Provider Evaluation & Management Training

1. Provider Evaluation & Management Training Christi Wesson, Assistant Director Misty Skelton, Assistant Director VMG Coding and Charge Entry

2. NP Billing • There are separate rules for billing Nurse Practitioner’s and nonbilling Nurse Practitioners. • Non Billing Nurse Practitioners can not bill for any services. The attending can only reference their ROS, Past, Family and Social history in order to bill.

3. Non Billing Acknowledgement

4. NP BILLING • NP billing for the admission service (this includes admission H&P’s) • According to the Vanderbilt Bylaws NP’s can not bill without the attending provider seeing the patient(except for CNM). • Prior to billing the attending will need to document his own note or countersign stating that he saw the patient and agrees with the NP’s note. • The preceptor will also need to review 20% of NP charts. • See next slides for appropriate Countersignature.

5. NP Countersignature • For Reviewing 20% of the NP’s notes. • For billing a shared visit and then documenting Key findings.

6. NP Billing cont. • Nurse Practitioners can bill and see patients for consults and consulting subsequent visits. • The attending does not have to attest or document a note prior to billing for these services. • These services are not shared visits. • If the attending and NP both document a note these can not be combined in order to bill. • Billing Nurse Practitioners can bill for procedures if it is within their scope of practice. • Critical Care cannot be a shared service.

7. Evaluation & Management Coding • 3 Key Components in an E&M service • History • Exam • Medical Decision Making • The level of service selected is based on the extent of the history &/or exam, and the complexity of the medical decision making required and documented by the provider.

8. Elements of History • Chief Complaint (CC) • History of present illness (HPI) • Review of systems (ROS) • Past medical, family, social history (PFSH)

9. History of Present Illness • Location – Where is the pain/problem? • Quality – What type of pain? (throbbing, constant, improving, worsening, acute, chronic) • Severity – How bad is the pain? (scale of 1-10, functional status, compared to other types of pain) • Timing – When did you first experience the problem? Specific time of day? Nocturnal? • Duration – How long do the symptoms last? (Onset 3 days ago, since last Monday, yesterday) • Context – What are you doing when the problems occurs? Associated with meals, exercise, or stress? • Modifying factors – What have you tried to alleviate the problem? Medications? What changes/alters the complaint? • Associated signs and symptoms – What else is bothering you when this occurs? (Fever w/ chills, headache w/ blurry visions, diaphoresis w/ chest pain)

10. History of Present Illness cont. • Tip – 4 HPI needed for admits & consults levels 3-5 • Tip – If any part of the history is unobtainable, you can document history unobtainable due to ______ (state the reason) Ex: pt intubated & sedated

11. Review of Systems (ROS) An inventory of body systems obtained through questions seeking to identify signs and/or symptoms which the patient has or has had. • Constitutional symptoms (e.g. fever, weight loss) • Eyes • Ears, Nose, Mouth, Throat • Cardiovascular • Respiratory • Gastrointestinal • Genitourinary • Musculoskeletal • Integumentary (including breasts) • Neurological • Psychiatric • Endocrine • Hematologic/Lymphatic • Allergic/Immunologic

12. Review of Systems (ROS) • May be recorded by ancillary staff or on a form completed by the patient • Provider must document that he/she reviewed and confirmed information recorded by others. • If unable to obtain, document why • Pertinent positives and negatives must be referred to in the notes

13. Unacceptable (ROS) statements • Review of system: negative • Review of system: None • Review of system Non-contributory • Review of system: unremarkable • Review of system: Full ROS was notable only for the findings listed in the HPI • 10 point review of systems was completed and is negative unless otherwise stated • Review of systems per HPI otherwise negative

14. Acceptable (ROS) statements • Review of systems are obtained based on medical necessity. Systems with pertinent positive or negative responses must be individually documented. • Example: • Review of (# of systems reviewed) system is negative except for: MSK: chronic back pain that is flaring, no HSM • Review of (# of systems reviewed) system is negative except as discussed per HPI • Document all pertinent positive and negative findings and document “All other systems reviewed and negative”

15. Past, Family & Social History • Past (past illness, injuries, operations, treatments, current medications, allergies) • Family (medical events of patient’s family, hereditary disease) • Social (living arrangements, level of education) Tip: DON’T use “noncontributory” Can use negative, but must document negative for what

16. Physical Exam Findings • Organ Systems (12) • Constitutional • Eyes • ENMT • Cardiovascular • Respiratory • GI • GU • Musculoskeletal • Skin • Neuro • Psych • Hem/Lymph/Immo • Body Areas (7) • Head including face • Neck • Chest, including breast • Abdomen • Genitalia, groin • Back including spine • Each extremity

17. Physical Exam Findings • Examples of Organ system exam: • Constitutional: Vital signs and general appearance • Eyes: Pupils: size, shape, equality, reaction to light & accommodation • ENMT: Sinus tenderness, pharynx, tonsils • Cardiovascular: Thrill, Rhythm, Sounds, Murmur, Edema • Respiratory: Breath Sounds, Wheeze, Spoken or Whispered voice. • GI: Hepatomegaly, Splenomegaly, Bowel sounds, bruits, rubs • GU: Examination of Bladder, Palpation of kidney -enlargement, CVA • tenderness

18. Physical Exam Findings • Examples of Organ system exam: • Musculoskeletal: ROM (range of motion), Strength, Stability, Gait • Skin: Color, texture, lesions, moles, birthmarks, rashes, dermatitis, dermatoses, hyperhidrosis, actinic damage, ulcers • Neuro: Sensory examination, Reflex Examination • Psych: hallucinations, delusions, obsessions, compulsions, Time, place, person • Hem/Lymph/Immo: Palpable cervical, axillary, inguinal nodes

19. Medical Decision Making • 2 of the 3 elements must be met or exceeded • Number of Diagnoses/Treatment Options • Amount & Complexity of Data • Level of Risk

20. Number of Diagnoses/Treatment Options • Each encounter should have an assessment/plan and diagnosis that is documented • Self limited/minor = 1 • Est problem: stable/improved = 1 • Est problem: worsening = 2 • New problem: no work-up = 3 • New problem: add work-up = 4

21. Amount & Complexity of Data • If a diagnostic service is ordered, planned, reviewed, or performed at the time of the E/M encounter, the type of service should be documented • Lab Test (80000 series) = 1 • X-Ray (70000 series) = 1 • Medical Test (90000 series) = 1 • Discuss test with performing physician = 1 • Independent review of images, testing or specimen = 2 • Decision to obtain old records and/or hx from someone other than patient =1 • Review/summarize old records and/or obtain hx from someone other than patient = 2

22. Table of Risk • Highest level of risk in any category determines the level of risk • Presenting Problem • Diagnostic Procedure • Management Options

23. Score Sheet – Table of Risk

24. Score Sheet – Type of Decision Making

25. Evaluation & Management Services

26. Questions