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Evaluation and Management Services
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  1. Evaluation and Management Services Montri D. Wongworawat Department of Orthopaedic Surgery Grand Rounds July 6, 2011

  2. Evaluation and Management • E/M • Professional face-to-face service between doctor and patient • Documentation to support the above • S: History • O: Physical • A: Decision Making • P: Decision Making

  3. Lecture Outline • Categories of E/M Services • Elements of the E/M Visit • Modifiers

  4. Categories of E/M Services PPO patient seen by your partner last year, consult requested by the ED, you see the patient and document • Encounter type? • Hospital/inpatient new • Hospital/inpatient consultation • Office/outpatient new • Office/outpatient consultation • Office/outpatient established

  5. Categories of E/M Services PPO patient seen by your partner last year, consult requested by the ED, you see the patient and document • Encounter type? • Hospital/inpatient new • Hospital/inpatient consultation • Office/outpatient new • Office/outpatient consultation • Office/outpatient established

  6. Categories of E/M Services Medicare patient seen by your partner last year, consult requested by the ED, you see the patient and document • Encounter type? • Hospital/inpatient new • Hospital/inpatient consultation • Office/outpatient new • Office/outpatient consultation • Office/outpatient established

  7. Categories of E/M Services Medicare patient seen by your partner last year, consult requested by the ED, you see the patient and document • Encounter type? • Hospital/inpatient new • Hospital/inpatient consultation • Office/outpatient new • Office/outpatient consultation • Office/outpatient established

  8. Categories of E/M Services Medicare patient never seen by you or your partner, consult requested by the ED, you see the patient and document • Encounter type? • Hospital/inpatient new • Hospital/inpatient consultation • Office/outpatient new • Office/outpatient consultation • Office/outpatient established

  9. Categories of E/M Services Medicare patient never seen by you or your partner, consult requested by the ED, you see the patient and document • Encounter type? • Hospital/inpatient new • Hospital/inpatient consultation • Office/outpatient new • Office/outpatient consultation • Office/outpatient established

  10. Categories of E/M Services • Office or other outpatient (includes ED) • New (requires all 3 key components) • Established (2 of 3 components) • Hospital inpatient • Initial hospital care (3 components) • Subsequent hospital care (2 of 3 components) • Hospital discharge • Consultations • Office or other outpatient • Initial inpatient

  11. Categories of E/M Services • Office or other outpatient • New (requires all 3 key components of E/M) • Never seen by your group • Seen by you or group member more than 3 years ago • Established (2 of 3 components of E/M) • Not New visit • Not Consultation

  12. Categories of E/M Services • Consultations • Definition • “A consultation is defined as a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.”

  13. Categories of E/M Services • Consultations • Guidelines • The consultant’s opinion is requested by another physician • Documentation of verbal or written request • Documentation of consultant’s opinion • Consultant may initiate treatment • Communication of consultant’s opinion to the requesting physician

  14. Categories of E/M Services • Consultations • Situations • Requests between physicians of the same group • Report consultation code if guidelines are met • Initiation of treatment • Usually stems from medical decision making portion of the E/M service • “Even though treatment is initiated, the initial service is still considered a consultative visit.” • If the consulting physician assumes care, the initial service should be reported as a consult.

  15. Categories of E/M Services • Consultations • Medicare eliminated this whole category

  16. Lecture Outline • Categories of E/M Services • Elements of the E/M Visit • Modifiers

  17. History Wrist pain, dull, constant, with numbness ROS Gen: weight gain, CV: none H/O DM • History type? • Problem focused (level 1) • Expanded problem focused (level 2) • Detailed (level 3) • Comprehensive (levels 4 and 5)

  18. History Wrist pain, dull, constant, with numbness ROS Gen: weight gain, CV: none H/O DM • History type? • Problem focused (level 1) • Expanded problem focused (level 2) • Detailed (level 3) • Comprehensive (levels 4 and 5)

  19. History • Detailed level • HPI-ROS-PFS 4-2-1

  20. History Wrist pain, sharp, dull, throbbing, aching ROS 10+ PMH: none, PSH: none, Meds: none • History type? • Problem focused (level 1) • Expanded problem focused (level 2) • Detailed (level 3) • Comprehensive (levels 4 and 5)

  21. History Wrist pain, sharp, dull, throbbing, aching ROS 10+ PMH: none, PSH: none, Meds: none • History type? • Problem focused (level 1) • Expanded problem focused (level 2) • Detailed (level 3) • Comprehensive (levels 4 and 5)

  22. History Wrist pain, constant, worsening, with numbness ROS 10+ PMH: none, FHx: Heart disease, SocHx: +EtOH • History type? • Problem focused (level 1) • Expanded problem focused (level 2) • Detailed (level 3) • Comprehensive (levels 4 and 5)

  23. History Wrist pain, constant, worsening, with numbness ROS 10+ PMH: none, FHx: Heart disease, SocHx: +EtOH • History type? • Problem focused (level 1) • Expanded problem focused (level 2) • Detailed (level 3) • Comprehensive (levels 4 and 5)

  24. Elements of the E/M Visit • History • CC (1 element) • Describe reason for visit • Every visit must have the CC stated

  25. Elements of the E/M Visit • History • HPI (4 elements) • Location: site of the problem • Quality: sharp, dull, throbbing • Severity: minor, moderate, severe • Duration: intermittent, constant • Timing: with exercise, nightly, after meals • Context: worsening, recurrent • Modifying factors: rest, heat, cold, elevation • Associated symptoms: numbness, tingling

  26. Elements of the E/M Visit • History • ROS (10 elements) • Constitutional • Eyes • Ear, nose, throat • Cardiovascular • Respiratory • Gastrointestinal • Genitourinary • Musculoskeletal • Integumentary • Neurologic • Psychiatric • Endocrine • Hematologic • Immunologic

  27. Elements of the E/M Visit • History • PFSH (3 elements) • Past history • Illnesses • Operations • Allergies • Family history • Social history • Occupation • Tobacco and alcohol use

  28. Elements of the E/M Visit

  29. Physical Examination No distress, intact cap refill in all fingers B UE: nontender except over palpable dorsal wrist mass, functional ROM, no dislocations, no atrophy, no wounds • Exam type? • Problem focused (level 1) • Expanded problem focused (level 2) • Detailed (level 3) • Comprehensive (levels 4 and 5)

  30. Physical Examination No distress, intact cap refill in all fingers B UE: nontender except over palpable dorsal wrist mass, functional ROM, no dislocations, no atrophy, no wounds • Exam type? • Problem focused (level 1) • Expanded problem focused (level 2) • Detailed (level 3) • Comprehensive (levels 4 and 5)

  31. Elements of the E/M Visit • Physical examination—Musculoskeletal • Constitutional (2 elements) • Cardiovascular and/or lymphatic (1 element) • Musculoskeletal (17 elements) • Skin (4 elements) • Neuropsychiatric (5 elements)

  32. Elements of the E/M Visit • Physical examination—Musculoskeletal • Constitutional (2 elements) • Vital signs (any 3 of the following items) • Temperature • Pulse • Respiration • Blood pressure • Height • Weight • General appearance

  33. Elements of the E/M Visit • Physical examination—Musculoskeletal • Cardiovascular and/or lymphatic (1 element) • Pulse • Capillary refill • Skin perfusion • Edema • Lymph node palpation

  34. Elements of the E/M Visit • Physical examination—Musculoskeletal • Musculoskeletal (17 elements) • Gait examination • In 4 of 6 body areas: (head/neck, trunk, 4 extremities) • Inspect/palpate • Assess ROM • Assess stability • Assess strength, tone, atrophy, or spasticity

  35. Elements of the E/M Visit • Physical examination—Musculoskeletal • Skin (4 elements) • In 4 of 6 body areas: (head/neck, trunk, 4 extremities) • Inspection and/or palpation

  36. Elements of the E/M Visit • Physical examination—Musculoskeletal • Neuropsychiatric (5 elements) • Coordination • Reflexes (deep tendon or pathologic) • Sensation • Orientation • Mood and affect

  37. Elements of the E/M Visit

  38. Decision Making Problem: New fracture, HTN, DM Risk: Major surgery with risk factors Data: Reviewed films • Decision type? • Straightfoward (levels 1 and 2) • Low (level 3) • Moderate (level 4) • High (level 5)

  39. Decision Making Problem: New fracture, HTN, DM (HIGH) Risk: Major surgery with risk factors (HIGH) Data: Reviewed films (LOW) • Decision type? • Straightfoward (levels 1 and 2) • Low (level 3) • Moderate (level 4) • High (level 5)

  40. Decision Making Problem: F/U fracture with displacement Risk: ORIF Data: Reviewed films • Decision type? • Straightfoward (levels 1 and 2) • Low (level 3) • Moderate (level 4) • High (level 5)

  41. Decision Making Problem: F/U fracture with displacement (LOW) Risk: ORIF (MOD) Data: Reviewed films (LOW) • Decision type? • Straightfoward (levels 1 and 2) • Low (level 3) • Moderate (level 4) • High (level 5)

  42. Decision Making Problem: New onset numbness, DM stable Risk: Major surgery Data: Read EMG report • Decision type? • Straightfoward (levels 1 and 2) • Low (level 3) • Moderate (level 4) • High (level 5)

  43. Decision Making Problem: New onset numbness, DM stable (HIGH) Risk: Major surgery (MODERATE) Data: Read EMG report (STRAIGHTFORWARD) • Decision type? • Straightfoward (levels 1 and 2) • Low (level 3) • Moderate (level 4) • High (level 5)

  44. Elements of the E/M Visit • Decision making • Number of diagnosis/management options • Risk of complications • Amount/complexity of data reviewed

  45. Elements of the E/M Visit • Decision making • Number of diagnosis/management options • Self-limited or minor problem 1 • Established problem 1 • Worsening problem 2 • New problem, no additional workup 3 • New problem, additional workup planned 4 • Add up points • Score = 1, 2, 3, 4+

  46. Elements of the E/M Visit • Decision making • Risk of complications • Minimal • Suture removal, lab tests, rest • Low • Two minor problems, sprain, order PT/OT, minor surgery without risk factors • Moderate • Two chronic illness, CT, MRI, aspiration, Rx, fx management, major surgery without risk factors, minor surgery with risk factors • High • Illness with severe exacerbation, abrupt neurological change, major surgery with risk factors, emergency surgery

  47. Elements of the E/M Visit • Decision making • Amount/complexity of data reviewed • Order test 1 • Review test result 1 • Discuss test with performing physician 1 • Decide to obtain records 1 • Review and summarize records 2 • Review x-ray or specimen 2 • Add up points • Score = 1, 2, 3, 4+

  48. Elements of the E/M Visit

  49. Elements of the E/M Visit • How do you decide level of service? • Components • History • Physical examination • Decision making • New patients and consultations • Need all 3 components • Code for lowest component • Established patients • Code for 2 out of 3 components

  50. Elements of the E/M Visit