Evaluation & Management Services

1. Evaluation & Management Services July 7, 2009 Brenda Edwards, CPC, CPC-I, CEMC Coding & Compliance Specialist KaMMCO

2. Medical Record Documentation • Records pertinent facts, findings and observations about an individual’s 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.

3. Golden Rule of Coding: If it is not documented, it is not done and therefore not billable!

4. 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.

5. 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 patient’s 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

6. 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.

7. Documentation Guidelines • New patients vs. established patient • New patient - One who hasn’t 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

8. 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)

9. 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

10. 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

12. History Elements • Chief Complaint is a clear and concise statement in the patient’s 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 provider’s “thought” process on paper

13. 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

14. Constitutional Eyes ENT Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary Neurological Psychiatric Allergic/Immunologic Endocrine Hematologic/Lymphatic Review of Systems • Review of systems is the patient’s positive and pertinent negative response to a series of questions.

15. 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

16. 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)

17. Medical Decision Making • Medical decision making is the provider’s “thought process” • Hardest element to translate into an audit form • The reason for encounter typically dictates the level of service selected

18. 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 provider’s “thought process” on paper

19. 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

20. 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

21. 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

22. The Hospital Card

23. 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

24. 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

25. 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.

26. 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

27. Hospital Consultations • Entire care of patient is not assumed • In order to bill must have 3 “R”s in writing • Request for an opinion • Render your opinion • Reply back to requesting provider of findings or recommendations

28. Concurrent Care • Patient is managed by multiple providers/specialties • Each can bill for their services, if specific conditions are being followed by each provider • Can’t bill for “courtesy visits”

29. 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

30. 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)

31. 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

32. 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 patient’s condition

33. 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 surgeon’s billing • Charge is typically 25% of the surgeon’s fee • Billable by Resident if rotation service but established patient of the resident is the recipient of the surgery

34. Outpatient Procedures • Billable by the Resident if not related to rotation or covering rotation for another Resident • Hospital card required (mainly for tracking)

35. Questions