Evaluation Management Coding

1. Evaluation & Management Coding How to Get the Workload Credit You Deserve Angela N. Andersen, CPC Lead Coder Naval Medical Center Portsmouth March 2007

2. E&M Coding Upon completion of this presentation, the participant should be able to: Identify the three key components of E&M coding Recognize the difference between new and established patients as it relates to documentation and coding. More accurately document and select the appropriate E&M code for the services rendered.

3. Contents: What are E&M Codes? Why Code? How do Codes equate to Workload Credit? Why is Documentation important? What documentation should be included on every encounter? Determining the correct E&M code Time as the determining factor for E&M code selection Preventive Medicine E&M code requirements

4. What are E&M Codes? The Evaluation & Management (E&M) codes are a sub-set of the CPT codes. Can be used by all privileged providers Describes: Complexity of care provided to a patient for non-procedural visits. The place of service (inpatient or outpatient) The type of service (new vs. est., consult, preventive, ER, critical care, etc)

5. Why Code? Why is it important to code in the military? REIMBURSEMENT Third Party Payers/Inter-agencies Prospective Payment System (PPS) FITREP input Over coding = Fraud Under coding = Lost RVUs/Revenue Why should we care about coding?? This is the military! FITREPs: Productivity standards are a FITREP bullet. Third Party Payers/Interagencies: FY05 this command brought it $_________ thru third party payers and interagency billing (CG) Learn to work smarter, not harder when it comes to coding. Make your coding ironclad, not able to be challenged by anyone. Allow your coder to help you.Why should we care about coding?? This is the military! FITREPs: Productivity standards are a FITREP bullet. Third Party Payers/Interagencies: FY05 this command brought it $_________ thru third party payers and interagency billing (CG) Learn to work smarter, not harder when it comes to coding. Make your coding ironclad, not able to be challenged by anyone. Allow your coder to help you.

6. Coding & Workload Credit A Relative Value Unit (RVU) is assigned to most of the CPT codes, including the E&M codes. The more complex the service, the higher the RVU value assigned New Patient RVUs > Established Patient RVUs Consult RVUs > New patient RVUs Prev Med RVUs > Established patient RVUs Under the PPS, RVU average = $72.00

7. What do Coders look for? Every patient encounter should be legible and include: Date of Encounter* Reason for the visit (chief complaint) Appropriate history of present illness An exam when necessary or appropriate; i.e. a new patient (consistency and problem pertinent) Review of lab, xray, other ancillary services when appropriate Assessment* Plan of care/Treatment options* Provider signature* *Taken Care of or required fields in AHLTA (CHCSII) Remember: It is the Content, not the volume, of documentation that determines your E&M code!

8. Determining the Correct E&M Code There are three key components to consider when selecting the appropriate E&M: History Exam Medical Decision Making (MDM) All three components must be documented for a new patient (new to clinic or not seen within the past three years). Indicate in CC if patient is new. Only two of the three components must be documented for established patients (seen within the past three years). E&M selection should never be based on the allotted time on the appointment schedule!

9. Why is Documentation Important? The documentation must support the E&M code you select. Your documentation must support the medical necessity of the services provided. The first step is to clearly document the reason for every visit – the chief complaint. The use of “Follow-up” is insufficient documentation as it does not indicate medical necessity. It is acceptable to document “Follow-up for _____”. Remember: The coding rule of thumb is “If it isn’t documented, it wasn’t done!”

10. Determining the Correct E&M Code To determine the correct level E&M code, consider the complexity of your patient’s condition and your medical decision making, then support that level of complexity with your documentation of history and/or exam. Remember: For a new clinic patient, initial consult, initial inpatient visit or ED encounter, you must document all three key components—history, exam and your medical decision making.

11. MDM Component Medical Decision Making (MDM) refers to the complexity of determining a diagnosis and/or the selection of a treatment option. It is measured by documentation of the following: Number of diagnoses and/or management options that must be considered. Amount and/or complexity of data to be reviewed. Risk of complications, morbidity and/or mortality, and co-morbidities. The four types of MDM include: Straightforward, Low Complexity, Moderate Complexity, and High Complexity. To assist in determining your level of MDM see Attachment A

12. History Component Documentation of History includes: Chief Complaint History of Present Illness (HPI) Review of Systems (ROS) Past, Family and or/Social History (PFSH) The extent of history is dependent on clinical judgment and the nature of the presenting problem. The four types of History include: Problem focused, Expanded Problem focused, Detailed and Comprehensive.

13. Determine your Documented Level of History Mark the entry in the farthest right column to describe your HPI, ROS and PFSH. If one column contains 3 marks, the type of history is indicated at the bottom. If no column has 3 marks, the column marked farthest to the left identifies the type of history.