Briefing: Evaluation Management - The Basics Date: 20 March 2007 Time: 1400 - 14:50

1. 1 Briefing: Evaluation & Management - The Basics Date: 20 March 2007 Time: 1400 - 14:50

2. 2 Objectives Principles of Documentation Key Componenents 1995 vs. 1997 The Differences � Patients and Services Review Questions

3. 3 The medical record should be complete and legible The documentation of each patient encounter should include: Reason for the encounter & relevant history, physical examination findings and prior diagnostic test results If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred Past and present diagnoses should be accessible to the treating and/or consulting physician Appropriate health risk factors should be identified. The patient�s progress, response to and changes in treatment, and revision of diagnosis should be documented The CPT and ICD-9-CM codes reported should be supported by the documentation in the medical record Medical Record Documentation

4. 4 Medical Record Documentation DoD uses 1995 vs.1997 Guidelines Medical record facilitates The ability to evaluate and monitor Communicate and provide continuity of care Accurate and timely claims review and payment Workload capture Utilization review and quality of care evaluations Collection of data

5. 5 Medical Record Documentation What Payers Want & Why The site of service The medical necessity and appropriateness of the diagnostic and/or therapeutic services provided That services provided have been accurately reported

6. 6 Medical Record Documentation What MHS Wants and Why The site (MEPRS) of service The provider of service The medical necessity and appropriateness of the diagnostic and/or therapeutic services provided That services provided have been accurately reported Let me repeat that last bullet�.. That the services have been accurately reported

7. 7 Three Key Components History Examination Medical Decision Making Additional Components Include Counseling Coordination of care Nature of presenting problem Time - Key or controlling factor when visit consists predominantly of counseling and coordination of care

8. 8 Three Key Components Require all 3 Key Components: New Patient Office or Outpatient Services Initial Office or Outpatient Consultation Services Initial Observation Care Services Initial Hospital Care Services Observation or Inpatient Care Services Admit/Discharge Same Date Initial Inpatient Consultation Services Emergency Department Services Require 2 of 3 key Components: Established Patient Office or Outpatient Services Subsequent Hospital Care Services

9. 9 Three Key Components History Problem Focused Expanded Problem Focused Detailed Comprehensive