Evaluation & Management Coding and Documentation 101 – the basics Coding and Documentation 101-SAC 3/31/2017 Evaluation & Management Coding and Documentation 101 – the basics Stephanie Ann Call, MD MSPH VCU Internal Medicine Training Program The Practice of Medicine Series - 2009

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

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

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.”

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

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)

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

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

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

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)

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)

Key Components History Physical Examination Decision Making

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)

History HPI elements Level of History 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

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

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

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

History – E/M levels Problem Focused Expanded Problem Focused Detailed 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

Problem Pertinent >1 History Type of History HPI ROS PFSH Problem Focused Brief 1-3 N/A Expanded Problem Focused Brief 1-3 Problem Pertinent >1 Detailed Extended 4+ Extended 2-9 Pertinent 1 Comprehensive Extended 4+ Compete (10+) Complete 2/3 or 3/3*

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

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

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

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

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

Medical Decision Making

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?

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

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

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

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

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

Risk of complication Minimal Low Moderate High

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

Medical Decision Making MDM - Level Dx/Mgmt Data Risk Straight-forward Minimal < 2 elements Minimal/none < 1 element Minimal Low Limited 3-4 elements Limited 2 elements Moderate Multiple 5-6 elements Multiple 3 elements High Extensive > 7 elements Extensive > 4 elements

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

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

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

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

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

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