Briefing: Advanced E&M, Validating the Level Date: 20 March 2007 Time: 1510-1600

1. Briefing: Advanced E&M, Validating the Level Date: 20 March 2007 Time: 1510-1600

2. Objectives • Understand Evaluation and Management Services • Identify critical components of E&M • Understand significance of each component • Recognize intent and purpose for levels of service • Learn how to apply to services rendered

3. Overview • Documentation • Evaluation and Management Factors • Evaluation and Management Codes • Review • Summary

4. Documentation Requirements • Principles of Documentation • The medical record should be complete and legible • The documentation of each patient encounter should include: • Date • Signature • 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, as well as revision of diagnosis should be documented • The CPT and ICD-9-CM codes reported should be supported by the documentation in the medical record • The documentation should support the intensity of the patient’s evaluation and/or treatment, including thought process, and the complexity of the medical decision making

5. Documentation Requirements • Evaluating Your Documentation • Reason for the patient encounter • Services provided correctly documented • Clear explanation of medical necessity of the level of E&M, diagnostic and therapeutic procedures (to include support services and supplies) • Assessment of patient’s condition • Patient’s progress/results of treatment • Patient plan of care • Patient’s condition, reasonable medical rationale for setting of service • Documentation supports the care given • Medical record is legible and comprehensible

6. Documentation Requirements • SOAP Format: • (S)ubjective: Chief complaint and the history of the present illness, review of systems and relevant past, family and or social history • (O)bjective: Physical evaluation examination and the diagnostic evaluation • (A)ssesment: Complexity of medical decision making • (P)lan: Complexity of medical decision making

7. Documentation Requirements • SNOCAMP Format: • (S)ubjective: Chief complaint and the history of the present illness, review of systems and relevant past, family and or social history • (N)ature of presenting problem: Chief complaint and the history of the present illness, review of systems and relevant past, family and or social history • (O)bjective: Physical evaluation examination and the diagnostic evaluation • (C)ounseling and/or coordination of care: • (A)ssessment: Complexity of medical decision making • (M)edical decision making: Complexity of medical decision making • (P)lan: Complexity of medical decision making

8. Documentation Requirements • Considerations: • Under-documentation • Over-coding • Decision making a requirement • Encounter note stand alone entry • Deficiencies

9. Documentation Requirements • Specific Pitfalls: • HPI: • Documentation must be explicit as to the condition being treated, or actual signs and symptoms and the differential diagnosis as appropriate for the encounter, as well as any conditions the patient may have that complicates or affect medical care • Exam: • Determined by the nature of the presenting problem, the documented HPI and additional history components • Comprehensive exams not necessary for every patient unless clearly supported by medical necessity • Medical Decision Making: Reflective of: • Hx and/or exam for the specific DOS • Diagnosis and management options • Complexity of data obtained, analyzed and reviewed • Overall risks of presenting condition, comorbidities and complicating conditions

10. Evaluation & Management Factors • Levels of Evaluation and Management: • Categories: • Place of service (e.g. office or hospital) • Type of service (e.g. critical care preventive medicine) • Further divided: • Status of medical visit (e.g. new or established)

11. Evaluation & Management Factors • Component Sequence and Code Selection: • Determine use of 95 or 97 guidelines • Complexity for the encounter suggested by the chief complaint will point directly at the level of medical decision making • When decision making at a certain level is required, the degrees of history and exam will follow • Safety in coding by decision making is that this component is the one most closely linked to medical necessity

12. Evaluation & Management Factors • Seven Components • Three key • History • Examination • Medical Decision Making • Four contributory • Counseling • Coordination of Care • Nature of Presenting Problem • Time

13. Evaluation & Management Factors • Key Components: • History • Examination • Medical Decision Making

14. Evaluation & Management Factors • Four contributory: • Counseling • Coordination of Care • Nature of Presenting Problem • Time

15. Evaluation & Management Factors • History • Chief Complaint (CC) • History of Present Illness (HPI) • Review of Systems (ROS) • Past Family, Medical and Social History (PFSH)

16. Evaluation & Management Factors • History: • Chief Complaint: • Concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter. The CC is usually stated in the patient’s own words • The medical record should clearly reflect the chief complaint • e.g. Patient complains of upset stomach, aching joints, and fatigue

17. Evaluation & Management Factors • History Of Present Illness (HPI) • QUALITY - Adjective qualifier of the type of sign/symptom, usually not measurable in degrees • LOCATION - Where in/on the body the signs/symptoms occurred • SEVERITY - Ranking of symptom/pain, describe with adjectives • DURATION - Specific time period • TIMING - Specifics as to when symptoms/pain occur • CONTEXT - Circumstances surrounding the occurrence • MODIFYING FACTORS - Palliative steps, successful or not • ASSOCIATED SIGNS AND SYMPTOMS - Any symptom associated with the chief complaint

18. Evaluation & Management Factors • History Of Present Illness (HPI): • Location (e.g. left, lower, Epigastric region) • Quality (e.g. sharp, dull, stabbing) • Severity (e.g. pain scale 5/10, severe, better) • Duration (e.g. two weeks, until today) • Timing (e.g. after meals, comes and goes) • Context (e.g. began during) • Modifying factors (e.g. feels better after applying ice) • Associated signs & symptoms (e.g. bloating, weakness) *1997 guidelines allow chronic or inactive conditions for a brief HPI

19. Evaluation & Management Factors • EXAMPLE • CC: A patient seen in the office complains of left ear pain • Brief HPI: Patient complains of dull ache in left ear over the past24 hours • quality, location, and duration • Extended HPI: Patient complains of dull ache in left ear over the past 24 hours. Patient states he went swimming two days ago • Symptoms somewhat relieved by warm compress and ibuprofen • Quality, location, duration, context, and modifying factors

20. Evaluation & Management Factors • ROS:Inventory of body systems • For purposes of the ROS, the following systems are recognized: • _Const _ENT _Endo _Eyes _GI _GU _Hem/Lymph _Integ/Skin _Resp _Card/Vasc _Musculo _Neuro _All/Lymph _Psych _All others negative • Problem pertinent - System directly related to the problem(s) identified in the HPI • Extended- System directly related to the problem(s) identified in the HPI and a limited number of additional systems • Minimum of two documented systems • Complete ROS -System(s) directly related to the problem(s) identified in the HPI and all additional body systems • Those systems with positive or pertinent negative responses must be individually documented • Remaining systems a notation including all other systems are negative is permissible

21. Evaluation & Management Factors • Case Example: • Chief Complaint: Earache • ROS: • Positive for left ear pain. Denies dizziness, tinnitus, fullness, or headache • Problem pertinent– systems reviewed are directly related to the chief complaint • Case Example: • Chief Complaint: F/u after cardiac cath. Patient states, “I feel great” • ROS: • Patient states he feels great. Denies chest pain, syncope, palpitations, and shortness of breath. Relates occasional unilateral, asymptomatic edema of left leg • Extended- cardiovascular and respiratory systems are reviewed

22. Evaluation & Management Factors • Case Example: • Chief Complaint: Earache • ROS: • Constitutional: Weight stable, + fatigue • Eyes: + loss of peripheral vision loss • ENMT: no complaints • Cardio: + palpitations; denied chest pain; denied calf pain, pressure, or edema • Resp: + SOB on exertion • GI: appetite good, denies heartburn and indigestion, + episodes of nausea Bowel movement daily; denies constipation or loose stools • Urinary: denies incontinence, frequency, nocturia, pain, or discomfort • Skin: + clammy, moist skin • Neuro: + fainting; denies numbness, tingling, or tremors • Psychiatric: denies memory loss or depression • Complete-inquired about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems

23. Evaluation & Management Factors • Past Family and/Or Social History (PFSH) • Past-including experiences with illnesses, operations, injuries, and treatment • Family-including a review of medical events, diseases, and hereditary conditions that may place him or her at risk • Social-including an age appropriate review of past and current activities • The social history of the mother can be taken into consideration for a newborn • Types • Pertinent: history area directly related to the problem(s) identified in the HPI • Complete: review of areas • 2 or 3 areas depending on category of E/M service

24. Evaluation & Management Factors • Past Family and Social History (PFSH): • Pertinent PFSH • At least one specific item from any of the three history areas must be documented for a pertinent PFSH • Complete PFSH • At least one specific item from two of the three history areas must be documented for a complete PFSH, established patient • At least one specific item from each of the three history areas must be documented for a complete PFSH, new patient

25. Evaluation & Management Factors • Case example PFSH • Pertinent- review of history directly related to the problem(s) identified in the HPI • Patient returns to office for follow-up of CABG Father died at age 61 following MI

26. Evaluation & Management Factors • Example • C/O cough, sore throat, runny nose and sneezing for 2 days. No fever or sputum. Not a smoker. Babysat grandson last week who has strep throat. • Chief Complaint: cough, sore throat, runny nose, sneezing • Brief HPI: Context- following babysitting, exposure to strep Duration- Two days • Problem pertinent ROS: Constitutional- fever Pulmonary- sputum • Two documented from different systems but both were problem pertinent • Pertinent PFSH: Social History – not a smoker

27. Evaluation & Management Factors • This record demonstrates the following key components • Chief complaint(s) documented • Several symptoms • Brief HPI • Described the chief complaint(s) • Context and Duration • Problem Pertinent ROS • The constitutional and pulmonary systems were documented • Both directly relate to the chief complaint • The EMDG states that the ROS that relates directly to the presenting problem is “pertinent” • An extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number of additional systems- • Pertinent PFSH • Included one area

28. Evaluation & Management Factors Brief (1-3) None Prob pert One PROBLEM FOCUSED

29. Exam – “Body areas” Head, including the face Neck Chest, including the breasts and axillae Abdomen Genitalia, groin, buttocks Back Each extremity Exam – “Organ Systems” Eyes Ears, nose, mouth, and Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurological Psychiatric Hematologic/Lymphatic/Immunologic Evaluation & Management Factors

30. Evaluation & Management Factors • Examination • Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented. A notation of “abnormal” without elaboration is insufficient • Abnormal or unexpected findings of the examination of any asymptomatic body area(s) or organ system(s) should be described • A brief statement or notation indicating “negative” or “normal” is sufficient to document normal finding related to unaffected area(s) or asymptomatic organ systems(s)

31. Evaluation & Management Factors • Examination • General Multi-System Exam • Single Organ System Exam • Cardiovascular Exam • Ear, Nose and Throat Exam • Eye Genitourinary Exam (Breaks out male and female) • Hematologic/Lymphatic/Immunologic Exam • Musculoskeletal Exam • Neurological Exam • Psychiatric Exam • Respiratory Exam • Skin Exam

32. Evaluation & Management Factors • General Multi-System Exam • Problem Focused – one to five elements identified by a bullet in one or more organ system(s) or body area(s) • Expanded Problem Focused - at least six elements identified by a bullet in one or more organ system(s) or body area(s) • Detailed – at least six organ systems or body areas. For each system or area selected, performance and documentation of at least two elements identified by a bullet is expected. Alternatively, a detailed examination may include performance and documentation of at least twelve elements identified by a bullet in two or more organ systems or body areas • Comprehensive– should include at least nine organ systems or body areas. For each system/area selected, all elements of the examination identified by a bullet should be performed, unless specific directions limit the content of the examination. For each area/system, documentation of at least two elements identified by a bullet is expected

33. Evaluation & Management Factors • Single Organ System Exams • Problem Focused – one to five elements identified by a bullet, whether in a box with a shaded or unshaded border • Expanded Problem Focused – at least six elements identified by a bullet, whether in a box with a shaded or unshaded border • Detailed – examinations other than the eye and psychiatric examinations should include performance and documentation of at least twelve elements identified by a bullet, whether in a box with a shaded or unshaded border • Eye and psychiatric examinations should include the performance and documentation of at least nine elements identified by a bullet, whether in a box with a shaded or unshaded border • Comprehensive – should include all elements identified by a bullet, whether in a shaded or unshaded box. Documentation of every element in each box with a shaded border and at least one element in each box with an unshaded border is expected

34. Evaluation & Management Factors • Exam - 1995 vs. 1997 • 1995 guidelines • Prob. focused: 1 body area or organ system • Exp. Prob. focused: 2-7 areas or systems (limited exam) • Detailed: 2-7 areas or systems (extended exam) • Comprehensive: 8 or more areas or systems • 1997 guidelines • Prob. focused: 1-5 elements • Exp. Prob. Focused: 6-12 elements • Detailed: at least 12 elements in 2 or more systems • Comprehensive: At least two bullets in each system

35. 1995 criteria (Examination) Body areas: Head, including the face Neck Chest, including breasts and axillae Abdomen Genitalia, groin, buttocks Back/Spine Each extremity  Organ systems: Constitutional Eyes Ears, nose, mouth and throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic/lymphatic/immunologic  1997 criteria (Examination) Organ systems/Body areas combined: Constitutional Cardiovascular Chest/Breasts Eyes Ears, nose, mouth, and throat (ENMT) Gastrointestinal Genitourinary-Male Genitourinary-Female Integumentary/Skin Lymphatic Musculoskeletal Neck Neurologic Respiratory Psychiatric ***Examination elements are bulleted*** ***Offers general multi-system and single system examination elements***  Evaluation & Management Factors

36. Evaluation & Management Factors • Complexity and Medical Decision Making: • Amount Number of diagnoses or treatment options • and/or complexity of data to be reviewed • Risk of complications and/or morbidity or mortality

37. Evaluation & Management Factors • Complexity and Medical Decision Making: • Number Of Diagnoses Or Management Options • Assessment, clinical impression, or diagnosis • Self limited or minor: stable, improved or worsening • Est. problem: improved, well controlled, resolving or resolved; or, b) inadequately controlled, worsening, or failing to change as expected • New problem: no additional work up planned /additional work up planned • Initiation of , or changes in, treatment • Referrals, consultations requested or advice sought

38. Evaluation & Management Factors • Complexity and Medical Decision Making: • Amount and/or Complexity of Data to Be Reviewed • Diagnostic test/procedure ordered, planned, scheduled, or performed • Review lab, radiology and/or other diagnostic tests • Acceptable documentation: “WBC elevated” or “chest x-ray unremarkable” • Report signed and dated • Obtain old records/obtain additional history from other sources • Old records reviewed” or “additional history obtained from family” without elaboration is insufficient

39. Evaluation & Management Factors • Complexity and Medical Decision Making: • Risk Of Significant Complications, Morbidity, And/Or Mortality • Comorbidities/underlying diseases or other factors • Surgical or invasive diagnostic procedure ordered, planned or scheduled • Surgical or invasive diagnostic procedure performed • Referral or decision to perform urgent surgical or invasive diagnostic procedure

40. Evaluation & Management Factors • Documentation Of An Encounter Dominated By Counseling Or Coordination Of Care • Should include the total length of time of the encounter and the record should describe the counseling and/or activities to coordinate care • Three questions must be answered “yes” to base your visit on time. • Does the documentation reveal total time? • Does documentation describe the content of counseling or coordinating care? • Does documentation reveal that more than half of time was counseling or coordinating care? (Are the History, Exam, and Medical Decision Making documented?)

41. Evaluation & Management Factors • Terms Commonly Used in E&M Codes: • Bullets: Under the 1997 guidelines each physical examination element is commonly referred to as a bullet • Interval history: Occurrence in a given area since the last visit • Prognosis: A forecast of the probable outcome of a condition or disease, and the prospects of recovery and disease residual, depending on the nature of the disease and the patients response to treatment • Morbidity: A diseased condition or state • Mortality: The condition of being mortal (death) • Chronic: An illness or disease of slow progression, or with little change • Acute: An illness or disease typically with severe symptoms, a rapid onset, and a short duration

42. Evaluation & Management Factors • Modifiers used with E&M Codes • 21 - Prolonged evaluation and management services • 24 - Unrelated to evaluation and management services by the same physician during a postoperative period • 25 - Significantly separate, identifiable evaluation and management service by the same physician on the day of a procedure or other service • 27 - Multiple outpatient hospital E&M encounters on the same day • 32 - Mandated services • 52 - Reduced services • 57 - Decision for surgery

43. Office or Other Outpatient Services (new) Evaluation & Management

44. Evaluation & Management • Office and Other Outpatient Services (99211) • “Direct supervision” • Some Appropriate Uses of 99211 • Requires Chief Complaint • BP checks • Weight • Medication reactions • Other services • Inappropriate uses of 99211 • Telephone calls • Prescription renewals • Not medically indicated pulse, temperature or blood pressures

45. Office or Other Outpatient Services (established) Evaluation & Management

46. Evaluation & Management • Hospital Observation Services • 48-hour maximum stay • Admitting physician only • Do not use: • When the patient is designated as observation status on one date and is subsequently admitted to the hospital on that same date

47. Evaluation & Management

48. Evaluation & Management

49. Evaluation & Management • Hospital Observation Services (99217-99220) • Things to remember……. • Only the physician that admitted the patient into observation status can capture these codes • All other physicians who see the patient in observation status must bill office and other outpatient service codes or outpatient consultation codes, as appropriate • Initial observation care codes are for the initial day of care only. This is determined by calendar date, not 24 hour period • Patient should not remain in observation status for greater than 48 hours • Global surgical fees rules apply unless the criteria is met for modifiers 24, 25, or 57

50. Evaluation & Management • Hospital Observation Services*99217- Discharge Day Management