Evaluation and Management Services

1. Evaluation and Management Services Montri D. Wongworawat Department of Orthopaedic Surgery Grand Rounds July 1, 2009

2. Evaluation and Management • E/M • Professional face-to-face service between doctor and patient • Documentation to support the above • S: History • O: Physical • A: Decision Making • P: Decision Making

3. Lecture Outline • Categories of E/M Services • Elements of the E/M Visit • Modifiers • Case Studies

4. Lecture Outline • Categories of E/M Services • Elements of the E/M Visit • Modifiers • Case Studies

5. Categories of E/M Services • Office or other outpatient (includes ED) • New (requires all 3 key components) • Established (2 of 3 components) • Hospital inpatient • Initial hospital care (3 components) • Subsequent hospital care (2 of 3 components) • Hospital discharge • Consultations • Office or other outpatient • Initial inpatient

6. Categories of E/M Services • Office or other outpatient • New (requires all 3 key components of E/M) • Never seen by your group • Seen by you or group member more than 3 years ago • Established (2 of 3 components of E/M) • Not New visit • Not Consultation

7. Categories of E/M Services • Consultations • Definition • “A consultation is defined as a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.”

8. Categories of E/M Services • Consultations • Guidelines • The consultant’s opinion is requested by another physician • Documentation of verbal or written request • Documentation of consultant’s opinion • Consultant may initiate treatment • Communication of consultant’s opinion to the requesting physician

9. Categories of E/M Services • Consultations • Situations • Requests between physicians of the same group • Report consultation code if guidelines are met • Initiation of treatment • Usually stems from medical decision making portion of the E/M service • “Even though treatment is initiated, the initial service is still considered a consultative visit.” • If the consulting physician assumes care, the initial service should be reported as a consult.

10. Lecture Outline • Categories of E/M Services • Elements of the E/M Visit • Modifiers • Case Studies

11. Elements of the E/M Visit • History • Chief complaint (CC) • History of present illness (HPI) • Review of systems (ROS) • Past, family, social history (PFSH) • Physical examination • Decision making • Number of diagnosis/management options • Risk of complications • Amount/complexity of data reviewed

12. Elements of the E/M Visit • History • CC (1 element) • Describe reason for visit • Every visit must have the CC stated

13. Elements of the E/M Visit • History • HPI (4 elements) • Location: site of the problem • Quality: sharp, dull, throbbing • Severity: minor, moderate, severe • Duration: intermittent, constant • Timing: with exercise, nightly, after meals • Context: worsening, recurrent • Modifying factors: rest, heat, cold, elevation • Associated symptoms: numbness, tingling

14. Elements of the E/M Visit • History • ROS (10 elements) • Constitutional • Eyes • Ear, nose, throat • Cardiovascular • Respiratory • Gastrointestinal • Genitourinary • Musculoskeletal • Integumentary • Neurologic • Psychiatric • Endocrine • Hematologic • Immunologic

15. Elements of the E/M Visit • History • PFSH (3 elements) • Past history • Illnesses • Operations • Allergies • Family history • Social history • Occupation • Tobacco and alcohol use

16. Elements of the E/M Visit • History • PFSH (3 elements) • Past history • Illnesses • Operations • Allergies • Family history • Social history • Occupation • Tobacco and alcohol use

17. Elements of the E/M Visit

18. Elements of the E/M Visit • Physical examination—Musculoskeletal • Constitutional (2 elements) • Cardiovascular or lymphatic (1 element) • Musculoskeletal (17 elements) • Skin (4 elements) • Neuropsychiatric (5 elements)

19. Elements of the E/M Visit • Physical examination—Musculoskeletal • Constitutional (2 elements) • Vital signs (any 3 of the following items) • Temperature • Pulse • Respiration • Blood pressure • Height • Weight • General appearance

20. Elements of the E/M Visit • Physical examination—Musculoskeletal • Cardiovascular or lymphatic (1 element) • Pulse • Capillary refill • Skin perfusion • Edema • Lymph node palpation

21. Elements of the E/M Visit • Physical examination—Musculoskeletal • Musculoskeletal (17 elements) • Gait examination • In 4 of 6 body areas: (head/neck, trunk, 4 extremities) • Inspect/palpate • Assess ROM • Assess stability • Assess strength, tone, atrophy, or spasticity

22. Elements of the E/M Visit • Physical examination—Musculoskeletal • Skin (4 elements) • In 4 of 6 body areas: (head/neck, trunk, 4 extremities) • Inspection and/or palpation

23. Elements of the E/M Visit • Physical examination—Musculoskeletal • Neuropsychiatric (5 elements) • Coordination • Reflexes (deep tendon or pathologic) • Sensation • Orientation • Mood and affect

24. Elements of the E/M Visit

25. Elements of the E/M Visit • Decision making • Number of diagnosis/management options • Risk of complications • Amount/complexity of data reviewed

26. Elements of the E/M Visit • Decision making • Number of diagnosis/management options • Self-limited or minor problem 1 • Established problem 1 • Worsening problem 2 • New problem, no additional workup 3 • New problem, additional workup planned 4 • Add up points • Score = 1, 2, 3, 4+

27. Elements of the E/M Visit • Decision making • Risk of complications • Minimal • Suture removal, lab tests, rest • Low • Two minor problems, sprain, order PT/OT, minor surgery without risk factors • Moderate • Two chronic illness, CT, MRI, aspiration, Rx, fx management, major surgery without risk factors, minor surgery with risk factors • High • Illness with severe exacerbation, abrupt neurological change, major surgery with risk factors, emergency surgery

28. Elements of the E/M Visit • Decision making • Amount/complexity of data reviewed • Order test 1 • Review test result 1 • Discuss test with performing physician 1 • Decide to obtain records 1 • Review and summarize records 2 • Review x-ray or specimen 2 • Add up points • Score = 1, 2, 3, 4+

29. Elements of the E/M Visit

30. Elements of the E/M Visit • How do you decide level of service? • Components • History • Physical examination • Decision making • New patients and consultations • Need all 3 components • Code for lowest component • Established patients • Code for 2 out of 3 components

31. Elements of the E/M Visit

32. Elements of the E/M Visit

33. Lecture Outline • Categories of E/M Services • Elements of the E/M Visit • Modifiers • Case Studies

34. Modifiers • What are modifiers? • Modifiers indicate that a service or procedure has been altered by circumstance but not changed in definition • How are modifiers reported? • Two digits appended to CPT code • Example: 99214-25

35. Modifiers • CPT modifiers -21: Prolonged E/M services -24: Unrelated E/M during postop period New problem, management of complication, etc. -25: Significant and separate E/M on the same day of procedure Note: chief complaint should be different than diagnosis, and procedure should be separately documented from the E/M note -57: Decision for surgery Appended to E & M code that resulted in the decision for surgery

36. Lecture Outline • Categories of E/M Services • Elements of the E/M Visit • Modifiers • Case Studies

37. Case Studies • Leveling an E/M visit • 58 y/o RHD male • Motorcycle accident • Left wrist pain

38. Case Studies • Leveling an E/M visit • History (comprehensive) • CC (1) • Left wrist injury • HPI (4) • 58 y/o RHD male sustains a motorcycle injury (context) this morning (timing), and has sharp pain (quality) in the left wrist (location). • ROS (10) • PFSH (3) • The patient has hypertension (past). Family history includes heart disease (family). He smokes 1 ppd x 23 yrs (social).

39. Case Studies • Leveling an E/M visit • Physical examination (comprehensive) • Constitutional (2) • T: 98.4, P 72, B/P 152/90 (3 vital signs) • The patient appears well developed and is in moderate distress (general appearance). • Cardiovascular (1) • He has good capillary refill in all fingertips of the left hand.

40. Case Studies • Leveling an E/M visit • Physical examination (comprehensive) • Musculoskeletal (17) • The patient is on bedrest, and gait cannot be examined (1). • Examination of the left upper extremity shows gross deformity at the wrist (1). ROM (1) and strength (1) is decreased due to pain. There is no joint laxity but definite motion across the fracture site (1) on examination. • Examination of the right upper and bilateral lower extremities reveals no tenderness (3), functional ROM (3), no dislocations (3), and no atrophy/weakness (3).

41. Case Studies • Leveling an E/M visit • Physical examination (comprehensive) • Skin (4) • No wounds are present on bilateral upper (2) and bilateral lower extremities (2). • Neuropsychiatric (5) • Patient has normal fine motor control (coordination). Babinski is symmetrically downgoing (reflex). He has intact sharp-dull differentiation to the radial, median, and ulnar nerve distributions of the left hand (sensation). He is oriented person, place, and time (orientation). His mood and affect are appropriate (mood and affect).

42. Case Studies • Leveling an E/M visit • Decision making (2 of 3 components) • Number of options • This patient presents with a new problem, and no further workup is necessary (3 points). He also has HTN, which is stable at this time (1 point). HIGH • Risk of complications • I recommend major surgery, with open treatment. His risk factors include HTN and tobacco use. HIGH • Complexity of data • I ordered x-ray films (1 point), and have personally reviewed them. The findings show a left distal radius fracture with intra-articular comminution (2 points). MODERATE

43. Case Studies • Leveling an E/M visit

44. Case Studies • Leveling an E/M visit

45. Case Studies • Selecting the correct category • A 30 y/o patient presents to your office for redness and swelling in the forearm. You obtain the history, perform examination, and order blood tests. You admit the patient on the same day for treatment. After completion of your office hours that day, you see him in the hospital.

46. Case Studies • Selecting the correct category • A 30 y/o patient presents to your office for redness and swelling in the forearm. You obtain the history, perform examination, and order blood tests. You admit the patient on the same day for treatment. After completion of your office hours that day, you see him in the hospital. • You will not separately report the office visit and the initial hospital care. • Only the initial hospital care (99221-99223) is reported.

47. Case Studies • Selecting the correct category • A 30 y/o patient presents to your office on Wednesday for redness and swelling in the forearm. You obtain the history, perform examination, and order blood tests. You admit the patient on the same day for treatment. On Thursday, you make rounds and see him as an inpatient. The patient is seen again on Friday.

48. Case Studies • Selecting the correct category • A 30 y/o patient presents to your office on Wednesday for redness and swelling in the forearm. You obtain the history, perform examination, and order blood tests. You admit the patient on the same day for treatment. On Thursday, you make rounds and see him as an inpatient. The patient is seen again on Friday. • You report the Wednesday office E/M code (99201-99205). • You also report the appropriate initial hospital care code (99221-99223) for Thursday, which is when you had his first inpatient encounter. • Rounds on Friday will be reported as subsequent hospital care (99231-99233).

49. Case Studies • Selecting the correct category • Dr. A (ED physician) requests your opinion and advice regarding the patient’s displaced tibia fracture. The request and the need for the consultation are documented. You perform the consultation, document your opinion and advice, and communicate this opinion and advice to Dr. A. You then assumes responsibility for the management by taking her to the OR the same day.

50. Case Studies • Selecting the correct category • Dr. A (ED physician) requests your opinion and advice regarding the patient’s displaced tibia fracture. The request and the need for the consultation are documented. You perform the consultation, document your opinion and advice, and communicate this opinion and advice to Dr. A. You then assumes responsibility for the management by taking her to the OR the same day. • You report your E/M services as an office or other outpatient consultation (99241-99245), with -57 modifier appended. • You also report the procedure code for treatment of tibial fracture using intramedullary device (27759).