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Understanding E+M

Understanding E+M. Larry Halem, MD, CPC VEP Regional Productivity Director. Documentation. The majority of physicians do not document properly which leads to the loss of revenue and decreased reimbursement It’s not more work, it’s doing the work appropriately.

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Understanding E+M

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  1. Understanding E+M Larry Halem, MD, CPC VEP Regional Productivity Director

  2. Documentation • The majority of physicians do not document properly which leads to the loss of revenue and decreased reimbursement • It’s not more work, it’s doing the work appropriately

  3. It’s your money. Stop giving it to the insurance companies

  4. Different Levels • There are 5 E+M levels (evaluation and management codes) • Level 1 (99281): 0.6 RVU • Level 2 (99282): 1.17 RVU • Level 3 (99283): 1.75 RVU • Level 4 (99284): 3.32 RVU • Level 5 (99285): 4.9 RVU

  5. What determines the E+M level • Determined by components of: • HPI • ROS • PE • MDM • Diagnosis

  6. History of Present Illness • History: history of present illness • Needs 1-3 components for a level 2 or 3 • Needs greater than or equal to 4 components for a level 4 or 5 • Different components • Quality • Location • Timing • Duration • Severity • Context • Modifying factors • Associated signs and symptoms

  7. Review of Systems • ROS: review of systems • Level 3: Need 1 • Level 4: Needs 2-9 total • Level 5: Needs 10 total • Documenting pertinent positives and marking all other negative and reviewed in HPI is adequate for a level 5 ROS

  8. Past Medical, Family, Social History • PFSH: • Level 4: Needs 1 • Level 5: Needs 2 • This is a large area that leads to down-coded charts. If you do not place a social or family history this will down-code the entire chart to a level 4

  9. Smoking Cessation • If they smoke: counsel them • There are 2 categories for billing, but for the ER we will typically only use category: greater than 3 minutes up to 10 minutes • RVU 0.3 RVU

  10. Examination • PE: physical exam • Level 3 and 4: Needs 2-7 body area/organ systems • Level 5: Needs greater or equal to 8 organ systems

  11. Medical Decision Making • Amount and Complexity of Data Reviewed • Level 3: 2 data points • Level 4: 3 data points • Level 5: 4 data points • Data points: • Order lab tests: 1 point • Order radiology tests: 1 point • Order ECG: 1 point • Decision to obtain old medical records and/or history from someone other than patient: 1 point • Review and summarization of old records and/or discussion of case with another health care provider: 2points • Independent visualization and interpretation of radiology study or ECG: 2 points

  12. Medical Decision Making • Risk of Complications, Morbidity, and Mortality • This is broken down into the: • Presenting problem • Diagnostic procedures ordered • Management and treatment given

  13. Medical Decision Making • Risk of Complications, Morbidity, and Mortality • Level 3: • Acute uncomplicated illness or injury • Minimal diagnostic tests performed • Minor procedures • Oral medications

  14. Medical Decision Making • Risk of Complications, Morbidity, and Mortality • Level 4: • Mild exacerbation of chronic problem, acute illness with systemic symptoms, or acute complicated injury • Diagnostic procedures such as labs, radiographic studies including x-ray and CT scans • IV fluids • IM medications for pain

  15. Medical Decision Making • Risk of Complications, Morbidity, and Mortality • Level 5 • Severe exacerbation of chronic problem or acute or chronic problem posing threat to life or limb • IV narcotic pain medications • IV medications requiring repeated dosing • Diagnostic procedures such as labs with advanced imaging including ultrasound, CT, or MRI • Treatment requiring intense monitoring • DNR or de-escalation of care

  16. Medical Decision Making • Formatting an MDM • Backbone of the MDM • Opening is a synopsis of the patient • Body of your MDM is building the differential • Final section is synopsis of the treatment given

  17. MDM: RUQ Abdominal Pain • Patient presents with abdominal pain. Labs were performed to evaluate for evidence of electrolyte abnormalities such as hyponatremia, hyperglycemia. Labs including LFT’s and lipase were performed to evaluate for evidence of pancreatitis or hepatitis. Urine shows no evidence of infection. Radiology studies, ultrasound abdomen was performed to evaluate for biliary pathology or cholecystitis and shows no acute intra-abdominal pathology. Patient improved in the ER with IV pain medications, IV antiemetics, and IV hydration.

  18. Medical Decision Making • It is the combination of the presenting complaint, diagnostic procedures ordered, and treatment given combined with the reviewed data points that determine the E+M level assigned. • This is the most important section that can be the difference between a level 3, level 4, and level 5

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