Briefing: Evaluation and Management “Hot Spots”

1. Briefing:Evaluation and Management “Hot Spots” Date: 23 March 2010 Time:1110 – 1200

2. Objectives Discuss questions on: • History Elements • Chief Complaint (cc) • History of Present Illness (HPI) • Review of Systems (ROS) • Past, Family and/or Social History (PFSH) • Medical Decision Making • Consultations and Referrals • Preventive Medicine • Time • Questions

3. History Elements • Chief complaint • The reason for the encounter usually stated in the patient’s own words • Every encounter must have one • 1997 Documentation Guidelines for Evaluation and Management Services • DG: the medical record should clearly reflect the chief complaint* *1997 Documentation Guidelines for Evaluation and Management Services

4. History Elements • History of present illness • Chronological description of the development of the patient’s illness • Location (headache, elbow, chest pain) • Quality (dull, throbbing, aching) • Severity (severe, mild, 7 on a scale of 1-10) • Duration (for the last week, since yesterday) • Timing (constant, at night, off & on) • Context (when I stand, after I fell, after eating) • Modifying factors (relief after taking Tylenol, better when I stand) • Associated signs and symptoms (n&v, swelling)

5. History Elements • History of present illness • Two levels of HPI • Brief – 1-3 elements • DG: The medical record should describe one to three elements of the present illness* • Extended – 4 or more elements or the status of at least three chronic or inactive conditions • DG: The medical record should describe at least four elements of the present illness, or the status of at least three chronic or inactive conditions* *1997 Documentation Guidelines for Evaluation and Management Services

6. History Elements • History of present illness • Question: If there are more than four elements of the HPI and no ROS, can you “borrow” from the HPI to get ROS? • Answer: Yes you can for “bullet counting” purposes. The HPI and ROS are often co-mingled in the note.

7. History Elements • Review of systems • Inventory of body systems • Systems recognized:

8. History Elements • Review of systems • Three levels of ROS • Problem pertinent • DG: the patient’s positive responses and pertinent negatives for the system related to the to the problem should be documented* • Extended • DG: the patient’s positive responses and pertinent negatives for two to nine systems should be documented * * 1997 Documentation Guidelines for Evaluation and Management Services

9. History Elements • Review of systems • Three levels of ROS…con’t • Complete • DG: at least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented* * 1997 Documentation Guidelines for Evaluation and Management Services

10. History Elements • Review of systems – other documentation guidelines • DG: The ROS and/or PFSH may be recorded by ancillary staff or on a for completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.* • Question: When there is an expanded problem focused history, what is the minimum ROS required? • Answer: At the very least one “problem pertinent” ROS, regardless of a positive or negative response. *1997 Documentation Guidelines for Evaluation and Management Services

11. History Elements • Past, Family and/or Social History (PFSH) • PFSH consists of a review of three areas: • Past history (the patient’s past experiences with illnesses, operations, injuries and treatments); • Family history (a review of medical events in the patient’s family, including diseases which may be hereditary or place the patient at risk); and • Social history (an age appropriate review of past and current activities).

12. History Elements Past, Family and/or Social History – documentation guidelines DG: At least one specific item from any of the three history areas must be documented for a pertinent PFSH* DG: At least one specific item from two of the three history areas must be documented for a complete PFSH for the following categories of E/M services: office or other outpatient services, established patient; emergency department; domiciliary care, established patient; and home care, established patient* * 1997 Documentation Guidelines for Evaluation and Management Services

13. History Elements Past, Family and/or Social History – documentation guidelines DG: At least one specific item from each of the three history areas must be documented for a complete PFSH for the following categories of E/M services: office or other outpatient services, new patient; hospital observation services; hospital inpatient services, initial care; consultations; comprehensive nursing facility assessments; domiciliary care, new patient; and home care, new patient* * 1997 Documentation Guidelines for Evaluation and Management Services

14. History Elements Question: Do all encounters require a PFSH? Answer: For certain categories of E/M services that include only an interval history, it is not necessary to record information about the PFSH. Those categories are subsequent hospital care, follow-up inpatient consultations and subsequent nursing facility care.

15. History Elements • History - other documentation guidelines • DG: The CC, ROS and PFSH may be listed as separate elements of history, or they may be included in the description of the history of the present illness* • DG: A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by: • describing any new ROS and/or PFSH information or noting there has been no change in the information; and • noting the date and location of the earlier ROS and/or PFSH* * 1997 Documentation Guidelines for Evaluation and Management Services

16. Medical Decision Making • Documentation of the complexity of Medical Decision Making (MDM) • The levels of E/M services recognize four types of medical decision making (straightforward, low complexity, moderate complexity and high complexity). Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by: • The number of possible diagnoses and/or the number of management options that must be considered; • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed; and • The risk of significant complications, morbidity and/or mortality, as well as co morbidities, associated with the patient's presenting problem(s), the diagnostic procedure(s) and/or the possible management options.

17. Medical Decision Making

18. Medical Decision Making • The number of possible diagnoses and/or the number of management options that must be considered is based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis and the management decisions that are made by the physician. • Question: An auditing worksheet I use, stated that the diagnoses/management options are referencing “to the patient”. Is this correct? • Answer: The 1997 Documentation Guidelines are quoted above: “by the physician”- the provider is determining diagnoses, not the patient • Question: Is MDM required to be one of the key components when determining an E/M level for established patients? • Answer: As of 2009 the MHS Coding Guidelines do require MDM to be one of the two required key components for established patient’s (rule 3.1.6.2). However, CMS states that Medical Necessity is the overarching criterion for patient encounters to be “paid”

19. Medical Decision Making • Amount and/or complexity of data to be reviewed • Includes: • Diagnostic service (test or procedure) is ordered, planned, scheduled, or performed • Review of lab, radiology and/or other diagnostic tests should be documented • Relevant findings from the review of old records • Direct visualization and independent interpretation of an image, tracing or specimen • Key – documentation must support

20. Medical Decision Making • The risk of significant complications, morbidity, and/or mortality • Based on the risks associated with the presenting problem(s), the diagnostic procedure(s), and the possible management options • Familiarize yourself w/CMS Table of Risk* • The highest level of risk in any one category (presenting problem(s), diagnostic procedure(s), or management options) determines the overall risk. * 1997 Documentation Guidelines for Evaluation and Management Services

21. Consultations & Referrals • Consultation – request for advice or opinion on condition • Referral – transfer care for treatment of condition to another provider • Question: We understand that the phrase “evaluate and treat” is a required documentation statement in order to receive payment for any referral/consultation. Is this true? • Answer: Not to my knowledge. It doesn’t make sense as the statement written like that basically turns every “real” consult into a referral. Just because both use the “consult” module, doesn’t automatically make it a consultation either.

22. Evaluation and Management New E/M Guidelines regarding consultation…and concurrent care and transfer of care ► Concurrent care is the provision of similar services (e.g., hospital visits) to the same patient by more than one physician on the same day. When concurrent care is provided, no special reporting is required. Transfer of care is the process where a physician who is managing some or all of a patient’s problems relinquishes this responsibility to another physician who explicitly agrees to accept this responsibility and who, from the initial encounter, is not providing consultative services.

23. Evaluation and Management The physician transferring care is then no longer providing care for these problems though he or she may continue providing care for other conditions when appropriate. Consultation codes should not be reported by the physician who has agreed to accept transfer of care before an initial evaluation but are appropriate to report if the decision to accept transfer of care cannot be made until after the initial consultation evaluation, regardless of the site of service.◄

24. Evaluation and Management • Consultations – New Definition • ►A consultation is a type of evaluation and management service provided by a physician at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition or problem.◄ • A physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit.

25. Evaluation and Management • ►A “consultation” initiated by a patient and/or family, and not requested by a physician or other appropriate source (eg, physician assistant, nurse practitioner, doctor of chiropractic, physical therapist, occupational therapist, speech-language pathologist, psychologist, social worker, lawyer, or insurance company), is not reported using the consultation codes but may be reported using the office visit, home service, or domiciliary/rest home care codes as appropriate.◄

26. Evaluation and Management • ►The written or verbal request for consult may be made by a physician or other appropriate source and documented in the patient’s medical records by either the consulting or requesting physician or other appropriate source the consultant’s opinion and any services that were ordered or performed must also be documented in the patient’s medical record and communicated by written report to the requesting physician or other appropriate source.◄

27. Evaluation and Management • ►To report services provided to a patient who is admitted to a hospital or nursing facility in the course of an encounter in the office or other ambulatory facility, see the notes for Initial Hospital Inpatient Care (pg 16 [AMA]) or Initial Nursing Facility Care (pg 24 [AMA]).◄ • Remember! Read the specific guidelines for “Office or Other Outpatient Consultations” and “Inpatient Consultations” in those subsections.

28. Preventive Medicine The “comprehensive” nature of the Preventive Medicine Services codes reflects an age and gender appropriate history/exam and is NOT synonymous with the “comprehensive” examination required in Evaluation and Management codes Preventive Medicine codes include counseling/anticipatory guidance/risk factor reduction interventions which are provided at the time of the initial or periodic comprehensive preventive medicine examination

29. Preventive Medicine • Counseling risk factor reduction and behavior change intervention • Risk factor reduction different from preventive counseling • For the purpose of promoting health and preventing illness or injury • Not to be used to counsel on current condition • Behavior change intervention • For persons who have a behavior that is often considered an illness itself, such as tobacco use and addiction, substance abuse/misuse, or obesity

30. Preventive Medicine • 99420 Administration and interpretation of health risk assessment instrument (e.g., health hazard appraisal) • Not really used much in DoD because the “administration” part of this code is rarely met, however: • DoD guidance states on 2.2.8.4 PRT (#2) and pre-deployment form 2795 (#2), page 2-12 initial post deployment evaluation on form 2796 (#1, #2) and the table on 6.17.1 for face-to-face provider encounter record review for readiness to assign this code for these specific encounters

31. Time • When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time MAY be considered the key or controlling factor to qualify for a particular level of E/M services* • In the case of visits which consist predominantly of counseling or coordination of care, time is the key or controlling factor to qualify for a particular level of E/M service**. • The time-in/time-out or total time spent counseling and/or coordinating care must be documented • The description of counseling/coordination of care needs to be documented *2010 CPT **1997 Documentation Guidelines for Evaluation and Management Services

32. Questions ?