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Evaluation & Management Services

July 7, 2009

Brenda Edwards, CPC, CPC-I, CEMC


Coding & Compliance Specialist
KaMMCO
Medical Record Documentation

Records pertinent facts, findings and


observations about an individuals
health history including past and
present illnesses, examinations, tests,
treatments and outcomes
Chronologically documents the care of
the patient
Is an important element contributing to
high quality care.
Golden Rule of Coding:

If it is not documented,
it is not done and
therefore not billable!
Accuracy is of the Utmost
Importance
Legibly document what you
have done.
Something that may seem
trivial for you to document
could be the reason you could
bill a higher level of service.
Principles of Documentation

Complete and legible


At least two patient identifiers
The reason for the encounter
Relevant history, physical examination findings and prior
diagnostic test results
Assessment, clinical impression or diagnosis and plan for care
included
Appropriate health risk factors identified as well as the
patients progress, response to and changes in treatment and
revision of diagnosis should be documented
The CPT and ICD-9 codes submitted must be supported by
the documentation in the medical record
Evaluation & Management Services

An E&M (evaluation & management)


service is any non-procedural service
provided to a patient. Office visit, hospital
admission, subsequent days, discharge, ER
visits and nursing home services are all
examples of E&M services
Documentation guidelines for E&M services
were first introduced by the Health Care
Finance Administration and the AMA in
1995.
Documentation Guidelines

New patients vs. established patient


New patient - One who hasnt been seen
by any provider of the same practice
(same tax id) in the past 3 years
Established patient May be new to
the provider but not new to the
practice
Evaluation & Management Services

Three components to an E&M visit

History
History of Present Illness (HPI)
Review of Systems (ROS)
Past, Family, Social History (PFSH)

Exam
Medical Decision Making (MDM)
Assignment of the E&M Code

Based on the documentation by the provider,


the level of the E&M service is determined by
the level of history, exam and MDM
New patient office visits, must all meet 3 out
of 3 levels of the History, Exam and MDM
Example: History was comprehensive, exam was
detailed and MDM was moderate, the criteria only
a 99203 was met only 2 out of the 3 levels for a
99204 were met
3 of 3 versus 2 of 3

3 of 3 means each required element (History, Exam & MDM)


are at least the same level or higher (can only code as high
as the lowest level of the three that is documented)
New patient office visit, ER, Inpatient H&P or consult require
3 of 3
Detailed history, detailed exam and detailed MDM = Detailed new
patient encounter
Problem Focused HPI, detailed exam and detailed MDM = Detailed
established patient encounter
Established patient only requires 2 of 3
Example: History was comprehensive, exam was detailed
and MDM was moderate, the criteria only a 99203 was met
only 2 out of the 3 levels for a 99204 were met
99201, 99241, 99202, 99242, 99203, 99243, 99204, 99244,
99212 99213 99214 99215

HPI Brief Brief Extended Extended


(1-3) (1-3) (4+) (4+)

ROS N/A 1 System Extended Complete


(2-9) (10+)

PFSH N/A N/A Pertinent Complete


(1-3) (3)

Type of Problem Expanded Detailed Comprehensive


History Focused
History Elements

Chief Complaint is a clear and concise


statement in the patients own words and
documented by the provider
3 Major sections of the Encounter
History
Includes chief complaint (CC), history of present illness
(HPI), review of systems (ROS) and past medical, family
and social history (PFSH)
Exam
Medical Decision Making
The providers thought process on paper
History of Present Illness

The medical record should clearly reflect the chief


complaint (the reason the patient came through
the door)
History of present illness can either be brief (1-3
elements) or extended (4+)
Location
Quality
Severity
Duration
Timing
Context
Modifying Factors
Associated Signs and/or Symptoms
Review of Systems

Review of systems is the patients positive and


pertinent negative response to a series of questions.

Constitutional Musculoskeletal
Eyes Integumentary
ENT Neurological
Cardiovascular Psychiatric
Respiratory Allergic/Immunologic
Gastrointestinal Endocrine
Genitourinary Hematologic/Lymphatic
Past, Family & Social History
Can be obtained once in the medical
record and then referred to at
subsequent visits, with additions or
changes added, as encountered
Must be initialed and dated to
validate review by provider
Examination

Problem focused (examination of the


affected body area)
Expanded problem focused (2-4 body
areas/systems)
Detailed (5-7 body areas/systems)
Comprehensive (8+ body areas/systems)
Medical Decision Making
Medical decision making is the
providers thought process
Hardest element to translate into an
audit form
The reason for encounter typically
dictates the level of service selected
Medical Decision Making

Based on
Complexity of the diagnosis/management options
Amount of complexity of data reviewed
Risk to the patient
Documentation of the MDM is hardest to quantify
Putting providers thought process on paper
Medical Decision Making

Levels of Risk (examples are not all inclusive)


Minimal risk
Sunburn, common cold, something a patient might not
typically see a doctor for.
Low risk
Well controlled hypertension, ankle sprain, cystitis
Moderate Risk
Exacerbation (mild) COPD, undiagnosed breast lump,
pneumonia
High Risk
Severe exacerbation of COPD, acute renal failure, abrupt
change in neurological status
Medical Decision Making
To qualify for a given level of decision
making, 2 of the 3 elements must be met
or exceeded
Example: A patient has stable diabetes, stable
hypertension and stable COPD (2 or more
stable chronic conditions-moderate), the
provider orders lab (minimal) and continues the
patient on current medication regimen
(moderate) the level of Medical Decision
Making is moderate
Time Based Visits

Provider must document amount of time


related to counseling (more than 50%) and
total time spent with patient
Provider must document subject matter
discussed, the more detailed the better
Example: 99213=a provider typically spends 15
minutes face-to-face. If more than 8 minutes was
spent counseling the patient on a new diagnosis
of hypertension, then the visit can be coded based
on time, regardless of the complexity of the
history, exam or MDM
The Hospital Card
History & Physical (99221-99223)

3 of 3 elements need to be met


No other E&M services provided on
the same day (ER or office visit) if the
admission is known
Date of H&P should match date of
admission to the floor
Subsequent Visits 99231-99233
2 of 3 elements need to be met
Review of medical record, reviewing
results, changes in pt status since last
assessment, examination
Time can be spent face to face or on
the unit or floor
Discharge 99238 & 99239

Must be a face to face encounter


Time must be documented
99238 30 minutes
99239 Greater than 30 minutes
Preparation of discharge instructions, medications
and/or placement arrangements
If a patient was seen in the AM and dies in the
afternoon (without provider present) cannot be
billed as a discharge. Only subsequent care
provided in the AM encounter.
Newborn Care

Initial assessment of newborn


Initial treatment of a normal newborn, born in the hospital
Subsequent visits
Evaluation of a normal newborn, per day
Discharge is the same as inpatient (99238 or 99239)
No charges are done by SFHC provider for NICU
babies followed by a pediatrician
Can bill for normal newborn care on day 1 if baby was
healthy and complications arise on day 2 that warrant
pediatrician involvement. Documentation should support
the change in billing
Circumcision is separately billable by performing provider
Hospital Consultations

Entire care of patient is not assumed


In order to bill must have 3 Rs in
writing
Request for an opinion
Render your opinion
Reply back to requesting provider of
findings or recommendations
Concurrent Care

Patient is managed by multiple


providers/specialties
Each can bill for their services, if
specific conditions are being followed
by each provider
Cant bill for courtesy visits
Emergency Room Visits

5 levels of services that follow standard


billing guidelines for a new patient (3 of
3 elements)
Procedures done during the visit are
separately billable with supporting
diagnoses
No card required
Billing is done off of dictated ER report
OB H&P and Delivery

No card required if normal delivery and


aftercare
Subsequent days may be billed if
diagnosis supports additional care and
treatment for complications/conditions
Management of a patient admitted for
observation is separately billable
(premature contractions, injury or
accident)
Critical Care

Can be performed in any setting (inpatient, ER or


office)
Not billed just because a patient is in the ICU
Time-based codes-documentation of time is required
Direct delivery of medical care for a critically ill or
injured patient
Time spent providing critical care is based on total
time spent engaging in work directly related to the
individual patient
Critical Care
Physician is not required to be at constant
bedside, but may be involved in patient care
decisions on the same floor or unit
Time spent outside the unit or floor may not be
reported as critical care since the physician is not
immediately available to the patient
Involves high complexity decision making to
assess, manipulate and support vital system
functions to prevent further life threatening
deterioration of the patients condition
Assistant Surgery

Billable by Resident if not related to rotation or


covering rotation for another resident
Hospital card required (mainly for tracking)
Billing is done from surgery report and surgeons
billing
Charge is typically 25% of the surgeons fee
Billable by Resident if rotation service but
established patient of the resident is the recipient
of the surgery
Outpatient Procedures

Billable by the Resident if not related


to rotation or covering rotation for
another Resident
Hospital card required (mainly for
tracking)
Questions

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