PHYSICIAN NETWORK SERVICES E&M overview Physician Network Services Coding Compliance Education

E&M overview Chief Complaint History: Should be clearly stated in every encounter History: HPI: - History of Present Illness: Location, Duration, Quality Context, Modifying Factors, Associated signs & Symptoms ROS: - Review of Systems: It is a Q&A format Relevant to the chief complaint ROS reviewed and negative, as long as positive/negative pertinent ROS are documented

Documentation Example E&M overview HPI: - History of Present Illness: Element Definition Documentation Example Location Place, whereabouts Pain in groin Quality Characteristics, grade Burning pain in groin Severity How hard it is to endure Hx of mild burning pain in groin become more intense, and/or pain scale Duration Length of time Hx of mild burning pain in groin become more intense for last 2 wks Timing Regulation of occurrence Intermittent groin pain, more intense and frequent last 2 wks Context Circumstances of occurrence Hx of groin pain …..since the patient bent down to pick up trash Modifying Factors Altering elements; condition Hx of groin pain ….. Has been taking Motrin 800 mg bid with some relief Signs/Symptoms Significantly related to the presenting problem, CC Hx of groin pain …. States he had a feeling of bowel and bladder urgency twice this week, OR no other sx noted

E&M overview ROS: - Review of Systems: The following systems are recognized Constitutional Musculoskeletal Eyes Integumentary Ears, Nose, Mouth, Throat Neurological Cardiovascular Psychiatric Respiratory Endocrine Gastrointestinal Hematologic/Lymphatic Genitourinary Allergic/Immunologic

E&M overview PFSH – Personal Family Social History Past History Past experiences with illnesses, operations, injuries, treatments, current medication, allergies, etc. Family History Family history of illness and diseases; hereditary Social History Age appropriate review of past and current activities; drugs/alcohol, marital status, occupation, exercise, etc.

E&M overview PFSH Terms not acceptable under the E&M documentation guidelines are: Non-contributory, non-pertinent and negative. Could be acceptable if they are followed by a statement such as: “PFS history was reviewed and was not contributory or pertinent to the chief complaint or negative for any medical or social problems”.

Expanded Problem Focused E&M overview History Determination E/M Level Type of History Needed Elements 99201 / 99212 Problem Focused HPI: 1-3 elements ROS: None PFSH: None 99202 / 99213 Expanded Problem Focused ROS: 1 Pertinent 99203 / 99214 Detailed HPI: >4 or 3+ chronics ROS: 2-9 PFSH: 1 Pertinent 99204/99205/99215 Comprehensive ROS: 10+ PFSH: Initial-3 Est-2

E&M overview Physical Examination Following the 1995 E&M documentation guidelines Includes organ systems and body areas The physical examination should support the medical necessity stated by the chief complaint Volume of documentation will not necessarily support the level of service billed

E&M OVERVIEW Body Areas and Organ Systems Body Areas Organ Systems Head and face Neck Chest, including breasts and axillae Abdomen Genitalia, buttocks and groin Back and spine Each extremity Constitutional Eyes Ears, nose mouth and throat Cardiovascular Respiratory Gastroenterology Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic, lymphatic, immunologic

Organ Systems/ Body Areas E&M overview Examination E/M Level Type of Exam Organ Systems/ Body Areas 99201 / 99212 Problem Focused 1 Organ System / Body Area 99202 / 99213 Expanded Problem Focused 2-4 Organ Systems/ Body Areas 99203 / 99214 Detailed 5-7 Organ Systems/ Body Areas 99204/99205 99215 Comprehensive 8 Organs Systems Only

E&M overview Medical Decision Making: Problem/diagnosis categories New and established problems different complexity Data: Labs, radiology, procedures ordered and/or reviewed Independent review of tests Decision to request records Review and summary of old records Risk: Presenting problem Diagnostic procedure Management options selected

E&M overview MDM Determination E/M Level Type of MDM Needed Elements 99201 / 99202/99212 Straight-Forward Dx: 0-1 point Data: 0-1 point Risk: Minimal 99203 / 99213 Low Complexity Dx: 2 points Data: 2 points Risk: Low 99204/ 99214 Moderate Complexity Dx: 3 points Data: 3 points Risk: Moderate 99205/ 99215 High Complexity Dx: 4 or more points Data: 4 or more points Risk: High

Expanded Problem Focused Bring It Together Code Determination- Meet all 3 requirements E/M Level New History Exam MDM 99201 Problem Focused Straight-Forward 99202 Expanded Problem Focused 99203 Detailed Low 99204 Comprehensive Moderate 99205 High You cannot code higher than your lowest met requirement

Expanded Problem Focused Bring It Together Code Determination- Meet 2 of 3 requirements E/M Level Est History Exam MDM 99212 Problem Focused Straight-Forward 99213 Expanded Problem Focused Low 99214 Detailed Moderate 99215 Comprehensive High You cannot code higher than your lowest met requirement

E&M overview Billing based on time A level of service can be determined based on time if more than 50% of the visit is spent coordinating care (inpatient only), and/or counseling (face-to-face) The total time must be recorded as well as a statement that more than 50% of the visit was counseling (face-to-face) or coordination of care (inpatient only)

E&M overview Billing based on time Examples More than half of this 30 minute visit was spent in counseling discussing …… Spent more than half of this 45 minute visit discussing the management of John’s asthma at school. Obtained mother’s permission to discuss with school nurse and physical education instructor. Given prescriptions for inhalers to remain at school, home, and day care. Discussed plan for severe SOB Level of service: 99204 (New patient) or 99215 (Established patient) 10/15 minutes spent counseling patient on…. Discussed the advisability of ENT referral for the evaluation of recurring tonsillitis. Mom agrees that more aggressive treatment or surgery should be explored Total time: 15 minutes Counseling: 10 minutes Level of service: 99213 (established patient)

E&M overview Level 5 To bill a level 5 for a new or established visit The E&M documentation guidelines must be met Meet the medical necessity and The condition(s) should have the acuity and high risk to pose a threat to life

E&M overview Most common findings Incomplete documentation Missing Chief Complaint A component of the E/M was not documented (New patients) Provider’s signature is missing or illegible Capturing of Review of Systems Physical Examination and Medical Necessity Diagnosis (specificity and priority) Missing Documentation of Orders Proper documentation for level 5 Preventive vs. Sick Visits

E&M overview QUESTIONS?

DOCUMENTATION GUIDELINES Non-Physician Provider Practice Guidelines Direct billing: a service is provided entirely by the mid-level provider (i.e. new problem, physician is not in the office suite, new patient). Incident-to billing: is billing under the supervising physician’s name as long as the mid-level provider is seeing an existing patient for an established problem, and the supervising physician has established a plan of care and he/she is in the office suite.

DOCUMENTATION GUIDELINES Incident-to services Medicare “incident-to” supervision guidelines must be met: The physician must be present in the office suite providing direct supervision. The physician must see all new patients and establish a plan of care. The Non-Physician Provider follows established patients and provides services that are part of the physician’s plan of care for the patient.

DOCUMENTATION GUIDELINES Incident-to services Medicare “incident-to” supervision guidelines must be met: The physician sees established patients when they present with new problems. The physician provides subsequent services that reflect his/her continuing active participation in and management of the course of treatment.

DOCUMENTATION GUIDELINES When Non-Physician Provider bills Medicare under his/her own billing number, he/she must document the service provided and sign the documentation indicating his/her responsibility for the service Billing for other insurance carriers When Non-Physician Provider bills under the provider number of the supervising physician, the physician may be required to co-sign the patient services indicating they accept the responsibility for the service.

DOCUMENTATION GUIDELINES INCIDENT-TO DECISION MAKING NO YES NO YES NO Non-physician practitioner provides services Was the physician in the suite? Use the non-physician practitioner’s provider number Was the problem new? This service should qualify for incident-to billing Allow fees at 85% of the fee schedule Use the physician’s provider number on the claim

DOCUMENTATION GUIDELINES Signature requirements Situation Performed by: Signature requirement: Ancillary Staff Must be signed by supervising provider Incident to NPP (Non-Physician Practitioner) May be signed by the NPP or the supervising physician Split/Shared: Office/Clinic setting Must meet incident-to NPP and Physician Hospital Inpatient/ Outpatient/ED setting Must be signed by billing provider

DOCUMENTATION GUIDELINES QUESTIONS?