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How to Code Correctly for E/M Services (1995 and 1997 Guidelines). General Principles of Documentation. Medical record should be complete and legible Each encounter should include Reason for the encounter Assessment, impression or diagnosis Plan for care Date and identity of observer.

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General principles of documentation
General Principles of Documentation Guidelines)

Medical record should be complete and legible

Each encounter should include

Reason for the encounter

Assessment, impression or diagnosis

Plan for care

Date and identity of observer


General principles of documentation1
General Principles of Documentation Guidelines)

Rationale for ordering ancillary services

Past and present relevant diagnoses

Health risk factors

Patient’s progress, response to treatment


Documentation of e m services
Documentation of E/M Services Guidelines)

Seven components define level of service

History

Examination

Medical decision making

Counseling

Coordination of care

Nature of presenting problem

Time


New patient outpatient visits this is where we are going
New Patient Outpatient Visits Guidelines)(this is where we are going)


History component
History Component Guidelines)

Chief complaint (CC)

History of present illness (HPI)

Review of systems (ROS)

Past, family and/or social history (PFSH)


History component1
History Component Guidelines)


How to code correctly for e
HPI Guidelines)

Eight possible elements

Location

Quality

Severity

Duration

Timing

Context

Modifying factors

Associated signs and symptoms


How to code correctly for e
HPI Guidelines)

Brief HPI

Consists of one to three elements-1995

Consists of at least one element -1997

Extended HPI

Consists of at least four or more elements (both 1995/1997)


Review of systems
Review of Systems Guidelines)

A system is considered reviewed if the patient’s positive responses and pertinent negatives are documented

**A ROS previously obtained would count as long as you note in your record that states no changes of ROS from date X/X/2011


How to code correctly for e
ROS Guidelines)

14 possible systems that can be reviewed:

Constitutional Eyes

Ears, nose, throat Cardiovascular

Respiratory Gastrointestinal

Genitourinary Musculoskeletal

Integumentary Neurological

Psychiatric Endocrine

Hematologic Allergic/Immunologic


Ros 1995 1997
ROS- 1995 & 1997 Guidelines)

Problem pertinent ROS

The system of the CC is reviewed

Extended ROS

Two-nine systems are reviewed

Complete ROS

At least 10 systems reviewed


Past family and or social history
Past, Family and/or Social History Guidelines)

Past History

Illnesses, operations, injuries and treatments

Family History

Review of medical events in the patient’s direct family members which may be relevant to the patient’s CC

Social History

Age appropriate review of past and current activities

**A PFSH previously obtained would count as long as you note in your record that states no changes of PFSH from date X/X/2011



New patient outpatient visits 97 we are 1 3 of the way there
New Patient Outpatient Visits ‘97 Guidelines)(we are 1/3 of the way there)


Examination component 95 97
Examination Component 95 & 97 Guidelines)

Four possible types of examinations

Problem focused -limited to a body area or organ system

Expanded problem focused -limited to a body area or organ system & other symptomatic or related organ system(s)

Detailed –extended examination of the affected body area(s)& other symptomatic or related organ system(s)

Comprehensive – a general multisystem examination or complete examination of a single organ system


11 systems that can be examined multisystem exam 1997
11 Systems that can be Examined (Multisystem Exam) 1997 Guidelines)

Cardiovascular

Eyes

Hematological

Neurological

Respiratory

Constitutional

Ear, nose, throat

Genitourinary

Musculoskeletal

Psychiatric

Integument


Constitutional elements
Constitutional Elements Guidelines)

General appearance of patient

Measurement of any three of the following seven vital signs

Sitting or standing BP

Supine BP

Pulse rate and regularity

Respiration

Temperature

Height

Weight


Cardiovascular elements
Cardiovascular Elements Guidelines)

Examination of pedal pulses

Examination of extremities for edema


Musculoskeletal elements
Musculoskeletal Elements Guidelines)

Inspection and/or palpation of digits and nails

Examination of gait and station


Musculoskeletal elements1
Musculoskeletal Elements Guidelines)

Examination of joints, bones and muscles of one or more of the following areas:

Left lower extremity

Right lower extremity


Musculoskeletal elements2
Musculoskeletal Elements Guidelines)

Inspection and/or palpation with notation of presence of any misalignments, asymmetry, crepitation, defects, tenderness, masses, effusions (1 point for each foot examined)

Assessment of range of motion with notation of any pain, crepitation, or contracture (1 point for each foot examined)


Musculoskeletal elements3
Musculoskeletal Elements Guidelines)

Assessment of stability with notation of any dislocation (luxation), subluxation or laxity (1 point for each foot examined)

Assessment of muscle strength and tone (1 point for each foot examined)


How to code correctly for e
Skin Guidelines)

Inspection of skin and subcutaneous tissue

Palpation of skin and subcutaneous tissue


Neurological
Neurological Guidelines)

Examination of deep tendon reflexes with notation of pathological reflexes

Examination of sensation


Psychiatric
Psychiatric Guidelines)

Orientation to time, person, and place

Recent and remote memory

Mood and affect (depression, anxiety, agitation)


Total of bullets 1997
Total # of bullets-1997 Guidelines)

The average podiatrist can get a total of 21 bullets in 7 systems


Examination summary
Examination Summary Guidelines)

Problem focused

One to five elements

Expanded problem focused

At least six elements

Detailed

At least twelve total elements in at least two systems

Comprehensive

At least two elements from at least nine systems


New patient outpatient visits we are 2 3 of the way there
New Patient Outpatient Visits Guidelines)(we are 2/3 of the way there)


Medical decision making
Medical Decision Making Guidelines)

Four levels of MDM based on

Number of diagnoses or management options

Amount and/or complexity of data reviewed

Risk to the patient



Number of diagnoses 1997
Number of Diagnoses-1997 Guidelines)

Number of Diagnoses

Self limiting minor - 1 point each

Established, stable/worsening - 2 points each

New, no additional workup - 3 points each

New, additional workup - 4 points each

Type of Diagnosis

1 point = minimal

2 points = limited

3 points = multiple

4 points = extensive


Number of diagnoses 1995
Number of Diagnoses-1995 Guidelines)

Number of Diagnoses

Self limiting minor - 1 point each

Established, stable improving - 1 point each

Established, worsening - 2 points each

New, no additional workup - 3 points each

New, additional workup - 4 points each

Type of Diagnosis

1 point = minimal

2 points = limited

3 points = multiple

4 points = extensive


Data reviewed 1997
Data Reviewed-1997 Guidelines)

Amount of Data Reviewed

Discussed with referring provider -1 point

Review of imaging studies, labs -2 points

Review of old records -2 points

Type of Data

0-1 point = minimal

2 points = limited

3 points = moderate

4 points = extensive


Data reviewed 1995
Data Reviewed-1995 Guidelines)

Amount of Data Reviewed

Review and/or order clinical lab tests – 1 point

Review and/or order tests in the radiology section of the CPT book – 1 point

Review and/or order tests in the medicine section of the CPT book – 1 point

Discussion of test results with performing physician-1 point

Decision to obtain old records and/or obtain history from someone other than the patient -1 point

Review and summarization of old records - 2 points

Independent visualization of image, tracing, or specimen itself (not simply review of report) – 2 points

Type of Data

0-1 point = minimal

2 points = limited

3 points = moderate

4 points = extensive


How to code correctly for e

Data Summary-1997 Guidelines)

Minimal = No data reviewed

Limited = Review of one ordered test, study, or old records

Moderate = Review of two tests, studies, or old records

Multiple = Review of three or more tests, studies, or old records


How to code correctly for e

Data Summary-1995 Guidelines)

Minimal or Low = No or one data reviewed

Limited = Review of two ordered test, study, or old records

Multiple = Review of three tests, studies, or old records

Extensive = Review of four or more tests, studies, or old records



How to code correctly for e

1995 and 1997 - TIME Guidelines)

  • Time can be considered as long as the physician documents the total time and suggests that counseling or coordinating care dominates more than 50%

  • Documentation may refer to: prognosis,, differential diagnosis, risk, benefits of treatment, instructions, compliance, risk reduction or discussion with another health care provider

  • Does the documentation reveal total time? Yes or No (Office require face to face and Inpatient unit/floor time)

  • Does the documentation describe the content of the counseling or coordinating care? Yes or No

  • Does the documentation reveal that more than half the time was counseling or coordinating care? Yes or No

  • ** All must be answered YES*


Mdm chart review
MDM Chart Review Guidelines)


Putting it all together
Putting It All Together Guidelines)

Level of History

Level of Exam

Level of MDM

Time spent face-to-face between physician and patient

Only considered if >50% of face-to-face time is spent in counseling


New patient outpatient visits we have arrived
New Patient Outpatient Visits Guidelines)(we have arrived)



Let s audit a patient note c c and ros
Let’s Audit a Patient Note C/C and ROS Guidelines)

Chief Complaint: This 54-year-old male presents back today with still a painful right foot. Patient indicates again this condition has existed for several months. Patient states condition has temporarily improved with the past treatments, which have included: strapping, stretching, and ice. Pain is best described as still aching and sharp. He also complains today that his toenails are still thickened and long and hurt in his shoes. Being diabetic, he wants his nail infection treated. (HPI = 4)

ROS: GI: (-) dyspepsia, Musculoskeletal: (+) hip or back pain (+) right foot pain, Skin: (+) nail infection (-) skin peeling or dryness. Endocrine: (+) hyperglycemia controlled (ROS = 4)

No change in PFSH (PFSH = 3)


Next let s review the exam
Next Let’s Review the Exam: Guidelines)

Physical Exam:

Cardiovascular: DP pulses are palpable, bilateral. PT pulses are palpable, bilateral. CFT is immediate bilateral. No edema observed bilateral. Varicosities are not observed bilateral. Skin temperature of lower extremities is warm to cool, proximal to distal bilateral. (2 bullets)

Neuro: Touch, pin, vibratory, and proprioception sensations are normal bilateral. Deep tendon reflexes normal bilateral.

(2 bullets)

Ortho: Right talo-calcaneal joint / sinus tarsi demonstrates moderate pain. Muscle strength is 5/5 for all groups tested bilateral. Muscle tone is normal bilateral. (5 points)

Derm: Right 2nd toenail distally, left 5th toenail, left 2nd toenail and left great toenails are dystrophic, thickened, loosening, crumbling and all have yellow discoloration and are painful to palpation. (2 points)


Diagnoses

Diagnoses: Guidelines)

Plan/Counseling and Various Treatments:

Impression: Right talo-calcaneal joint pain. Left 5th toenail, left 2nd toenail, left great toenail and right 2nd toenail painful onychomycosis. Controlled diabetes mellitus, type II (NIDDM).(Dx-extensive)

Plan/Counseling:I explained to the patient the etiology again and treatment options for his joint pain including stretching exercises, strapping and tapings, rest, OTC insoles, orthotics, NSAIDs, new shoe gear, injections and surgery. I discussed again that conservative care options usually decrease symptoms in 6 months. I recommended custom orthoses to the patient as the previous strapping was beneficial. I explained that orthoses may decrease pronation, increase shock absorption, possibly prevent surgery and improve the biomechanics of his extremity. I discussed the procedure for fabrication of the devices. I explained to the patient the etiology and treatment options for his onychomycosis including no treatment, oral, periodic debridement and topical medication. Blood work was ordered. The possibility of recurrence was discussed. We discussed the oral medication. He wants to proceed with this treatment option; he will get his blood work before starting the medication and then be seen in

the office in 3 months.(Risk-high, Data-extensive)


Plan counseling and various treatments cont
Plan/Counseling and Various Treatments, cont. Guidelines)

We discussed the side effects listed in the package insert as well as

medication interactions. If this patient starts on any other medicine, it

must first be checked for any interactions. He allowed a photo to be taken

of the feet seen above today to track progress of the oral medicine in the

future. He was casted for orthoses today.

Two appointments were made, first to the office in 3 months to evaluate

the effect of the antifungal treatment, and at the second appointment, we

will dispense the orthotics and reassess the effects of the treatment for the

subtalar joint pain.

Prescriptions:

1) Labs: Ordered CBC and ALT/AST Sig: Patient has Onychomycosis and to check for any blood disorders secondary to the

medication, ICD9=110.1

2) Terbenafine Dosage: 250 mg tablet Sig: 1 po QD x 84 days

re: onychomycosis (ICD9=110.1) Dispense: 84 Refills: 0

3) Celebrex Dosage: 200 mg capsule Sig 1 po QD x 30 Refill X 2



Proper coding of this case
Proper Coding of this Case Guidelines)

99214 based on 2 out of 3 minimum criteria met

The casting for the custom orthotics is billed as S0395 (Impression casting of a foot performed by a practitioner other than the manufacturer of the orthotic)


Medicare consultations
Medicare Consultations Guidelines)

Remember: As of /2010 do not use the consultation codes for Medicare patients

Cannot use:

Office / Outpatient consultation codes

99241 – 99245

Inpatient consultation codes

99251 - 99255


Medicare consultations1
Medicare Consultations Guidelines)

Office / Outpatient consultations for Medicare patients:

99201 – 99205 and 99212 – 22915

Inpatient consultations for Medicare patients

99221 – 99223 (initial hospital care for new or established patient)

99231 – 99233 (subsequent hospital care)


Medicare consultations2
Medicare Consultations Guidelines)

Remember:

99221 requires a detailed or comprehensive H&P and straightforward or low complexity medical decision-making

99222 requires a comprehensive H&P and moderate complexity medical decision-making

99223 requires a comprehensive H&P and high complexity medical decision-making


Medicare consultations3
Medicare Consultations Guidelines)

Remember:

99231 requires a problem focused H&P and straightforward or low complexity medical decision-making

99232 requires a problem focused H&P and moderate complexity medical decision-making

99233 requires a detailed H&P and high complexity medical decision-making


Questions
Questions? Guidelines)