Evaluation & Management Coding and Documentation 101 – the basics

1. Evaluation & ManagementCoding and Documentation101 – the basics Stephanie Ann Call, MD MSPH VCU Internal Medicine Training Program The Practice of Medicine Series - 2009

2. Learning Objectives • At the end of this session, residents will be able to • describe what medical documentation facilitates • identify three key components in selecting the levels of E/M services • select the appropriate level of an E&M service for a new and established patient in either the outpatient or inpatient setting • identify resources for compliance

3. Evaluation and Management (E&M) Documentation • One of most commonly billed procedures • May be billed for new or established patients • Includes office, hospital, nursing home visits, consultations, phone and overall management, ICU care, discharge planning • 1995/1997 Medicare guidelines – can use both • Medicare Physician Guide: A Resource for Residents, Practicing Physicians, and Other Health Care Professionals –http://www.cms.hhs.gov/MLNProducts/downloads/physicianguide.pdf • Chapter 5 – E&M Documentation • Great references and resource lists

4. Why document? • Medical /legal issues • To tell the story of the patient – communicate to others • To have the opportunity for reimbursement for the service provided • “E&M documentation is the pathway that translates a physician’s patient care work into the claims and reimbursement mechanism” • Medicare … “if it is not documented, it wasn’t done.”

5. What does documentation facilitate? • The ability to evaluate and plan the patient’s treatment • The ability to monitor patients health over time • Communication and continuity of care among healthcare professionals • Appropriate utilization review and quality of care evaluations • Collection of data for research and evaluation

6. General Principles of Documenting • Legibility – all documents MUST be legible • Defined as easily read by peers (other clinicians) • Required information: • Patient name, MR, date of service on each page • Date AND time (for inpatient) • Reason for encounter, relevant history, PE findings • Review of lab, x-ray data, other ancillary services • Assessment, clinical impression or diagnosis • Plan of care (including d/c plan if appropriate) • Legible identity of observer (authenticated)

7. General Principles of Documenting • If not documented, rationale for ordering diagnostics or ancillary services should be easily inferred • Past and present diagnoses should be accessible to physician – can be in chart • Appropriate health risk factors should be identified • Patient progress, response to and changes in treatment should be documented

8. General Principles of Documenting • Documentation should support the intensity of the evaluation or treatment, including thought processes and complexity of medical decision making • All entries should be dated and authenticated by physician signature • CPT and ICD-9-CM codes reported should reflect documentaton in the medical records

10. Components of an E&M service • Seven components use to define level of E&M service (exceptions to rule if predominantly counseling or coordination of care) • Key components • History • Examination • Medical Decision Making • Contributory components • Counseling • Coordination of Care • Nature of Presenting Problem • Time

11. Components of an E&M service • Seven components use to define level of E&M service (exceptions to rule if predominantly counseling or coordination of care) • Key components • History • Examination • Medical Decision Making • Contributory components • Counseling • Coordination of Care • Nature of Presenting Problem • Time Used in selecting level of E/M service (some exceptions)

12. Determining Level of Service • Table to determine appropriate level of service based on documentation (as a reflection of complexity of care provided) in three key component areas • Each key component has graded levels • Different criteria for new patient vs established • Different criteria for inpatient vs outpatient • Procedure codes identified by tables – determine the level of service and amount of reimbursement (99201, 99202, 99203, etc)

13. Key Components • History • Physical Examination • Decision Making

14. History – elements (4) • Chief complaint (CC) • Required for ALL levels of E/M coding • Reason for encounter • If follow up … “follow up for …” • NOT “routine f/u” • Must be documented by resident, NP, PA or attending • History of Present Illness (HPI) • Review of Systems (ROS) • Past, Family, Social History (PFSH)

15. History • HPI elements • Location • Quality • Severity • Duration • Timing • Context • Modifying Factors • Associated Signs and Symptoms • Level of History • Brief – status of 1-2 chronic conditions or 1-3 above • Extended – status of 3 chronic conditions or 4+ above

16. History • Review of Systems (ROS) • Do not have to write a notation for all systems • Document the positive and pertinent negatives • “all other systems negative” – include number checked • Should have “usual” template • Level for ROS based on number of systems • Problem pertinent – related to problem only +/- • Extended – positive and pertinent responses for 2-9 systems • Complete ROS is 10+ • ROS • Constitutional, eyes, ears, nose, throat, cv, respiratory, gi, gu, musculoskeletal, skin, neuro, psych, endo, heme, lymph, allergic, immunological

17. History • Past, Family and Social (PFSH) • Past History – review of patient’s past illnesses, injuries, treatments • Includes major illness, injury, operations, prior hospitalizations, current meds, allergies • Social History – age appropriate review of past and current activities • May include marital status, living situation, employment and occupational hx, use of drugs/alcohol/tobacco, ed • Family History – review of medical events in family

18. History • PFSH • Pertinent – review of history area directly related to problem identified in HPI – at least one item from any of P, F, S • Complete – review of 2-3 PFSH areas if f/u visit, 3/3 areas if new patient

19. History – E/M levels • Problem Focused • CC, 1-3 HPI elements • Expanded Problem Focused • CC, 1-3 HPI, problem pertinent system review (>1) • Detailed • CC, 4+ HPI, problem pertinent ROS + 2-9 additional ROS, pertinent PFSH (1 element) • Comprehensive • CC, 4+ HPI, complete ROS (10+), complete PFSH

20. History

21. Exam • Organ systems • For a general multi-system exam • Body areas

22. Vital Signs, General Symptoms Eyes ENT CV Respiratory GI GU Musculoskeletal Skin Neurological Psychiatric Heme/Lymph/Immuno Exam – Organ Systems

23. Exam – Body Areas • Head/face • Neck • Breast/Axillary • Abdomen • Genitalia • Back/spine • Extremity

24. Exam • Document specific abnormal and relevant negative findings of affected or symptomatic area • Document abnormal or unexpected findings of unaffected or asymptomatic areas • “abnormal” is insufficient • Templates ok • Reference cards, review sheets

25. Exam – levels (see p81 guide) • Problem focused • Limited to affected body area or organ system (1-6 elements) • Expanded Problem Focused • Affected system plus other symptomatic or related (6) • Detailed • Extended exam of affected area and other symptomatic or related organ system • Comprehensive • Multisystem exam (8-12) or complete single system

26. Medical Decision Making

27. Medical Decision Making - tips • TELL THE STORY • The medical record must clearly support all diagnoses reported on the claim • Document impressions, diagnoses, tests ordered and/or reviewed AND the plan of care • What is the complexity of care for this patient AT THIS TIME? • Is the patient improved, resolved, unresponding?

28. Medical Decision Making • Complexity of establishing a diagnosis • Four types/levels – guided by … • The number of diagnoses or management options • The amount or complexity of data ordered or reviewed • The risk of complications and morbidity/mortality

29. Medical Decision Making • 4 levels • Straightforward • Low Complexity • Moderate Complexity • High Complexity • 3 subcomponents • Diagnoses and Management Options • Amount and Complexity of Data • Risk of Complications

30. Decision Making • To qualify for a specific level of Decision Making, 2 of the 3 elements listed for that specific category must be met or exceeded • Diagnosed problems less complex than undiagnosed • Consider • How many diagnostic tests ordered • Did you request a consult

31. Diagnoses and Management Options • For established diagnosis • Improved, resolved, unresponding • If diagnosis not established • Possible, probable, rule out • Document treatment plan • Include medication changes • Therapies • Patient instructions, nursing instructions

32. Amount and complexity of data • Review and/or order of clinical lab and XR tests • Review and/or order of diagnostic tests • XR, scans, nuclear med, cardiac cath, echo, ekg, eeg, non-invasive vasc, PFTs • Document review of old records • Document information from family or caretaker • Summarize relevant findings, if any • If not, document fact that reviews done

33. Risk of complication • Minimal • Low • Moderate • High

34. Documenting Risk • See tables on “risk” • Make sure to document • Co-morbidities • Underlying diseases • Other factors increasing risk

35. Medical Decision Making

36. What code do I choose? • Step 1: Is the patient New or Established, Inpatient or Outpatient? • New = 3 key components • Established = 2 of 3 key components • Step 2: What level of History and Exam was performed? • Use reference card for definitions • Step 3: Review the 3 subcomponents for Medical Decision Making • ‘meets or exceeds’ is issue

37. What code do I choose? • Step 4: Compare your assessments against the requirements for a given level of service • May not match exactly • ‘meets or exceeds’ is key phrase

38. New and Established Patients • 3 of 3 Key Components • New patient office • Initial Inpatient Admission • Initial Consultation • 2 of 3 Key Components • Established Office • Subsequent Inpatient care

39. Time • Choose code based on face-to-face time with the patient when OVER 50% of the visit was spent in counseling • Document the total time spent with the patient • Document the total time spent in counseling • Document the content of the counseling, and • Choose the level of E/M by the total amount of time

40. Other E&M Issues • Consultations • Incident to • NPs, PAs, midwives, Clinical Nurse Specialists • Shared visits • Involves physician and non-physician practitioner • Prolonged services • Critical Care • Teaching Physicians (including GE exemption codes)

41. Learning Objectives • At the end of this session, residents will • Be able to describe what medical documentation facilitates • Be able to identify three key components in selecting the levels of E/M services • Be able to select the appropriate level of an E&M service for a new and established patient in either the outpatient or inpatient setting • Be able to identify resources for compliance