Practical E

1. Practical E/M: Solutions to  Optimize Medical Quality,  Compliance, & Efficiency Medical Necessity & Levels of Care Practical E/M Methodology Intelligent Medical Record Tools Stephen R. Levinson, M.D. ASALLC@aol.com www.PracticalEM.com

2. Disclaimer This presentation is designed to provide accurate and authoritative information in regard to the subject matter covered. The information includes both reporting and interpretation of materials in various publications, as well as interpretation of policies of various organizations. This information is subject to individual interpretation and to changes over time Presenter has personal interests in consulting, presenting, writing about, and developing software in order to help physicians achieve compliant medical records and to help them facilitate quality patient care

3. Demographics Med record taught? Lawrence Weed (comp); Bates� Guide to H & P SOAP notes (comp?) E/M & Doc. Guidelines?? Format? Writing on Paper Dictation Electronic Need an approach & tools that match physicians� work flow in all formats

4. What are Overall Issues for E/M?I + C + Q

5. Overview of H&P and Medical Record Conventional approach to E/M training has failed, by usability, compliance, and quality measures Albert Einstein�s definition of insanity ? �Insanity: doing the same thing over and over again and expecting different results� We need an approach that will work for MDs To accomplish this, we have to start with a clean E/M slate, which should sound reasonable to all of us

6. Overview of H&P and Medical Record The E/M clean slate: Practical E/M is not a modification of previous methodology, so we don�t compare to that. We start from scratch with an approach proven to work for physicians

7. Overview of H&P and Medical Record Medical record approach: this is not a modification of the time-saving shortcuts that evolved by cutting out parts of the medical record we learned early in medical school. Rather, the IMR gives us the tools we should have been given in the 2nd year of medical school Allows comprehensive H&P, the most effective diagnostic tool available, in 10 - 15 minutes

8. Where Did the E/M System Come From? Raiders of Lost Ark storage facility? Administrivia? Standard of care?

9. CPT�s E/M System is a Valid Reflection of Quality Care Physicians are Taught �Bates Guide to the H&P� 7 Elements of the HPI: p. 3 8th: �timing� incl. �duration� 16 ROS Systems: p. 5 - 8 PFSH: p. 4 � 5 Physical Exam: p. 9 MDM: p. 36 � 38 Data review, Dx, plans NPP: p. 37 Nature of Patient�s Problem When to consider NPP: p. 36 �CPT & 1997 Doc. Guidelines� 8 Elements of the HPI: p. 7 14 Systems of the ROS: p. 8 Combines GU, skin/breast PFSH: p. 9 Physical Exam: p. 13 - 16 MDM: p. 43 Data review, Dx, plans, risks NPP: CPT p. 2 � 3 Nature of Presenting Problem When to consider NPP: Practical E/M, p. 119

10. CPT�s E/M System is a Codification of the Quality Care Approach We Teach Physicians CPT�s E/M Section & Doc. Guidelines match concept for concept, and almost word for word, with the text �Bates Guide to the Physical Exam and Medical History� Therefore E/M is not only a coding system, it can be used as a blueprint to guide and facilitate quality patient care i.e., E/M compliance is a reasonable model of quality care

11. Promising, But One Problem Remains: Efficiency The problem is that in medical school, he only tools we are given to document a comprehensive H&P are a pen & blank paper This results in an unrealistic 45 � 60 minutes to provide and document comprehensive care! Need to bring you effective tools that will help you provide and document this high level H&P in 10 - 15 minutes (easily & with compliance)

12. SOAP Note: Problem for Compliance & Quality Problem focused SOAP is a �shortcut� When used as designed, allows performing & documenting problem focused (level 1) care! Subjective = just an HPI Objective = just the abnl findings Assessment = 1 Dx Plan = 1 Rx No separation of Rx & data ordered No doc. of complexity of data No doc. of risks No doc of NPP

13. What are Physician Issues and Measures for Medical Records? 1) Compliance 2) Efficiency 3) Usability 4) Quality Care 5) Data Integrity 6) (Productivity) Addressing #1, 2 & 3 e #4, 5, & 6 (care and reimbursement levels appropriate for severity of each patient�s illnesses)

14. Medical Necessity Cornerstone of Compliant Coding & The Foundation for Practical E/M

15. Medical Necessity �Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code� Medicare Claims Processing Manual, Chapter 12, section 30.6.1 Definition(s)? Service that meets the standard of care for addressing a patient�s medical condition

16. *Medical Necessity Definition Synopsis of the comprehensive definition applied in the HMO class action lawsuit settlements: Health care services that a Physician, exercising prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are (a) in accord with generally accepted standards of practice; (b) clinically appropriate, in terms of type, frequency, extent, site and duration (c) considered effective for the patient�s illness, injury or disease; (d) not primarily for the convenience of the patient or Physician (e) not more costly than an alternative service that is at least as likely to produce equivalent therapeutic or diagnostic results

17. Which of the 7 Elements of E/M Directly Relates to Medical Necessity? Medical History Chief Complaint; HPI; PFSH; ROS Physical Examination Medical Decision Making (MDM) Data reviewed &/or ordered # of diagnoses &/or treatment options Risk of problems, tests, treatments Nature of the presenting problem (NPP) Counseling Coordination of Care Time

18. CPT Integrates Medical Necessity into E/M Compliance Levels of NPP refer to an illness�s risks (M&M) and probability of functional impairment without treatment these factors support medical necessity Appendix C provides Clinical Examples that illustrate medical necessity (ie, the NPP) �Clinical examples�are provided to assist physicians in understanding the meaning of the desriptors and selecting the correct code� (p.4) Appendix C advises: assess the level of medical necessity, then provide the level of care warranted

19. Document Questions About Medical Necessity

20. Practical E/M:  Documentation  &  Coding Solutions with Intelligent Medical Records

21. �Practical E/M� is About: QUALITY CARE And integrating the requirements of the E/M system in a fashion that facilitates achieving quality care - efficiently

22. Challenges Inherent in the �Classic� E/M Approach Provide a Document a Code (with no NPP) This approach has created multiple problems (has failed) Inappropriate E/M codes, documentation, & medical necessity Non-compliant: audits show up to 80% failure rate Absence of guidance for compliant care & documentation Negative impact on physician productivity Negative impact on quality of care Audit fear a submitting low level E/M codes a low reimbursements a inadequate time available to provide higher levels of care

23. The Conventional E/M Approach:2 Potential Financial Calamities Over-coding (code>NPP) & under-documenting (care<code submitted) Return of funds Extrapolation Penalties for fraud Undercoding Coding below documentation a inadequate reimbursement for care Coding below NPP a loss of income that is warranted by the E/M coding system (& by the patient)

24. Practical E/M Avoids Financial Calamities with the �Goldilocks Approach� Using CPT�s measure of Medical Necessity to ensure that selected codes Not too high, Not too low, But �Just Right�

25. Judging Medical Records and Their Impact on Quality Care

26. The Medical Record Should be a Reflection of the Care Provided With conventional approaches, all too often this is true � it documents the limitations!

27. Similarly, Medical Care is a Reflection of the Medical Record Tools Employed Enhancing the quality of the tools enhances the quality of the care Improved diagnosis Improved planning Audit protection Medico-legal protection

28. Cornerstones of the Practical E/M Philosophy Quality care must be the principle measure for medical records The process must �work� for clinicians Intuitivity The �nature of presenting problem� (NPP) indicates the level of care and coding warranted by the patient�s illness Coding and documentation are integrated into the process of providing care Use tools not rules

29. Solving the Problem:Rules vs. Tools

30. MDs Must Remember Only the Two Basic CMS Audit Rules If care was not documented in the medical record, it was not done (CMS Carriers� Manual, section 7103.1(I) ) In accordance with the Social Security Law, Medicare will not pay for services that are not medically necessary (Soc.Sec. section 1862)

31. Solution: �Practical E/M� Approach + an �Intelligent Medical Record� �The solution to the �problem� of compliance is to see compliance as a solution� Dean Edward D. Miller, Hopkins Medical News winter 2002 That is, build the medical record on a foundation of tools that ensure compliance and efficiency And the record will facilitate quality care

32. Keys to Practical E/M Approach Select Correct Type of Service Comprehensive medical history every visit **Select Nature of Presenting Problem (NPP) and identify level of care warranted by severity of illness (CPT) Perform & doc. exam, guided by documentation prompts Complete ALL elements of the MDM, guided by documentation prompts Document the NPP

33. Practical E/M Methodology IsSuggested by CPT Option I, in the E/M section: Perform & document care, then calculate an appropriate E/M code Focus is on three �key components� Option II, in the Clinical Examples section: Identify level of care warranted by illness severity (NPP) Perform & document extent of care warranted by severity of illness (for the 3 key components) Focus is on the NPP (severity & risk of illness) Consider this a mandatory fourth component (CPT includes NPP in every TOS that considers Hx, exam, & MDM)

34. Document Questions @ the Practical E/M Approach to Compliant Doc & Coding

35. Considerations on Type of Service Initial visit Established patient visit Consultation

36. Outpatient Type-of-Service Rules New patient: no services within 3 years from M.D. or a partner of same specialty Established patient: has received services from M.D. or a partner within 3 years Consultation: CPT rules Opinion requested by another physician or other appropriate source (not by patient or family) Care rendered and documented Written opinion to requestor (not photocopy of H&P) No transfer of responsibility for all care (CMS rule) **No separate category in CPT for �referral�; new issue

37. Building an IMR to Fulfill the Promise of Practical E/M

38. Building Blocks for an IMR:Achieving Compliance, Efficiency, & Usability Interface Graphic (yes/no; normal/abnormal responses) Narrative (descriptions & details) Personnel entry options (patient/staff/MD) Format Written / dictated / electronic / **hybrids Data entry vs. Data storage/retrieval This is NOT an EHR, but the same medical record principles can (and should) be applied to EHRs

39. The Critical Importance of Appropriate Use of a Narrative Interface Medical History Tells a story of the patient�s problems Physical Examination Paints a verbal picture of the patient�s abnormal findings MDM: Impressions: creates a logic tree for diagnosis Treatment options: creates a blueprint for future care

40. Keys to Practical E/M ApproachStep 2: IMR and the Medical History (After step 1: selecting the correct type of service) Comprehensive medical history every visit Outpatient, inpatient, E.R., etc Initial visit requirements: Complete PFSH & ROS; extended HPI Established outpatient visit requirements Update of a complete PFSH & ROS; extended HPI Established inpatient visit requirements Update of a complete ROS; extended HPI

43. Established Visit Requirements: PFSH & ROS Do Not repeat all the questions State �I reviewed old history� �Photocopy� old history (EHRs) DO Update ROS & PFSH = �no change since 1/1/02, except��.� Effect on coding Effect on quality of care

45. IMR & History of Present Illness (HPI) MUST be a �chronological description� Documentation prompts for the 8 elements of the HPI. The 8 elements are not enough Duration, timing, severity for every visit Next element = �extended� HPI Alternative of documentation of status of 3 chronic conditions (not just a listing) Provides an extended HPI; it does NOT set NPP or level of care

47. The Medical History and Quality of Care: Problem Focused Care (incl. SOAP)

48. Problem Focused Care � Disguised

49. Care with a Comprehensive History

50. *Keys to Practical E/M ApproachStep 3: IMR and the NPP Following assessment of patient history, Select probable Nature of Presenting Problem (NPP) and identify appropriate level of care that appears to be warranted by severity of illness Refer to documentation prompt for NPP Based on CPT indicators Refer to �clinical examples� appendix C

51. *The Key Practical E/M Insight Step 3: Severity of Illness Nature of the Presenting Problem is the key to correct coding It sets the upper limit for level of care which �is medically necessary� (i.e., �warranted�) It also RAISES the bar to the level of care that is medically indicated

53. *Keys to Practical E/M Approach:Step 4: IMR and the Physical Examination Appropriate exam template Perform & document examination Following the IMR documentation prompts Graphic interface for efficient documentation of all normal findings Narrative interface for efficient and high quality documentation of abnormal findings Added feature to facilitate pertinent normals

55. *Keys to Practical E/M ApproachStep 5: IMR & Medical Decision Making Complete the MDM Following the IMR documentation prompts IMR includes all elements of MDM Separate data ordered from treatment plans! Include complexity of data Include 3 types of risk Focus on two of the 3 sub-components Risk of presenting illnesses Number of possible diagnoses or treatment options Use �rule out� diagnoses and appropriate adjectives

58. *Keys to Practical E/M ApproachStep 6: IMR & Final documentation of NPP Document the NPP (final assessment) Option of Time and �counseling visits� Document time and effort, when appropriate

60. Meeting Physician & Facility E/M Challenges for Inpatient Compliance Blank paper (or tape) inadequate Fewer levels of care Level of care still based on NPP Especially for subsequent care Key is compliant documentation prompts

61. Inpatient Subsequent Visits (2 out of 3 paradigm)

62. IMR Special Features Document informational hand-outs Diagrams (separate page) Optional �incident to� section Optional �physician presence� section (separate page, based on IL372) Format Hybrid #1: Writing + Dictation

63. �Incident To� & �Physician Presence� Tools �Incident To� for PAs & APRNs �Physician Presence� for academic centers Forms for easy documentation (based on IL372)

64. �Practical E/M� for Docs -Summary Patient enters complete PFSH & ROS (for new patients) Physician reviews, completes positives Update the PFSH & ROS for established patients Physician enters extended HPI Refer to nature of presenting problems Select initial NPP & appropriate level of care Use doc. prompts to ensure sufficient care & documentation of exam and MDM sections; confirm final level of NPP Therefore, level of care is selected on basis of medical indications, and documentation supports that level of care When you sign, you are complete & compliant

65. Practical E/M, IMR Design, & Electronic Health Records Note: EMRs have not solved E/M compliance; see Part B News 5/1/06 �The potential of such upcoding (by EMR software) has attracted the government�s attention� �EMR software�may lead them to �select & bill for higher level E/M codes than medically reasonable & necessary� Practical E/M concepts and IMR design functionality are adaptable to EHRs; these principles are essential to enable EHRs to help physicians provide high quality and compliant clinical care

66. Strategies for Success:  Working Together with  Your Professional Coders

67. Are There Any Reasons NOT to Adopt a Practical E/M Approach � Other than Inertia? Quality of patient care should be equal or increased Efficiency (time spent) should be equal or improved Documentation and coding should comply with the requirements of the E/M coding system and be �audit proof� Productivity should equal or exceed current levels i.e., compliant E/M code levels should actually increase (unless a physician is now over-coding significantly). Ancillary benefits Reduced after-hours time required to complete patient charts, which translates into more personal and family time ? concern about potential for financially damaging audits ? enjoyment of the patient care process

68. Questions on Practical E/M Solutions Thank you for your interest Contact: asallc@aol.com Website: www.PracticalEM.com www.IntelligentMedicalRecords.com Availability of custom IMR forms & Practical E/M manual: Now: asallc@aol.com Future: interactive web site under development Stephen R. Levinson, MD