Documenting Evaluation & Management (E&M) Services

1. Documenting Evaluation & Management (E&M) Services Presented by: Karen Kvarfordt, RHIA, CCS-P, CCDS AHIMA Approved ICD-10-CM/PCS Trainer President, DiagnosisPlus, Inc. 2015

2. What is documentation and why is it important? • Medical record documentation is required to record pertinent facts, findings, and observations about an individual’s health history. • Assists physicians and other health care professionals in evaluating and planning the patient’s immediate treatment and monitoring his/her health over time. “If it isn’t documented, it didn’t happen”!

3. The Elements of Medical Documentation • The reason the patient presented to see the physician/provider. • Complete details of the information provided by the patient and by the evaluation of the patient. • The results of diagnostic, consultative, and/or therapeutic services provided to the patient. • The assessment of the patient conditions. • The plan for the care of the patient, including advice from other physician specialists. • Other services, procedures and supplies provided to the patient. • The time spent with the patient, if counseling or coordinating care was provided.

4. The Elements of Medical Documentation… • The style and form of medical documentation depends on the provider. However, it is important that any reader of the medical record be able to understand the service rendered and medical necessity for the service. • The medical documentation must be legible and understandable for all providers who care for the patient. If the handwriting of the physician cannot be read, Medicare auditors, as well as other payers, consider the service as not billable.

5. Illegible

6. And some more… • Abbreviations or shorthand used in documentation should be listed on an identification key accessible to all who read the documentation. • All entries should be dated and signed according to the Evaluation and Management Services Guide published by CMS. • It is recommended that medical documentation be completed during or immediately following the service provided.

7. Evaluating Your Documentation • Is the reason for the patient encounter documented in the medical record? Is the Chief Complaint documented by the physician? • Does the medical record clearly explain the medical necessity of the level of E&M service, diagnostic and therapeutic procedures, support services and supplies provided? • Is the assessment of the patient’s condition apparent in the medical record? • Medical record should tell the patient story!

8. Other Points to Consider • Documentation guidelines in the Evaluation and Management Services Guide also indicate that the documentation should be able to validate where the services were rendered and that the services were medically necessary and appropriate. • The ICD-9-CM & CPT codes reported on the UB (facility) & 1500 (professional) should be supported by the documentation in the medical record.

9. And a few more Points… • The history areas and medical decision making areas frequently suffer from lack of detail. It is common to see the words “Patient here for f/u” as the chief complaint and the HPI. This is insufficient as is “Patient here to establish MD.” • With decision making, the notations “continuepresent meds” and “f/u 3 months” tells nothing of the problem(s), the status of the problem, and the treatment or management of the problem.

10. What is an E&M Code?

11. Evaluation & management • E&M services refer to visits and consultations furnished by physicians and/or providers. • Billing for a patient visit requires the selection of a CPT code that best represents the level of E&M service provided. For example, there are five (5) CPT codes that may be selected to bill for office or other outpatient visits for a “new” patient.

12. New patient e&m • 99201 – Usually the presenting problem(s) are self-limited or minor and the physician typically spends 10 minutes face-to-face with the patient and/or family. E&M requires the following three key components: • Problem focused history • Problem focused examination • Straightforward medical decision making

13. New patient e&m • 99202 – Usually the presenting problem(s) are of low to moderate severity and the physician typically spends 20 minutes face-to-face with the patient and/or family. E&M requires the following three key components: • Expanded problem focused history • Expanded problem examination • Straightforward medical decision making

14. New patient e&m • 99203 – Usually the presenting problem(s) are of moderate severity and the physician typically spends 30 minutes face-to-face with the patient and/or family. E&M requires the following three key components: • Detailed history • Detailed examination • Medical decision making of low complexity

15. New patient e&m • 99204 – Usually the presenting problem(s) are of moderate to high severity and the physician typically spends 45 minutes face-to-face with the patient and/or family. E&M requires the following three key components: • Comprehensive history • Comprehensive examination • Medical decision making of moderate complexity

16. New patient e&m • 99205 – Usually the presenting problem(s) are of moderate to high severity and the physician typically spends 60 minutes face-to-face with the patient and/or family. E&M requires the following three key components: • Comprehensive history • Comprehensive examination • Medical decision making of high complexity

17. New vs. established • To determine the appropriate level of service for a patient's visit, it is necessary to first determine whether the patient is ‘new’ or already ‘established’. • CPT 2012 Revised Definitions: • New- “A new patient is one who has not received any professional services from the physician or another physician of the exact same specialty and subspecialty who belong to the same group practice within the past three years”.

18. Established – “An established patient is one who has received professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice within the past three years”. • Exception! Patients seen in the Emergency Room do not have the distinction of ‘new’ vs. ‘established’.

19. Emergency Room • ER providers use following CPT codes: • 99821 • Problem focused history & examination • Straightforward MDM • Usually presenting problem(s) are self limited or minor. • 99282 • Expanded problem focused history & examination • Low complexity MDM • Usually presenting problem(s) are of low to moderate complexity • 99283 • Expanded problem focused history & examination • Moderate complexity MDM • Presenting problem(s) are of moderate severity

20. And a few more… • 99284 • Detailed history and examination • MDM of moderate complexity • Usually the presenting problem(s) are of high severity, and require urgent eval by the physician but do not pose an immediate significant threat to life/physiological function • 99285 • Comprehensive history & exam and MDM of high complexity • High severity and pose an immediate significant threat to life/physiological function

21. Documentation guidelines • 1995 Documentation Guidelines • General multi-system exam (7 body areas or 12 body systems) • Problem Focused = 1 • Expanded Problem Focused = 2-4 • Detailed = 5-7 • Comprehensive = 8 or more

22. Documentation guidelines • 1997 Documentation Guidelines • Multi-system exam or one of ten individualized single system exams • Get ‘credit’ for documentation of 3 or more chronic conditions • History and Medical Decision Making are the same for 1995 & 1997 • CMS – Use whichever set of results is most in the physicians’ favor. • However, you can’t mix & match!

23. Documentation of E&M services • The three key components of E&M services are: • History • Physical Examination • Medical Decision Making • Please note that just because the E&M level is dependent on two or three key components, performance & documentation of one component, ie, examination, at the highest level doesnot necessarily mean that the encounter in its entirety qualifies for the highest level of E&M.

24. Chief Complaint (CC) • Chief Complaint – Each note must always include a chief complaint even if the chief complaint describes that the patient is presenting for follow-up of a previous problem, the reason for the visit must be clear as in “Patient presenting for f/u ofuncontrolled hypertension.” • Usually stated in the patient’s own words. • Sometimes referred to as “presenting problem.” • Example: Patient complains of upset stomach, aching joints, or fever.

25. Key Components(History) • Information that is given by the patient to the physician • The history consists of 3 parts • History of Present Illness (HPI) • Review of Systems (ROS) • Past, Family, Social History (PFSH) • Remember! The Chief Complaint and the HPI must be documented by the physician.

26. Four types of history

27. Key Components(History) • History of Present Illness– Includes information described by the patient about the current condition including: • Location – refers to the location of the problem/symptoms – left lower quadrant; left leg; right arm; etc. • Severity – severity of the presenting problem – mild, severe; increasing; resolving, etc. • Timing – the interval of the pain or suffering – every night; constant; comes and goes; intermittent, etc. • Modifying Factors – how is the pain symptom modified – relieved by standing erect; better after taking aspirin; walking makes pain worse; etc. • Quality – descriptive adjective – dull; sharp; aching; stinging; throbbing, etc. • Duration – how long the patient has had the symptoms – two days; since last visit; since this morning, etc. • Context – describes how the symptoms began or occurred – after the auto accident; after eating out at a restaurant; when I sit down; etc. • Associated Signs and Symptoms – these are significant signs/symptoms that the patient feels are related to/part of their injury or illness – dizziness with nausea; swelling with injury; double vision with headache, etc.

28. History… • Alternate HPI • Documentation of three chronic illnesses • Must be related to chief complaint • Status of each condition must be documented • Example • Chief Complaint (CC) • Follow-up of HTN & Lower Extremity Edema • HPI – • (1)Patient states that home BP readings have been 130/80 – 145/85 with Diovan. (2)Patient states legs are not as swollen at end of day. (3)She states that headaches are less frequent and severe. (4) She has also been able to lose some weight and has more energy. • Brief HPI consists of 1 to 3 elements of the HPI • Extended HPIconsists of at least 4 elements of the HPI or the status of at least 3 chronic or inactive conditions

29. ROS (review of systems) • Review of Systems– Includes the patient’s “inventory” of signs and/or symptoms. These are most often answers to questions asked by the provider in order to establish a working diagnosis. Systems are: • Constitutional – weight loss, fever, chills, malaise, etc. • Ear, nose throat, and mouth – hearing loss, sinusitis, sore throat, oral cavities, etc. • Gastrointestinal – nausea, vomiting, diarrhea, constipation, ulcer, etc. • Integumentary – skin rashes, moles, dryness, lumps, pigmentation, etc. • Endocrine – polyuria, polydipsia, cold-heat intolerance, diabetes, etc. • Genitourinary – hematuria, nocturia, menopause, incontinence, etc. • Hematologic/Lymphatic – anemia, bruising, bleeding, lymph node enlargement, etc. • Eyes – diplopia, blurred vision, glasses, etc. • Cardiovascular – chest pain or pressure, palpitations, murmur, hypertension, etc. • Musculoskeletal – arthritis, joint stiffness, swelling, myalgias, gout, etc. • Neurologic – dizziness, syncope, seizures, vertigo, weakness, tremor, etc. • Allergic/Immunologic – allergies to medicine, food, etc./hepatitis, HIV, etc. • Respiratory – cough, wheezing, asthma, etc. • Psychiatric – depression, agitation, panic-anxiety, memory disturbance, etc.

30. More on ros… • The Review of Systems should be pertinent to the presenting problem – All pertinent positive and negatives should be documented. If all systems are reviewed, after the pertinent systems are documented, the statement “all other systems have been reviewed and are negative” will be appropriate for a complete review of systems. • If a separate form is used for the Review of Systems, it should be dated and initialed by the provider with pertinent comments noted. This can be referred to by documenting “Review of Systems as noted on face sheet dated __ ______ has been reviewed with the following changes”. • But be careful in using this statement! It is not necessary to have a complete ROS for a minor problem such as a sprained ankle or sinusitis. Right?

31. Three types of ros • Problem Pertinent • Inquiries about the system directly related to the problem identified in the HPI. • The patient’s positive responses and pertinent negatives for the system related to the problem should be documented • In the following example, one system – the ear- is reviewed: • Chief Complaint: Earache • ROS: Positive for left ear pain. Denies dizziness, tinnitus, fullness or headache

32. Three types of ros • Extended/Expanded Problem • Inquiries about the system directly related to the problem(s) identified in the HPI and a limited number (two to nine) of additional systems. • Patient’s positive responses and pertinent negatives for two to nine systems should be documented. • In the following example, two systems – cardiovascular and respiratory- are reviewed: • Chief Complaint: Follow-up visit in office after cardiac cath. Patient states “I feel great.” • ROS: Patient states he feels great and denies chest pain, syncope, palpitations, and shortness of breath. Relates occasional unilateral, asymptomatic edema of the left leg.

33. Three types of ros • Complete • Inquiries about the system(s) directly related to the problem(s) identified in the HPI plus all additional (minimum of 10) body systems. • At least 10 organ systems must be reviewed with positive systems or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating “all other systems are negative” is permissible. • In the following example, 10 signs & symptoms are reviewed: • Chief Complaint: Patient complains of “fainting spell.” • ROS: • Constitutional: weight stable, + fatigue • Eyes: + loss of peripheral vision • Ear, Nose, Mouth, Throat: no complaints • Cardiovascular: + palpitations; denies chest pain, calf pain, pressure or edema • Respiratory: + shortness of breath on exertion • Gastrointestinal: appetite good, denies heartburn, + episodes of nausea • Urinary: denies incontinence, frequency, urgency, nocturia • Skin: + clammy, moist skin • Neurological: + fainting; denies numbness, tingling and/or tremors • Psychiatric: denies memory loss or depression. Mood pleasant.

34. Past, family & social history (PFSH) • Past, Family & Social History • May also be documented by “Refer to history on face sheet dated __ __ ____ with the following changes:” • Past Medical History – includes adult & childhood illnesses or trauma, vaccinations & screenings, past surgical history, past & current medications, allergies. • Family History – includes parents, siblings, children, genetic disease of the family or other family history. • Social History – Information about the patient’s habits and circumstances – smoking, alcohol, drug use; sexual orientation, marital status, living arrangements, occupation, education, religion, recent travel.

35. What if you can’t get the history from the patient? • History is unobtainable: • Patient is unconscious, mentally ill, unable to speak, intoxicated, intubated • No other source is available • Document the reason why the patient is unable to communicate and also that no other source is available, if applicable. • Physician is given credit for PFSH if unable to obtain from the patient.

36. Physical exam • Key Components of Physical Exam • Should be pertinent to the presenting problem, i.e. if an established patient is in for follow-up of allergic rhinitis, a head to toe exam is not necessary. • Should never, ever be copied forward from a previous visit. • Care should be taken when using a check off form with “Normal” – not just go down the line √ off systems! • Some auditors consider “WNL” as “We Never Looked.

37. General multi-system exam

38. 1997 documentation guidelines • The 10 single organ system examinations are: • Cardiovascular • Ear, Nose, Mouth and Throat • Eyes • Genitourinary (male & female) • Hematologic/Lymphatic/Immunologic • Musculoskeletal • Neurological • Psychiatric • Respiratory • Skin

39. Documentation guidelines of exam • Specific abnormal and relevant negative findings of the exam of the affected or symptomatic body area(s) or organ system(s) should be documented. • A notation of “abnormal” without elaboration is insufficient. • Brief statement or notation indicating ‘negative’ or ‘normal’ is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s).

40. Key Components Medical Decision Making • Number of diagnosis(es) or management options: • All known diagnoses that are being treated or affect treatment • Undiagnosed conditions that are being evaluated • Treatments being used, considered or planned • Plays the ‘primary’ role in determining the correct level of service

41. Amount &/or complexity of data to be reviewed • If a diagnostic service is ordered, planned, scheduled or performed at the time of the E&M visit, the type of service should be documented. • Review of labs or any diagnostic tests should be documented. • “WBC elevated” or “chest x-ray unremarkable” is acceptable. The review may be documented by initialing & dating the report that contains the test results. • Decision to obtain medical records or history from someone other than the patient must be documented. • “Old records reviewed” or “additional history obtained from the family” without further elaboration is not sufficient – no credit should be given.

42. Table of risk • Risk of significant complications, morbidity, and mortality is based on the risks associated with: • Presenting problem(s) or number of diagnoses and/or risk of complications (Chief Complaint) • Diagnostic procedures ordered • Possible management options • Table of Risk

43. And then there is “Time” • Used in selecting an E&M code only when Counseling and/or Coordination of care represents more than 50% of the time spent face-to-face (outpatient) or bedside and on the floor or unit with the patient or family (inpatient). • Both time elements – total length of time for the visit and total length of time involved in Counseling and/or Coordination of care – as well as the nature of the counseling and/or coordination of care must be documented explicitlyin the medical record.

44. S O A P – Not the cleaning kind! • (S)ubjective • Chief Complaint – Each note must always include a chief complaint. • History of Present Illness • Review of Systems • Past Medical, Family and Social History

45. S O A P – Format (O)bjective • Physical Examination – the second of the three key components for evaluation and management is documented by the provider. • Amount and Complexity of Data • Review of tests, records, independent review of tracings, specimens, etc.

46. S O A P – Format (A)ssessment • Number of diagnoses: The following should be considered: • All known diagnoses that are being treated or affect treatment • Undiagnosed conditions that are being evaluated • Risk of complications and/or morbidity or mortality

47. S O A P – Format (P)lan • Treatment Options: • Prescription drug management • Diagnostic tests • IV Fluids • Surgeries • Decision not to resuscitate • Return to Office • Referral to another physician • Physical, Occupational, Speech Therapy • Over the Counter Drugs

48. Prolonged services • CPT codes 99354-99357 are used when a physician provides prolonged services involving direct (face-to-face) patient contact beyond the usual service in either the inpatient or outpatient setting. • Reported in addition to E&M level. • Report the total duration of the face-to-face time spent even if not continuous.

49. More on prolonged services • Bill the first hour with CPT 99354, 99356 • Each additional 30 minutes with CPT 99355, 99357 • Can only be reported ‘once’ per day • Less than 30 minutes is included in the E&M level • Example: • Physician performed a visit that met the definition of visit code 99213 & the total duration of the direct face-to-face services (including the visit) was 65 minutes. • Physician bills E&M 99213 and 1 unit of CPT 99354.

50. Inpatient • Initial Hospital Care • 99221 (low severity – 30 minutes) • 99222 (moderate severity – 50 minutes) • 99223 (high severity – 70 minutes) • Subsequent Hospital Care • 99231 (Stable, recovering or improving – 15 minutes at bedside) • 99232 (Responding inadequately/developed minor complication – 25 min) • 99233 (Unstable/developed significant complication or new problem – 35 min)