Evaluation and Management Coding Advisor

Evaluation and Management Coding Advisor

Contents Chapter 1: Introduction...1 High Volume Services...1 Documenting Evaluation and Management Services...1 Documentation and the EHR...3 Summary...3 Knowledge Assessment...4 Chapter 2: History of Evaluation and Management Coding...5 Introduction...5 Origin and Development of Evaluation and Management Codes...5 Components of E/M Services...7 Documentation Guidelines for Evaluation and Management Services...11 Knowledge Assessment...14 Chapter 3: Documenting the History...15 Introduction...15 Documentation of History...15 Summary...28 Knowledge Assessment...28 Chapter 4: Documenting the Exam...31 Introduction...31 Documentation of Examination...31 Summary...36 Knowledge Assessment...37 Chapter 5: Documenting the Decision Making.39 Introduction...39 Summary...48 Knowledge Assessment...49 Chapter 7: Counting the Elements and Code Selection... 59 Introduction...59 Medical Necessity and Decision Making... 59 Overdocumenting the Encounter... 60 Two or Three Elements/Components Required...62 Admission Documentation... 63 Observation Services... 66 Observation or Inpatient Care Services (Admit and Discharge on Same Date)... 68 Prolonged Services...69 Summary... 70 Knowledge Assessment... 71 Chapter 8: Other Evaluation and Management Issues... 73 Introduction...73 Current Issues Consultations... 73 Current Issues Hospital E/M Guidelines...76 Telephone Calls... 77 Incident-To Guidelines... 78 Critical Care and E/M Services... 82 Care Plan Oversight... 85 Telehealth Services...90 Modifier 25... 95 Preventive Services and Modifier 33... 97 Initial Preventive Physical Exam and Annual Wellness Visit... 104 Evaluation and Management Services Code 99211... 107 Knowledge Assessment... 109 Chapter 9: Teaching Physician Guidelines... 111 Knowledge Assessment... 118 Chapter 6: Documenting Counseling, Coordination, Time, and the Presenting Problem...51 Introduction...51 Counseling and Coordination of Care...52 Time...54 Nature of Presenting Problem...54 Knowledge Assessment...57 Chapter 10: Electronic Health Records... 121 Introduction...121 Defining an EHR... 121 Health Information Technology for Economic and Clinical Health (HITECH) Act... 125 Meaningful Use... 129 Certified Suppliers...141 EHR Documentation of Encounters...142 Summary... 144 2014 OptumInsight, Inc. i

Evaluation and Management Coding Advisor Knowledge Assessment... 144 Chapter 11: Templates and the Electronic Health Record... 147 Introduction... 147 Determining the Types of Templates... 148 Developing Templates... 149 Sample Templates... 151 Knowledge Assessment... 158 Chapter 12: EHR Encoders... 159 Introduction... 159 Defining an Encoder... 159 Brief Review of Evaluation and Management (E/M) Coding... 159 Auto Selection... 160 Provider Selection... 161 Coder Verification... 164 Code Edit Systems... 164 Summary... 165 Knowledge Assessment... 165 Chapter 13: After EHR Implementation... 167 Introduction... 167 Monitoring Claim Trends... 167 Productivity... 168 Coding Changes... 169 Education... 170 Data Capture... 171 Summary... 173 Knowledge Assessment... 174 Chapter 14: Knowledge Assessment Answers 175 Chapter 1...175 Chapter 2...175 Chapter 3...176 Chapter 4...178 Chapter 5...179 Chapter 6...180 Chapter 7...182 Chapter 8...184 Chapter 9...187 Chapter 10...188 Chapter 11...190 Chapter 12...191 Chapter 13...192 Appendix A: Physician E/M Code Self-Audit Forms... 195 Appendix B: Bell Curve Comparative Data... 205 Glossary... 289 Index... 299 ii 2014 OptumInsight, Inc.

Evaluation and Management Coding Advisor medical record when time is used to select a code for a visit that predominantly involves coordination of care or counseling. COUNSELING AND COORDINATION OF CARE Counseling is defined in the CPT book as a discussion with a patient and/or family concerning one or more of the following areas: Diagnostic results, impressions, and/or recommended diagnostic studies Prognosis Risks and benefits of management (treatment) options Instructions for management (treatment) and/or follow-up Importance of compliance with chosen management (treatment) options Risk factor reduction Patient and family education DOCUMENTATION SAMPLE Meets Expected Requirements: I had a discussion with the patient about his hypertension. The patient has a good understanding about the potential side effects of the various drugs used to treat his disease. I apprised the patient in detail of the potential side effects of not treating his condition. The patient expressed an understanding of the high risks of noncompliance, stating no one had spelled it out before. I firmly explained to the patient that I would be willing to help him explore alternative therapy for hypertension, but only if he were to strictly adhere to a conventional regimen of therapy until his hypertension was well controlled and stable. Does NOT Meet Expected Requirements: I apprised the patient in detail of the potential side effects of not treating his condition. Additional criterion for code selection revolves around counseling and coordination of care. Counseling, coordination of care, and the nature of the presenting problem are not major considerations in most encounters, so they generally provide contributory information to the code selection process. The exception arises when counseling or coordination of care dominates the encounter (more than 50 percent of the time spent). In these cases, time determines the proper code. Documentation of the exact amount of time spent will substantiate the selected code. For office encounters, count only the time spent face-to-face with the patient and/or family; for hospital or other inpatient encounters, count the time spent in the patient s unit or on the patient s floor, but be sure the time spent and counted is directed at 52 2014 OptumInsight, Inc.

Chapter 6: Documenting Counseling, Coordination, Time, and the Presenting Problem caring only for that patient. The time assigned to each code is an average and varies by physician. Along with the time, the medical record should explain what was discussed during the encounter. If a physician coordinates care with an interdisciplinary team of physicians or health professionals/agencies without a patient encounter, report it as a case management service (codes 99361 and 99362). DOCUMENTATION SAMPLE Meets Expected Requirements: After evaluating the patient in recovery from a stroke, I spoke at length (approximately 30 minutes) with the hospital s rehabilitation service to coordinate an appropriate physical therapy plan. Does NOT Meet Expected Requirements: Discussed physical therapy plan with hospital s rehabilitation service When counseling and/or coordination of care takes up more than 50 percent of the total visit time, the element of time is the key or controlling factor for selecting the appropriate level of E/M code and must be documented in the record. Often this element is difficult to determine from the standard documentation. Specifically designating what was discussed, as well as documenting the time involved providing this service will help substantiate a level of E/M service code. Moreover, documenting this component whether or not it takes up most of the time spent with the patient may help support the provider s position during a malpractice suit. It can also be helpful to show that the physician discussed diagnosis and management options with the patient or family. DOCUMENTATION SAMPLE Meets Expected Requirements: I spent 25 minutes discussing with the patient the risks and possible complications of the procedure, as well as alternative treatments. We also discussed possible lifestyle adjustments that may be necessary as a result of the surgery. Patient acknowledged understanding and wishes to proceed with the surgery. Total face-to-face time with patient 40 minutes. Does NOT Meet Expected Requirements: After evaluating the patient, I spent a considerable amount of time explaining the procedure. DEFINITIONS Counseling. Discussion with a patient and/or family concerning one or more of the following areas: diagnostic results, impressions, and/or recommended diagnostic studies; prognosis; risks and benefits of management (treatment) options; instructions for management (treatment) and/or follow-up; importance of compliance with chosen management (treatment) options; risk factor reduction; and patient and family education. Coordination of care. Often provided concurrently with counseling and includes treatment instructions to the patient or caregiver, special accommodations for home, work, school, vacation, or other locations, coordination with other providers, agencies, and living arrangements. Coordination of care is used to determine a level of service only when provided in the presence of the patient; otherwise, when provided without a patient encounter, report with case management codes. 2014 OptumInsight, Inc. 53

Appendix B: Bell Curve Comparative Data CARDIOLOGY Initial Observation Care New Patient 99201 $36.18 $26.39 99202 $64.27 $46.82 99203 $95.87 $69.84 99204 $152.06 $112.36 99205 $192.96 $144.63 99218 $64.02 $49.59 99219 $106.72 $82.42 99220 $149.30 $115.24 Initial Hospital Care Established Patient 99221 $96.58 $75.98 99222 $132.56 $104.13 99223 $195.34 $153.72 99211 $19.67 $14.21 99212 $38.93 $28.31 99213 $66.10 $46.87 99214 $100.01 $72.05 99215 $135.01 $99.16 Subsequent Hosptial Care 99231 $38.74 $30.69 99232 $70.81 $56.19 99233 $102.04 $80.97 2014 OptumInsight Inc. 213

Evaluation and Management Coding Advisor Emergency Department CRITICAL CARE (INTENSIVISTS) New Patient Critical Care 99281 $20.95 $15.84 99282 $41.13 $31.49 99283 $62.76 $47.33 99284 $118.90 $91.57 99285 $177.23 $137.69 99201 $34.46 $25.22 99202 $63.91 $44.57 99203 $94.19 $69.67 99204 $150.16 $113.02 99205 $189.40 $144.65 Established Patient 99291 $227.34 $180.59 99292 $112.26 $89.41 99211 $19.90 $14.87 99212 $38.44 $28.14 99213 $65.36 $47.39 99214 $98.55 $72.92 99215 $131.12 $98.04 214 2014 OptumInsight Inc.