Guidelines Presented by: Kristi A. Gutierrez CCS-P, CPC, CEMC
Objectives Participants will gain a working knowledge of Medicare s 1995 Evaluation & Management Documentation Guidelines. Participants will be able to apply the knowledge in everyday ysituations while seeing gpatients in order to utilize the correct level of Evaluation & Management Service and document that service to meet Medicare s Guidelines.
Agenda Medicare s 95 Documentation Guidelines (DG) for Providers New and Established Patient Visits Consultations Hospital Services C di E l i & M S i B d Coding an Evaluation & Management Service Based on Time
Overview Medicare s 1995 guidelines were developed to assist providers in choosing a level of service. Per Medicare s DG the visit is made up of three (3) key components: History; Physical Exam; and Mdi Medical Decision ii Mki Making.
What does Medicare need documented to bill a level of service? History Chief Complaint (CC) History of Present Illness (HPI) Review of Systems (ROS) Past, family and/or social history (PFSH) Examination Medical Decision Making (MDM)
Medical Decision Making (MDM) Medical Decision Making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by:
MDM Cont d Number of possible diagnoses and/or number of management options that must be considered; The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed; and The risk of significant complications, morbidity and/or mortality, as well as co-morbities, associated with the patients presenting problem(s), the diagnostic procedure(s) and/or the possible management options.
Number of Management Options/Diagnoses Self limited/minor (max 2 problems) or Est prob stable/improved = 1 point Established Problem worsening = 2 points New problem; no additional work up planned (max 1 prob) = 3 points New problem; additional work up pp planned (max 1 prob) = 4 points
Scoring the Number of Diagnoses or Management Options 1 point = Minimal 2 points 3 points 4 points or more = Limited = Multiple = Extensive
Amount or complexity of data reviewed Review and/or order of clinical lab tests =1 point (max) Review and/or order radiology tests =1 point (max) Review and/or order 90000 series tests t =1 point (max) Discussion of test results w/performing physician =1 point Decision to obtain old records and/or obtain history from someone other than the patient Review and summarization of old records and/or obtaining history from someone other than the patient and/or discussion i of case with another health care provider Independent visualization of image, tracing or specimen itself (not simply reviewing report) =1 point =2 points =2 points
Scoring the Amount or Complexity of Data Reviewed 1 point = Minimal 2 points 3 points 4 points or more = Limited = Moderate = Extensive
Table of Risk Presenting Problem(s) Diagnostic Proc.Ordered Management Option(s) Selected One self limited or minor problem e.g. cold, insect bite, tinea corporis. 2 or more self-limited or minor problems 1 stable chronic illness Acute uncomp illness or inj 1 or more chronic illnesses w/ mild exacerbation 2 or more stable chronic illnesses 1 or more chronic illnesses w/ severe exacerbation Acute or chronic illness w/ threat to life/limb Lab tests req. venipuncture, chest X-rays rays, EKG-EEG EEG, UA, Ultrasound, e.g. echo, KOH prep. Physiologic tests not under stress Non-cardiovascular imaging Superficial needle biopsies Physiologic tests under stress Diagnostic endoscopies Deep needle biopsies Cardiovascular imaging Cardiac EP studies Diagnostic endo w/risks Discography Rest Gargles Elastic bandages Superficial dressings Level of Risk G l Minimal OTC drugs Minor surg no risks PT/OT IV fluids no additives Minor surg w/ risks Elective major surg Rx drug manage IV fluid w/ additives Elec. major surg w/ risks Emerg major surg Parenteral controlled Rx Low Moderate High **** This is an abbreviated Table of Risk. Use Medicare guidelines for full Table of Risk
Scoring the Table of Risk The highest level of risk from any column is the level to choose.
Scoring the Overall MDM Number Diagnoses or Management Options Amount or Complexity of Data Reviewed Risk MDM Level Minimal Minimal Minimal Straightforward Limited Limited Low Low Multiple Moderate Moderate Moderate Extensive Extensive High High Circle the score for each area of the MDM. Two (2) out of three (3) must meet or exceed the level chosen.
History The history portion of the chart is made up of four (4) components Chief Complaint (CC) History of Present Illness (HPI) Review of Systems (ROS) Past, Family and/or Social History (PFSH) The HPI, ROS and PFSH must all meet or exceed the scoring for the overall level chosen for the History portion of the chart.
Chief Complaint (CC) Every patient visit needs to list a CC. The CC is a concise statement describing the symptom, problem, condition, diagnosis, provider recommended return or other factor that is the reason for the encounter.
Scoring the CC Per Medicare s DG there is no scoring of the CC although the guidelines do state that the CC needs to be present.
History of Present Illness (HPI) The HPI is a chronological description of the development of the patient s present illness from the first sign and/or symptom or from the previous encounter to the present.
HPI Cont d Per Medicare DG the HPI includes: Location Quality Severity Duration Timing Context Modifying factors Associated signs and symptoms.
Scoring the HPI Count the number of elements the provider documented for the HPI. One (1) to three (3) elements constitutes a Brief HPI Four (4) or more elements constitutes an Extended HPI
Review of Systems (ROS) A ROS is an inventory of the body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced. The ROS may be obtained dby ancillary staff or by a form the patient fills out (this may also be obtained by Medical Students.) It must be evidenced that it was reviewed by the provider and any information supplementing or confirming i the ROS must be documented. d
ROS Cont d Per Medicare DG the following systems are recognized: Constitutional Eyes Ears, nose, mouth, throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary Neurological Psychiatric Endocrine Hematologic/Lymphatic ti Allergic/Immunologic
ROS Cont d If a template is used to document the ROS, each box must be individually marked and all positive systems must be commented on. When documenting the patient record, the statement all other systems reviewed and negative is considered a complete ROS after commenting on the systems with positive responses. The statement non contributory is not sufficient i documentation of a ROS.
Scoring the ROS Count the number of elements documented in the ROS. One (1) element is a Problem Pertinent ROS Two (2) to nine (9) elements is an Extended ROS Ten (10) or more elements is a Complete ROS
Past, Family, Social History (PFSH) The PFSH consists of a review of three areas: Past history (the patient s past experiences with illnesses, surgeries, injuries, etc) Family history (the patient s review of significant family medical events) Social history (an age appropriate review of past and current activities) i i
PFSH Cont d The PFSH may be obtained by ancillary staff or through a form the patient fills out (this too may be obtained by a Medical Student.) It must be evidenced that it was reviewed by the provider and any information supplementing or confirming the PFSH must be documented.
Scoring the PFSH Count the number of elements documented for the PFSH One (1) element from any of the three (3) areas constitutes a Pertinent PFSH One (1) element from two (2) of the three (3) areas constitutes t a Complete PFSH for: established patients, ED, subsequent nursing facility care, domiciliary care (est. pt),or home care (est. pt) One (1) element from all of the three (3) areas constitutes a Complete PFSH for: new patients, hospital observation services, hospital inpatient services initial care, consults, comprehensive nursing facility evals, domiciliary care (new pt) or home care (new pt)
Scoring the Overall History HPI ROS PFSH Overall History Brief N/A N/A Problem Focused Brief Problem Pertinent N/A Expanded Problem Focused Extended Extended Pertinent Detailed Extended Complete Complete Comprehensive Circle the score in each column. All three (3) must meet or exceed the level of service chosen.
Exam Medicare s DG recognize the following body areas and organ systems: Head, including the face Neck Chest, including the breasts & axillae Abdomen Genitalia, groin, buttocks Back, including spine Each extremity Constitutional (e.g. vitals, appearance) Eyes Ears, nose, mouth and throat Cardiovascular Respiratory Gastrointestinal
Exam Cont d Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic/lymphatic/immunologic
Exam Cont d Specific abnormal and relevant negative findings of the affected area should be documented. A notation of abnormal without elaboration is not sufficient. A brief statement or notation noting negative or normal is sufficient for unaffected/asymptomatic areas.
Scoring the Exam Count the number of elements documented as examined by the provider: Problem Focused Examination - limited exam of affected body area or organ system (1) Expanded Problem Focused Examination - limited exam of affected body area or organ system and other symptomatic related organ systems (2-7) Detailed - extended exam of affected body areas or organ systems and other symptomatic or related organ systems (2-7) Comprehensive -a general multi-system t exam or complete exam of a single organ system (8 or more)
Scoring the Overall Chart New patients 3 out of 3 areas must meet or exceed the level of service chosen Etblihd Established patients t 2 out of 3 areas must meet or exceed the level of service chosen Consultations 3 out of 3 areas must meet or exceed the level of service chosen Initial Observation Services 3 out of 3 areas must meet or exceed the level of service chosen Initial Hospital Services 3 out of 3 areas must meet or exceed the level of service chosen
New Patient Office Visits New Patient A new patient is a patient who has not had a face to face encounter in the last three years: By the same provider By a provider of the same specialty in the same group
New Patients History Exam MDM CPT Problem Focused Problem Focused Straightforward 99201 Expanded Expanded Problem Focused Problem Focused Straightforward 99202 Detailed Detailed Low 99203 Comprehensive Comprehensive Moderate 99204 Comprehensive Comprehensive High 99205 ** All three must meet or exceed the level of service you have chosen
Established Patients History Exam MDM CPT NA NA NA 99211 Problem Focused Problem Focused Straightforward 99212 Expanded Problem Focused Expanded Problem Focused Low 99213 Detailed Detailed Moderate 99214 Comprehensive Comprehensive High 99215 ** Two out of the three elements must meet or exceed the level of service you have chosen
Consultations A consultation is distinguished from a visit because it is done at the request of a referring provider and the consultant prepares a report of his/her findings that is provided to the referring provider for his or her use in treatment of the patient.
The three R s of a Consultation Request - Documentation of the Request for consultation from the referring provider Reason - The Reason for the consult which must be medically reasonable and necessary Report - The written Report by the consultant which was provided back to the referring physician
Outpatient Consultations History Exam MDM CPT Problem Focused Problem Focused Straightforward 99241 Expanded Problem Expanded Problem Straightforward Focused Focused 99242 Detailed Detailed Low 99243 Comprehensive Comprehensive Moderate 99244 Comprehensive Comprehensive High 99245 **Three out of the three must meet or exceed the level of service you have chosen
Inpatient Consultations History Exam MDM CPT Problem Focused Problem Focused Straightforward hf 99251 Expanded Problem Focused Expanded Problem Focused Straightforward 99252 Detailed Detailed Low 99253 Comprehensive Comprehensive Moderate 99254 Comprehensive Comprehensive High 99255 **Three out of the three must meet or exceed the level of service you have chosen
Initial Hospital Observation Services History Exam MDM CPT Detailed/ Comprehensive Detailed/ Comprehensive Straightforward/ Low 99218 Comprehensive Comprehensive Moderate 99219 Comprehensive Comprehensive High 99220 **Three out of the three must meet or exceed the level of service you have chosen
Initial Hospital Services History Exam MDM CPT Detailed/ Detailed/ Straightforward/ Comprehensive Comprehensive Low 99221 Comprehensive Comprehensive Moderate 99222 Comprehensive Comprehensive High 99223 **Three out of the three must meet or exceed the level of service you have chosen
Subsequent Hospital Services History Exam MDM CPT Detailed/ Detailed/ Straightforward/ Comprehensive Comprehensive Low 99231 Comprehensive Comprehensive Moderate 99232 Comprehensive Comprehensive High 99233 **Two out of the three must meet or exceed the level of service you have chosen
Observation or Inpatient Care Services History Exam MDM CPT Detailed/ Comprehensive Detailed/ Comprehensive Straightforward/ Low 99234 Comprehensive Comprehensive Moderate 99235 Comprehensive Comprehensive High 99236 **Three out of the three must meet or exceed the level of service you have chosen These codes are for patients that are admitted and discharged on the same day.
Time Based Evaluation & Management Services Time may be the controlling factor when determining a level of service. In order to use time as the controlling factor, the provider must document the following: The total face-to-face time spent with the patient That over 50% of that time was spent in counseling or coordination of care for the patient The nature or content of the counseling and coordination of care
Time Based Evaluation & Management Services cont d Medicare expects that coding based on time is the exception to the rule not a regular occurrence. In order to determine what level of service was provided based on time, look at the average time spent for that level of service. For example, the average time spent (according to the CPT manual) for a 99214 is 25 minutes.
Now that I know how to document to support coding based on time. Where can I find the average time spent for each visit?
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