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					         Coding Education & Training Program, HIM Department




Documentation Requirements for
   Evaluation & Management
            Services




                                                     2/1/2011   1
           Coding Education & Training Program, HIM Department
              Presentation Goals




Introduce the 3 Key Components to an E/M Service
 History
 Examination
 Medical Decision Making
Introduce the UC Davis Health System Audit Tool,
version 2.6
Review time and how it may effect a level of service
Review critical care documentation guidelines
Review Teaching Physician Guidelines



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                          Coding Education & Training Program, HIM Department
                                                   Overview of E/M Services

Classification of Common E/M Services
      Office or Other Outpatient Services
       New Patient                                     99201-99205
       Established Patient                             99211-99215
      Consultations
       Office or Other Outpatient Consultations        99241-99245
       Initial Inpatient Consultations                 99251-99255
      Hospital Inpatient Services
       Initial Hospital Care                           99221-99223
       Subsequent Hospital Care                        99231-99233
       Hospital Discharge Services                     99238-99239
      Emergency Department Services
       New or Established                              99281-99285
      Critical Care
       Over 24 months of age                           99291-99296
      Preventive Medicine
       Initial Preventive Medicine                     99381-99387
       Established Patient                             99391-99397
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                    Coding Education & Training Program, HIM Department
                                            Overview of E/M Services


Classification of Other E/M Services

     Nursing Facility/SNF/Rest Homes, etc         99304-99350
     Prolonged Services                           99354-99359
     Care Plan Oversight                          99374-99380




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                          Coding Education & Training Program, HIM Department
                                                      Overview of E/M Section

Code assignment in the CPT E/M Section vary according to three factors:

         Place of Service
            office, hospital, emergency room, nursing home
         Type of Service
            consultation, admission, office visit
         Patient Status
            new patient, established patient, inpatient, outpatient

Each E/M category includes three to five levels of service

The levels indicate the wide variations in skill, time, effort, responsibility
and knowledge required to diagnose, treat or prevent an illness or injury

                                                                          2/1/2011   5
                     Coding Education & Training Program, HIM Department
                                              Overview of E/M Section

In a Teaching Setting, a fourth factor needs to be considered:

       Reimbursement Factor(s)
        Performing Provider vs Billing Provider (NP/PA vs
          MD)?
        Are there additional Payor Specific Guidelines (Medi-
          cal/Medicare)?
          1. Have the documentation guidelines been met?
          Note: As of January 1, 2010, Medicare no longer recognizes
             Consultation Codes (Inpatient/Outpatient). Provider must
             use New Patient or Established Patient visit codes only.
        Is the clinician (NP/PA) on the Hospital Cost Report?

                                                                 2/1/2011   6
                          Coding Education & Training Program, HIM Department
                                                      Overview of E/M Section

All providers who are licensed to provide medical services may use the same
E/M codes for reporting their services regardless of specialty

The specific level is referring to the last digit in each E/M service code for
example, a 99201 is referred to as a “New Patient, level 1”

This level requires meeting or exceeding the following Three Key
Components:

        a problem focused History
        a problem focused Exam
        straightforward Medical Decision Making



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                       Coding Education & Training Program, HIM Department
                                                Overview of E/M Section

The E/M levels are selected based on the clinicians documentation

Therefore, it is important that the clinician documents each patient
encounter as accurate and complete as possible

What should be considered when analyzing the patient’s medical
   record?
      Does the documentation justify the medical necessity of the
      service and/or procedure performed?
      Does the documentation support the level of service reported?
      Is the documentation legible?
      Are there specific payer documentation guidelines and have
      they been met?
                                                                   2/1/2011   8
                       Coding Education & Training Program, HIM Department
                                                   Overview of E/M Section

Medical Necessity

Medicare defines "medical necessity" as services or items reasonable
and necessary for the diagnosis or treatment of illness or injury or to
improve the functioning of a malformed body member

       Clinician vs Coder
        Questions regarding an extensive write up for a minor
          problem should be referred back to the clinician for
          clarification


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                       Coding Education & Training Program, HIM Department
                                                     Overview of E/M Section

Medicare-Selection of Level of E/M Service

The CMS Manual, Publication 100-4, Chapter 12, §30.6.1 - Selection of
Level of Evaluation and Management Service states the following:

“Medical necessity of a service is the overarching criterion for payment in
addition to the individual requirements of a CPT code.

It would not be medically necessary or appropriate to bill a higher level of
evaluation and management service when a lower level of service is
warranted.




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                  Coding Education & Training Program, HIM Department




Medicare Update – January 1, 2010

All consultation codes have been eliminated for Medicare
     and Medicaid

•   Inpatient setting
      Use Initial Hospital Day and Subsequent Hospital Day
      codes
•   Outpatient setting
      Use New or Established Evaluation and Management
      (E/M) codes


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                          Coding Education & Training Program, HIM Department
                                                            Overview of E/M Section

Medicare-Selection of Level of E/M Service, con’t

The volume of documentation should not be the primary influence upon which a
specific level of service is billed.

Documentation should support the level of service reported. The service should be
documented during, or as soon as practicable after it is provided in order to maintain
an accurate medical record.

Instruct physicians to select the code for the service based upon the content of
the service.

The duration of the visit is an ancillary factor and does not control the
level of the service to be billed unless more than 50 percent of the face-to-face time
(for non-inpatient services) is spent providing counseling or coordination of care.”


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                     Coding Education & Training Program, HIM Department
                                                 Overview of E/M Section


E/M Guidelines

There are two guidelines that may be utilized, 1995 or 1997

       Providers/Coders may use either guideline
       Whichever is most advantageous to the provider
       Must follow one guideline per patient encounter
       Cannot mix and match




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                     Coding Education & Training Program, HIM Department
                                                 Overview of E/M Section


1995
       Based on the number and/or extent of body areas or organ
       systems examined
1997
       Based on the examination of specific bulleted items identified
       within a body area or organ system




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                          Coding Education & Training Program, HIM Department
                                                                      E/M Terms

New Patient
        According to the American Medical Association, a new patient is one who
        has not received any professional services from a given physician or another
        physician of the same specialty who belongs to the same group practice
        within the past three (3) years
Established Patient
        According to the American Medical Association, an established patient is
        one who has received professional services from that physician or another
        physician of the same specialty within the same group within the past three
        (3) years
Consultations
        A type of service provided by a licensed provider whose opinion or advice
        regarding evaluation and/or management of a specific problem is requested
        by another licensed provider or appropriate source. For example, a
        Physician, NP, PA



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                             Coding Education & Training Program, HIM Department
                                                                                     E/M Terms

Consultations vs Referral
        Consultation
           Services rendered to give advice or an opinion to a requesting provider about a
            patient’s diagnosis and/or management of a condition
            1. The 4 R’s
                     Request
                     Render opinion
                     Report
                     Reason
        Referral
            Transfer of care
            Referring provider transfers the responsibility for managing the
             patient’s complete care for a condition to the receiving physician and
             the receiving physician documents approval of care



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                          Coding Education & Training Program, HIM Department
                                                                        E/M Services

Remember, documentation must support the medical necessity and the level of service
Billed. The Level of Service is based on the documentation of the 3 Key Components
and the Contributing Factors:

        3 Key Components
         History
         Examination
         Medical Decision Making
        Contributing Factors
         Nature of Presenting Problem
         Time
            1. Outpatient Setting (Counseling by Provider face-to-face)
            2. Inpatient Setting (Counseling by Provider face-to-face and/or
               Coordination of Care)


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                       Coding Education & Training Program, HIM Department
                                                    E/M – History Component

Now let’s take a look at the History Component on the Audit
Tool

The History is divided into four levels:

       Problem Focused
       Expanded Problem Focused
       Detailed
       Comprehensive

These levels are determined by……


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                Coding Education & Training Program, HIM Department
                                              E/M – History Component



Four Elements
    History levels are determined by the following 4 elements
    1. Chief Complaint (CC)
    2. History of Present Illness (HPI)
    3. Review of Systems (ROS)
    4. Past, Family, and/or Social History (PFSH)
    The extent of the history is dependent upon clinical judgment
    and on the nature of the presenting problem(s)
    Not all histories will have or need all elements


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                          Coding Education & Training Program, HIM Department
                                                                 E/M – History Component

The Four Elements of History
  1.   Chief Complaint (CC)
        A concise statement describing the symptom, problem, condition,
            diagnosis, or other factor as the reason for the encounter. Example:a
            return visit recommended by the physician
  2.   History of Present Illness (HPI)
        Describes the patient’s developing condition/problem from the first
            sign and/or symptom or from the previous encounter to the present or
            the status of three chronic or inactive conditions
  3.   Review of Systems (ROS)
        An inventory of body systems obtained through a series of questions
            seeking to identify signs and/or symptoms the patient may be
            experiencing or has experienced
  4.   Past, Family, and Social History (PFSH)
        Review of the patient’s past history, family history, and social history


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                     Coding Education & Training Program, HIM Department
                                                 E/M – History Component

Chief Complaint
     The reason for seeking medical care should be recorded in
     the patient’s own words

        “Patient complains of left foot pain due to fall last month.”




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                      Coding Education & Training Program, HIM Department
                                                     E/M – History Component


The History of Present Illness (HPI)

      Two types
       1. Brief HPI
           1 to 3 HPI Elements
       2. Extended HPI
           4 or more HPI Elements or the status of at least 3
             chronic or inactive conditions




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                       Coding Education & Training Program, HIM Department
                                                            E/M – History Component
The HPI Elements
       Location – Where the symptom or problem is occurring
           Abdomen, chest, leg, arm, head
       Severity - A rating or description of severity of the symptom or pain
           Bad, intolerable, minimal, slight
       Timing – When symptom or pain occurs
           Before bed, upon waking, two hours after taking medicine, continuous
       Quality – The character of the sign or symptom
           Burning, dull, puffy, puss-filled, red, itchy
       Duration – How long a pain or symptom lasts, has been present, or persisted
           For two months, since prescription began
       Associated signs/symptoms – Any organ system or body area complaints
       associated with the chief complaint
           Rash with blistering, nausea and vomiting, abdominal pain
       Context – Instances or items that can be associated with the chief complaint
           When walking, in company of smokers, at work
       Modifying factors – Actions taken or things done to effect the symptom or
       pain, making it better or worse
           Improves when lying down, worse after eating
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                  Coding Education & Training Program, HIM Department
                                                 E/M – History Component


The HPI

Example of an extended HPI with 4 or more elements

HPI: For the past two days she has had chills, fever and muscle
aches. She feels worse in the evening. Her illness is so severe she
has not been able to work.

      Duration
      Associated Signs
      Timing
      Severity

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                      Coding Education & Training Program, HIM Department
                                                     E/M – History Component

The HPI

Extended HPI with status of at least three chronic or inactive conditions.

Example:

The patient is currently under my care for the management of hypertension
controlled with diet and exercise, diabetes controlled with insulin, and asthma
requiring inhaler twice daily.




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                          Coding Education & Training Program, HIM Department
                                                                     E/M – History Component

The Review of Systems (ROS)
       ROS includes 14 systems
           1.    Constitutional symptoms (fever, weight loss, etc)
           2.    Eyes
           3.    Ears, nose, mouth, throat
           4.    Cardiovascular
           5.    Respiratory
           6.    Gastrointestinal
           7.    Genitourinary
           8.    Musculoskeletal
           9.    Integumentary (skin and/or breast)
           10.   Neurological
           11.   Psychiatric
           12.   Endocrine
           13.   Hematologic/Lymphatic
           14.   Allergic/Immunologic
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                  Coding Education & Training Program, HIM Department
                                              E/M – History Component


The ROS

ROS has 3 types

   1. Problem Pertinent
       1 system
   2. Extended
       2-9 systems
   3. Complete
       10 or more systems



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                          Coding Education & Training Program, HIM Department
                                                          E/M – History Component

The ROS

Medicare Documentation Guidelines

       Problem Pertinent ROS
        The patient's positive responses and pertinent negatives for the system
           related to the problem should be documented.
       Extended ROS
        The patient's positive responses and pertinent negatives for two to
           nine system should be documented.
       Complete ROS
        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.

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                             Coding Education & Training Program, HIM Department
                                                              E/M – History Component

The ROS

Example of a complete ROS:

The provider can list pertinent findings in 2 or more systems and note all
other systems are negative
         A patient is seen in the physician’s office with flu-like symptoms. For the past
         two days she has had chills, fever, and muscle aches. She feels worse in the
         evening. Her illness is so severe she has not been able to work. (Provider
         queries patient on at least ten systems, notes pertinent findings) She has lost
         7 pounds in the last month. She denies abdominal pain, diarrhea, and
         vomiting. All other systems are negative.

          Constitutional
          Gastrointestinal
          “All other systems are negative” gives provider credit for a complete ROS
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                       Coding Education & Training Program, HIM Department
                                                     E/M – History Component

The Past, Family, and Social History (PFSH)

       Past History
        The patient’s past experience with illnesses, operations,
          injuries and treatments
       Family History
        A review of medical events in the patient’s family, including
          diseases that may be hereditary or place the patient at risk
       Social History
        Age appropriate review of past and current activities




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                        Coding Education & Training Program, HIM Department
                                                      E/M – History Component

The PFSH
      There are two types of PFSH, pertinent and complete
      The required elements for each differs based on the patient status
       New patient status
         1. Pertinent
               1 specific item from any of the 3 history areas
         2. Complete
               1 specific item from each of the 3 history areas
       Established patient status
         1. Pertinent
               1 specific item from any of the 3 history areas
         2. Complete
               1 specific item from any 2 of the 3 history areas
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                      Coding Education & Training Program, HIM Department
                                                       E/M – History Component

The PFSH

      If the PFSH is non-contributory a statement is required in the
      documentation to qualify it for a complete PFSH
       Example:
           1. “Reviewed PFSH, non-contributory to current condition.”

      For those categories of E/M services that require only an interval
      history, it is not necessary to record information about PFSH
       Example:
           1. Subsequent hospital care
           2. Subsequent nursing facility care



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                    Coding Education & Training Program, HIM Department

                                              Overall History Component
Each history element must be met or exceeded to determine
an overall history level

Let’s look at an example
        CC
         Must be present in patient’s medical record
        HPI
         Extended
        ROS
         Complete
        PSFH
         Pertinent
        Overall History level = Detailed

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                                            Coding Education & Training Program, HIM Department
                                                                                 E/M – History Component

    Example Outpatient Grid

HPI
Location          Severity        Timing      Modifying Factors                       Brief                          Extended
Quality           Duration       Context      Associated Signs & Symptoms             1-3                            4 or more


ROS
Constitutional   Ears, Nose Throat, Mouth   Skin/breast   Endo                               Pertinent   Extended          Complete
Hem/Lymph                                                                    None                to         2-9
Eyes              Card/Vasc      GI          Neuro         Allergy/Immune                    Problem
Resp              Musculo        GU          Psych         All Others Neg                        1
PFSH
                                                                                      None               Pertinent         Complete
Past Medical History    Family History     Social History
Established Patient: only need 2 to be considered “Complete”
New Patient: Requires all 3 to be considered “Complete”
OVERALL HISTORY LEVEL
                                                                            Problem       Expanded       Detailed        Comprehensive
                                                                            Focused        Problem
                                                                                           Focused




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                     Coding Education & Training Program, HIM Department
                                                             E/M History



Caveat

         Patient is unable to speak
         Physician must document this
          “Patient intubated, unable to obtain History”
         Provider gets credit for a complete History!




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                          Coding Education & Training Program, HIM Department
                                                   E/M – Examination Component
Now let’s look at the Examination Portion of the
Audit Tool

        Four Levels
         Problem Focused
         Expanded Problem Focused
         Detailed
         Comprehensive

        Exam Elements
                 Body Areas
                 Organ Systems
                  (Cannot combine Body Areas and Organ Systems for
                  Comprehensive Exam)
        2 Types
         Multi-system
         Single Organ System

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                                            Coding Education & Training Program, HIM Department
                                                                           E/M Examination Elements



Body Areas:
                                                      0-1       2-4        5-7        >=8
Head/face        chest, including breasts & axillae

Neck             back, spine       each extremity

genitalia, groin, buttocks         abdomen


Organ Systems:

Constitutional     ears, nose, mouth, throat

Eyes                resp         GI           GU

Cardio             skin         neuro        psych

Hem, lymph, immune              musculo
                                                      Problem   Expanded   Detailed   Comprehensive
OVERALL EXAMINATION LEVEL                             Focused   Problem
                                                                Focused




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                                Coding Education & Training Program, HIM Department


Examination   Problem Focused     Expanded            Detailed                Comprehensive
                                  Problem Focused




1995          1 Body Area or      Limited Exam        Extended Exam 5-7       8 Organ Systems or a
              Organ System        2-4 Body Areas or   Body Areas or Organ     Comprehensive Single
                                  Organ Systems       Systems                 Organ System Exam




1997          Any 1-5 Bullets     Any 6+ Bullets      General: 2 bullets      General: Perform all,
                                                      from 6 or more organ    document 2 bullets from 9
                                                      systems/body areas or   Organ Systems/body areas
                                                      12 bullets from 2 or
                                                      more organ              All Others: Perform all,
                                                      systems/body areas      document all elements in
                                                      Eye/Psych: 9+           each bolded box and 1
                                                      bullets                 element in each un-bolded
                                                      All Others: 12+         box
                                                      bullets

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                Coding Education & Training Program, HIM Department
                           E/M – Medical Decision Making Component


Now let’s look at the Medical Decision Making Portion of the
Audit Tool
  Four Levels
  1. Straightforward
  2. Low Complexity
  3. Moderate Complexity
  4. High Complexity
  To determine the level of Medical Decision Making, two of the
  three following Elements must meet or exceed
      Elements
            Number of Diagnoses or Treatment Options
            Amount and/or Complexity of Data to be Reviewed
            Risk of Complication and/or Morbidity/Mortality


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                      Coding Education & Training Program, HIM Department
                                    E/M – Medical Decision Making Component

              Number of Diagnoses or Treatment Options

                              3 Categories

1.   Self-limited or minor
        stable, improved or worse

2.   Established problem
        stable, improved, worsening

3.   New problem to examiner
       no additional work up planned
       additional work-up planned
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                       Coding Education & Training Program, HIM Department
                                   E/M – Medical Decision Making Component


1.
Self-limited or minor (stable, improved or worse)
        Sore throat
        Earache (simple)
        Simple laceration
           This category does not indicate that the problem is new or
            established
           American Medical Association (AMA)
            1. “A problem that runs a definitive and prescribed course, is
                transient in nature, and is not likely to permanently alter
                health status or has a good prognosis with
                management/compliance.”


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                      Coding Education & Training Program, HIM Department
                                  E/M – Medical Decision Making Component



2.
Established problem; stable, improved
    For this provider/specialty group – usually diagnosis and treatment
    has already been started



Established problem; worsening
    For this provider/specialty group; must be documented or CLEARLY
    implied, (pain has increased, etc.)




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                     Coding Education & Training Program, HIM Department
                                E/M – Medical Decision Making Component

3.
New problem to examiner; no additional work- up planned

New problem to examiner; additional work-up Planned
       Starting treatment does not constitute “additional work-up”.
       Any diagnostic study or plan to help find a definitive
          diagnosis.

   Example:
    Radiology
    Laboratory
    Consultation with another physician

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                     Coding Education & Training Program, HIM Department



NUMBER OF DIAGNOSES AND/OR TREATMENT OPTIONS

               A                            BC                =D

       Problem(s) status           Number         Points     Result

Self–limited or minor               max=2              1
(stable, improved or worse)
Est. problem; stable, improved                         1

Est. problem; worsening                                2

New problem;                        max=1              3
no additional workup planned
New Problem;                                           4
additional workup planned
                                               Total


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                       Coding Education & Training Program, HIM Department
                                   E/M – Medical Decision Making Component

Amount and/or Complexity of Data to be Reviewed
     Review &/or order of clinical lab tests
     Review &/or order in the radiology section of the CPT
     Review &/or order of tests in the medicine section
     Discussion of test results with performing physician
     Decision to obtain old records &/or history from someone other than
     patient
     Review and summarization of old records &/or obtaining history
     from someone other than patient &/or discussion of case with another
     health care provider
     Independent visualization of image, tracing or specimen itself (not
     simple review of report)

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                     Coding Education & Training Program, HIM Department
                                 E/M – Medical Decision Making Component



Review &/or order of clinical lab tests
      Any documentation of the review of tests previously ordered

       Example(s):
         Test results documented in notes
         Documentation that Provider reviewed results

       Documentation that indicates tests are ordered




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                     Coding Education & Training Program, HIM Department
                                 E/M – Medical Decision Making Component



Review &/or order in the radiology section of the CPT
      Review of Report not actual film

    Example(s):
        Documentation of review of x-ray report
        Documentation that a x-ray was ordered

       Not viewed in Stentor (review of actual film)




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                   Coding Education & Training Program, HIM Department
                              E/M – Medical Decision Making Component



Review &/or order of tests in the medicine Section

      Report(s) is reviewed or ordered

Example(s):
      EKG Report

      Stress Test

      Documentation that a medicine test was ordered




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                       Coding Education & Training Program, HIM Department
                                   E/M – Medical Decision Making Component



Discussion of test results with performing physician

       Discussion = verbal communication and NOT a report or letter

Example:
          Pathologist viewing specimen then pages ordering MD to discuss
           results
          PCP MD pages MD Specialist to discuss test results




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                      Coding Education & Training Program, HIM Department
                                  E/M – Medical Decision Making Component



Decision to obtain old records &/or history from someone other than
patient

       Documentation should support the reason/need to get old records
       or obtain the history from someone other than the patient

    Does not include:
         Parent’s of pediatric patient
         Interpreter




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                     Coding Education & Training Program, HIM Department
                                E/M – Medical Decision Making Component



Review and summarization of old records &/or obtaining history from
someone other than patient &/or discussion of case with another
health care provider

       Summarize the review of old record or history and document how
       it pertains to the patients current problem

       It must be Additional/Relevant information




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                      Coding Education & Training Program, HIM Department
                                 E/M – Medical Decision Making Component



Independent visualization of image, tracing or
specimen itself (not simple review of written report)

    Does not include:
         Rapid Strep Test
         Urine Pregnancy Test

    Does include:
          Reviewing image in Stentor, etc.
          EKG Strip


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                                Coding Education & Training Program, HIM Department



AMOUNT AND/OR COMPLEXITY OF DATA REVIEWED

                                                                                            Points

Review &/or order of clinical lab tests                                                       1

Review &/or order in the radiology section of CPT                                             1

Review &/or order of tests in the medicine section of CPT                                     1

Discussion of test results with performing physician                                          1

Decision to obtain old records &/or obtain history from someone other than patient            1

Review and summarization of old records &/or obtaining history from someone other             2
than patient &/or discussion of case with another health care provider
Independent visualization of image, tracing or specimen itself (not simply review of          2
report)
                                                                                    Total


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                     Coding Education & Training Program, HIM Department
                                E/M – Medical Decision Making Component



Risk of Complication and/or Morbidity/Mortality

       Four Levels
         Minimal
         Low
         Moderate
         High




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                                                         Coding Education & Training Program, HIM Department
Table of Risk

Level of   Presenting Problem(s)                                           Diagnostic Procedure(s) Ordered                        Management Option Selected
Risk


Minimal    * One self–limited or minor problem,                      * Lab tests requiring venipuncture                   * Rest
           e.g. cold, insect bite                                    * CXRs                                               * Gargles
                                                                     * ECG/EEG, U/A, echo                                 * Elastic bandages
                                                                                                                          * Superficial dressings


Low        * 2 or more self–limited or minor problems                * Physiologic tests not under stress, e.g. PFTs      * OTC drugs
           * 1 stable chronic illness                                * Non–CV imaging with contrast, e.g. barium          * Minor surgery w/ no identified risk factors
           • * Acute uncomplicated illness or injury,
                                                                     enema                                                * PT, OT
           e.g. cystitis, sprain
                                                                     * Superficial needle biopsy                          • IV fluids w/out additives
                                                                     * Clinical lab test requiring arterial puncture
                                                                     * Skin biopsies

Moderate   * 1 or more chronic illnesses with mild exacerbation,     * Physiologic test under stress, e.g. cardiac        * Minor surgery with identified risk factors
           progression, or side effects of treatment                 stress test, fetal contraction stress test           * Elective major surgery (open, percutaneous, or
           * 2 or more stable chronic illnesses
                                                                     * Diagnostic endoscopies with no identified risk     endoscopic) with no identified risk factors
           * Undiagnosed new problem with uncertain prognosis,
           e.g., lump in breast                                      factors                                              * Prescription drugs
           * Acute illness with systemic symptoms, e.g.              * Deep needle or incisional biopsy                   * Therapeutic nuclear medicine
           pyelonephritis, pneumonia, colitis                        * CV imaging studies with contrast and no            * IV fluids w/ additives
           * Acute complicated injury, e.g. head injury with brief   identified risk factors, e.g. arteriogram and        * Closed tx of fracture or dislocation without
           LOC                                                       cardiac cath                                         manipulation
High       * 1 or more chronic illnesses with severe                 * Obtain fluid from body cavity
                                                                       CV imaging studies with contrast with identified   * Elective major surgery w/ identified risk factors
           exacerbation, progression, or side effects of             risk factors                                         * Emergency major surgery
           treatment                                                 * Cardiac EP test                                    * Parenteral controlled substances
           * Acute or chronic illnesses or injuries that may         * Diagnostic endoscopies with identified risk        * Drug therapy requiring intensive monitoring for
           pose a threat to life or bodily functions, e.g.           factors                                              toxicity
           peritonitis, acute failure, multiple injuries, acute      * Discography                                        * Decision not to resuscitate or to de–escalate
           MI                                                                                                             care because of poor prognosis
           * An abrupt change in neurological status, e.g.
           seizure
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                                      Final Medical Decision-Making Level

2 of the 3 Elements must be met or exceeded

       Number of Diagnosis or Treatment Options
       Amount and/or Complexity of Data Reviewed
       Risk of Complication and/or Morbidity/Mortality




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Final Result for Medical Decision Making
(must meet or exceed two out of three elements)


Number
                          <=1           2             3             >=4
diagnoses/treatment
                          Minimal       Limited       Multiple      Extensive
options


Amount & complexity of    <=1           2             3             >=4
data                      Minimal       Limited       Multiple      Extensive



Highest risk              Minimal       Low           Moderate      High


                          Straight-                   Moderate
Type of decision making                 Low Complex                 High Complex
                          forward                     Complex


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Example of Medical Decision Making

 Number of Diagnoses or Treatment Options


 Assessment: The diabetes is controlled with diet and exercise, blood glucose
 levels are within acceptable limits. The high blood pressure that we have been
 monitoring and trying to control with diet and exercise is now far above an
 acceptable range. The first problem is considered an established stable
 problem while the blood pressure is an established problem worsening.



           Established Problem – Stable Improved
           Established Problem – Worsening


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Example of Medical Decision Making


    Amount &/or Complexity of Data Reviewed

         The patient comes in for a recheck of diabetes that is controlled with
         diet and exercise, blood glucose levels are within acceptable limits,
         and high blood pressure that you have been monitoring and trying to
         control with diet and exercise is through the roof. A CBC, Chemical
         profile, urinalysis,electrocardiogram, and chest x-ray are ordered.

             Review &/or order of clinical lab tests
             Review &/or order of tests in the medicine section of CPT
             Review &/or order in the radiology section of CPT


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Example of Medical Decision Making

 Risk of Complications &/or Morbidity of Mortality

      The patient comes in for a recheck of diabetes that is controlled with diet
      and exercise, blood glucose levels are within acceptable limits, and high
      blood pressure that you have been monitoring and trying to control with
      diet and exercise is through the roof. A CBC, Chemical profile,
      urinalysis,electrocardiogram, and chest x-ray are ordered. Impression: 1.
      Diabetes-controlled. 2. Hypertension- uncontrolled. Atenolol 50 mg
      prescribed. The patient is to return in one week for recheck.

           1 or more chronic illnesses with mild exacerbation, progression
            or side effects of treatment
           Lab test requiring venipuncture/CXRs/ECG
           Prescription Drugs

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                                                      Contributing Factors

Time
       The American Medical Association guidelines state that when
       counseling and/or coordination of care dominates (MORE THAN
       50%) the physician/patient and/or family encounter (face-to-face
       time) then time may be considered the key or controlling factor to
       qualify for a particular level of E/M services

Documentation of time is key if time is the determining factor
     The total amount of time spent with the patient must be clearly
     documented
     The record should describe the counseling and/or activity to
     coordinate care
        “A total of 30 minutes was spent with the patient, more than half
         of this time was spent discussing treatment options and
         subsequent effects of chemotherapy.”
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                                                                         Time

Typical Times


New Office Visit               99201-10 99202-20 99203-30 99204-45 99205-60
Office Consult                 99241-15 99242-30 99243-40 99244-60 99245-80
Inpatient Consult              99251-20 99252-40 99253-55 99254-80 99255-110


Established Office Visit       99211- 5 99212-10 99213-15 99214-25 99215-40


Initial Hospital Observation   99218-30 99219-50 99220-70
Initial Hospital Visit         99221-30 99222-50 99223-70


Subsequent Hospital Visit      99231-15 99232-25 99233-35



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                                                     E/M – Critical Care


Critical Care

Definition
    Critical care is the care of critically ill or critically injured
    patients who require the full, exclusive attention by a
    physician(s). A critical illness or injury “acutely impairs one
    or more vital organ systems such that there is high probability
    of imminent or life threatening deterioration in the patient’s
    condition”.



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                                                    E/M – Critical Care

Critical Care, con’t

Documentation Requirements
   Since critical care is a time-based code, the physician progress
   note must contain documentation of the total time involved
   providing critical care services. In a teaching environment, the
   time recorded as critical care time is the actual time spent by
   the physician, not a resident, fellow, or allied health provider.
   The time must be personally documented by the teaching
   physician. Teaching time does not count toward critical care
   time. Critical care of less than 30 minutes duration on any
   given day is reported with an evaluation and management
   code.
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                                                     E/M – Critical Care


Critical Care, con’t

Example Documentation
   Patient seen and examined with Dr. Resident. Reviewed and
   agree with his note and the plan of care we developed
   together.
   One hour of critical care time personally performed due to
   patient’s hemodynamic instability. Patient was resuscitated
   with 2 units of packed red blood cells. Obtained additional
   studies to determine possible causes for patient’s instabilities.


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                                                 E/M – Teaching Facility


Teaching Facility


       Documentation requirements for State and Federal Payers
        The teaching physician saw the patient
        The teaching physician reviewed the resident’s note, and
          agreed or revised the findings
        The teaching physician actively participated in the care by
          either documenting involvement in the development of the
          plan or by changing the plan




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                                                E/M – Teaching Facility


Teaching Physician

      Examples of minimally acceptable documentation
       “I saw the patient with the resident and agree with the
         resident’s findings and plan we developed.”
       “I saw and evaluated the patient. Discussed with the resident
         and agree with the resident’s findings and plan we developed
         as documented in the resident’s note.”
       “See the resident’s note for details. I saw and evaluated the
         patient and agree with the resident’s findings and plans we
         developed as written.”


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                                                E/M – Teaching Facility


Teaching Physician

      Examples of unacceptable documentation for State and Federal
      Payers
       “Agree with above.”
       “Rounded, Reviewed, Agree.”
       “Discussed with resident.” “Agree.”
       “Seen and Agree.”
       “Patient seen and evaluated.”
       A legible countersignature and/or identity alone does not meet
         State and Federal payer requirements

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                                                           E/M – Teaching Facility


Teaching Physician

Non-State and Non-Federal Documentation Requirements
(Commercial Payers):
       Minimum evidence of review by the attending shall be demonstrated by
       countersignature in the patient medical record

Other requirements:
        The teaching physician shall be promptly available
        If the service includes direct patient contact, the teaching physician’s
        availability must include the ability to be physically present to review the
        resident’s note and ensure the services were furnished appropriately



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                                              E/M – Teaching Facility


Medical Students

      The teaching physician and/or resident must reference the
      medical student’s dated documentation

      The medical student’s documentation may only contribute in
      two elements of the History component
       The Review of Systems and the Past Medical, Family, Social
         History (ROS and PFSH)




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                                       E/M – Differences, Inpatient vs Outpatient


Inpatient Encounters vs Outpatient Encounters
        Inpatient Encounters
         Key Components are the same
            1. History
            2. Examination
            3. Medical Decision Making
         Elements within each component are the same
         Difference
            1. Levels
                 Example: Initial H&P has 3 levels, not 5
            2. Number of Elements Required
                 Example: Initial H&P requires a Complete ROS (10 or more
                    systems) for levels 2 and 3

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                                          E/M – Differences, Inpatient vs Outpatient

Inpatient Encounters vs Outpatient Encounters
          Inpatient Encounters
             Initial Hospital Visit/Hospital Observation Levels
                  1. Detailed
                  2. Comprehensive
             Subsequent Hospital Visit/Follow-up Consult Levels
                  1. Problem Focused
                  2. Expanded Problem Focused
                  3. Detailed
             Initial Hospital Consultation Levels
                  1. Problem Focused
                  2. Expanded Problem Focused
                  3. Detailed
                  4. Comprehensive

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                                               Pulling it All Together
Overall E/M Code Selection
        Place of Service
           Hospital vs Physician’s Office
        Type of Service
           Consultation vs Office Visit vs Admission
        Patient Status
           New Patient vs Established Patient
           Outpatient vs Inpatient
        Documentation Requirements
           State/Federal Payer vs Non-State/Non-Federal Payer
        Any Contributing Factors?
           Time


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                                                    Pulling It All Together

Overall E/M Code Selection
       Key Components must be met or exceeded
        New Patient/ER/Consultation
          1. Requires all three key components
        Established Patient
          1. Requires two of three key components




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                                                            Resources

UCDHS Coding Education & Training Program
   http://www.ucdmc.ucdavis.edu/himetp

       (916) 734-0559

Coding Advisory Board (CAB)
   http://intranet.ucdmc.ucdavis.edu/cab/

Medicare Medlearn Matters
   http://www.cms.hhs.gov/MedlearnMattersArticles/

Compliance Office
   http://www.ucdmc.ucdavis.edu/compliance/
       (916) 734-8808


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