Chapter 2 Evaluation and Management Coding MED 123 Chapter 2 Evaluation and Management Coding

Pg. 40 The basic format of E/M service codes consist of five elements. Are listed by unique code numbers beginning with 99. Generally identify the place or type of service. Define the content, extent, or level of the service (for example detailed history and detailed exam) Describe the nature of the presenting problem (for example, moderate severity) Identify the type typically required to provide a service.

Documentation Guidelines Documentation is the basis for all coding, including E/M services. In 1995, the American Medical Association and the Centers for Medicare and Medicaid Services implemented documentation guidelines to clarify E/M code assignment for both physicians and claims reviewers. Still left too much for interpretation.

In 1997, CMS and the AMA collaborated on a revised edition of the documentation guidelines. Both the 1995 and 1997 guidelines are acceptable for use in determining an E/M code. Physicians are encouraged to use the set of guidelines that is most advantageous for that particular visit.

Pg. 41 When submitting insurance claims for payment, physicians use E/M codes to report professional services rendered to patients. Documentation must support the charges (CPT) and diagnoses (ICD-9-CM) codes submitted. Many payers have edit systems that deny or reject claims if the highest level of specificity of a diagnosis is not submitted. Submitting a code that is not supported in the health record may constitute fraud or abuse. Physicians and coders must work together to ensure that clinical documentation substantiates the level of service code assigned.

The medical record should be complete and legible. General Principles of Medical Record Documentation Appendix C.1 Pg. 418 The principles of documentation listed below are applicable to all types of medical and surgical services in all settings. The medical record should be complete and legible. The documentation of each patient encounter should include: reason for the encounter and relevant history, physical exam findings and prior diagnostic results. Assessment, clinical impression, or diagnosis; Plan for care; and Date and legible identity of the observer.

If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred. Past and present diagnoses should be accessible to the treating and/or consulting physician. Appropriate health risk factors should be identified. The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented. The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.

Evaluation and Management Services (99201 – 99499) Pg. 41 Although E/M codes begin with the number 99201, they are found at the front of the CPT codebook.

New or Established Patient A new patient is one who has not received any face-to- face professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years. An established patient is one who has received professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years. When the physician is on call or covering for another physician, the patient’s encounter is classified in the same manner as if the physician had been available.

When a physician sees a patient in the hospital (for example, a newborn) and the patient then presents to the clinic, the patient is considered an established patient upon his or her first encounter with the physician at the clinic.

Concurrent Care When two or more physicians provide similar services (for example, hospital visits or consultations) to the same patient on the same day, the CPT codebook defines this as concurrent care. Health plans often limit reimbursement to one physician per day unless the physicians have different specialties and the services of more than one physician are medically necessary.

Levels of E/M Services Before an E/M service code can be assigned, three questions must be considered: What type of service is the patient receiving? Initial or subsequent care? Consultation? Critical Care? What is the place of service? Physician’s office or clinic? Hospital inpatient or outpatient department? Emergency Department? Nursing facility or rehabilitation unit? Is the patient new or established?

Components in Selecting the Level of E/M Service History, examination, and medical decision making are the key components, or essential factors, that must be considered first when selecting an E/M service code. Documentation in the health record must support code-level selection by describing the key components and the pertinent contributing factors. Physician selection of E/M codes is recommended to ensure clinical validity for service levels.

Compare Office or Other Outpatient Services Some categories require the history, examination, and medical decision making for a given encounter to meet or exceed a given level to bill for that level of service. Others require that only two of these three key components meet or exceed the stated requirements. Compare Office or Other Outpatient Services New Patient Established Patient

Key Components pg 419 Key components History Examination Medical Decision Making Counseling or coordination of care Key component is time.

History Pg. 45 The history component consists of documentation of some or all of the following: Chief complaint (CC) History of the present illness (HPI) Review of Systems (ROS) Past medical, family, and social history (PFSH)

Chief Complaint “a concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter, usually stated in the patient’s words.” (AMA 2005) The medical record should clearly state the chief complaint.

History of the Present Illness (HPI) The level of the history of the present illness (minimal, problem focused, expanded focus, detailed, comprehensive) is distinguished by the amount of detail that is documented.

Extended HPI 4 + elements. HPI is brief or extended based on how many of the eight elements are documented. Brief HPI 1-3 elements Extended HPI 4 + elements. HPI Element Definition Example Location Where on the body the symptom is occurring Leg, head, arm, etc Quality Characteristics, grade Burning, gnawing, stabbing Severity How hard it is to endure, ranked 1 to 10 Severe, mild, intense Duration How long? 2 days, months, hours Timing When it occurs At night, after meals Context Situation associated with the symptom Big meal, after sitting Modifying factors Things that make it better or worse Pain less w/ Tylenol Associated signs and symptoms What else happens when this symptom is present Chest pain leads to shortness of breath

Review of Systems The review of systems (ROS) is an inventory of body systems obtained through a series of questions asked of patients that may identify signs and symptoms they may be experiencing or have experienced in the past. Items of ROS can be found in the history as well and still counted as part of the ROS, however, the same item cannot be counted in both sections.

Three levels of review are considered when determining the level of ROS documented. Problem-pertinent ROS, which entails review of one body system that is related directly to the presenting problem. Extended ROS, which involves review of the body systems that are related directly to the presenting problem as well as additional body systems, for a total of two to nine body systems Complete ROS, which includes review of ten or more body systems. Constitutional symptoms (ex: fever or weight loss) Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary (skin and/or breast) Neurological Psychiatric Endocrine Hematologic/ Lymphatic Allergic/ Immunologic

The physician may document those systems that have findings and state “all others reviewed and are negative” if the patient denies any other issues. This qualifies the visit for a complete review of systems.

Past Medical, Family, and Social History Two levels of documentation are considered when determining the level of past medical, family, and social history: Pertinent, which includes at least one item from one of the areas of past history Complete, which entails at least two specifics from at least two history areas documented for an established patient or discussion of all three areas of the past history for a new patient.

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 that may be hereditary or place the patient at risk); and Social history (an age-appropriate review of past and current activities).

Documentation of Examination The levels of E/M services are based on four types of examination that are defined as follows: Problem focused- a limited examination of the affected body area or organ system. Expanded problem focused- a limited examination of the affected body area or organ system and other symptomatic or related organ system(s). Detailed- an extended examination of the affected body area(s) and other symptomatic or related organ system(s). Comprehensive- a general multisystem examination or complete examination of a single organ system.

For the purposes of examination the following areas are recognized Body Areas Head, including the face Neck Chest, including breasts and axillae Abdomen Genitalia, groin, buttocks Back, including spine Each Extremity Organ Systems Constitutional (ex: vital signs, general appearance) Eyes Ears, Nose, Mouth, and Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic/ Lymphatic/ Immunologic

Documentation Guidelines Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented. A notation of “abnormal” without elaboration is insufficient. The medical record for a general multisystem examination should include findings about 8 or more of the 12 organ systems.

Medical Decision Making Medical Decision making is the third key component used in determining a level of service. There are four types of medical decision making: Straightforward Low complexity Moderate complexity High complexity

The type of medical decision making is determined 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 The risk of significant complications, morbidity, and/or mortality, as well as comorbidities associated with the patient’s presenting problem(s), the diagnostic procedure(s), and/or the possible management options.