Evaluation & Management Services

E/M Coding Key components Contributory factors History Physical examination Medical Decision making Contributory factors Nature of the presenting problem Medical Necessity drives code selection Extent of counseling Coordination of care Time

E/M Guidelines Medicare and Commercial Insurance Medicaid CMS 1995 and 1997 E/M guidelines Use either set 1997 approved by AMA Medicaid Does not use ‘95 or ‘97 guidelines Uses AMA guidelines found in the CPT book E/M Service Guidelines section in “Instructions for selecting a Level of E/M Service”

Medical Necessity A service that is reasonable and necessary for the diagnosis and treatment of illness or injury, or to improve the functioning of a malformed body member Government definition

History Definitions Chief complaint (CC) Reason for the visit History of present illness (HPI) Chronological review of condition/complaint Review of systems (ROS) Inventory of systems through questions Past, Family, Social, History (PFSH)

History Problem Focused Detailed Chief Complaint  Chief Complaint Brief HPI (1-3)  Extended HPI (4 or status of No ROS 3 chronic/inactive) No PFSH  Extended ROS (2-9) Expanded Problem  Pertinent PFSH (1) Focused Comprehensive Problem pertinent ROS (1) 3 chronic/inactive) No PFSH  Complete ROS (10) ALL 3 elements must be  Complete PFSH (2 or 3 met: HPI,ROS,PFSH based on category of E/M)

CPT History Guidelines (Medicaid) Problem focused: CC; brief HPI Expanded problem focused: CC; brief HPI, problem pertinent ROS Detailed: CC; extended HPI, problem pertinent ROS extended to include a review of limited number of additional systems; pertinent PFSH directly related to the patient’s problems Comprehensive: CC; extended HPI, ROS which is directly related to the problem(s) identified in the HPI plus a review of all additional body systems; complete PFSH

History Example CC - Vaginal discharge HPI - New patient is complaining of a white vaginal (location) discharge for the past 2 days (duration) with a heavier flow in the morning (timing). There is no change with Monistat (modifying factor). ROS - Patient denies itching (integumentary), burning with urination (genitourinary) or fever (constitutional). PFSH - Patient has had 2 sexual partners in the past 60 days (social)

History Example History Level = Detailed (3 of 3) CC HPI = Extended (4+ elements) ROS = Extended (3 elements) PFSH = Pertinent (1 element)

Physical Exam Problem Focused Expanded Problem Focused Detailed (95)<1 body area/ organ system (97) 1-5 elements Expanded Problem Focused (95) 2-4 body areas/ organ systems (97) 6 - 11 elements Detailed (95) 5-7 body areas/organ systems (97) 12 elements in 2+areas/systems Comprehensive (95) 8 organ systems (97) General exam: Perform all elements document at least 2 elements in each of 9 areas/systems

CPT Physical Exam Guidelines (Medicaid) Problem focused: limited exam of the affected body area or organ system Expanded problem focused: limited exam of the affected body area or organ system and other symptomatic or related organ system(s) Detailed: extended exam of the affected body area(s) and other symptomatic or related organ system(s) Comprehensive: general multi-system exam or a complete exam of a single organ system

Physical Exam Example Vaginal Discharge Exam Constitutional BP, temp, pulse Genitourinary Examination of external genitalia Examination of cervix Physical Exam level = Expanded Problem Focused At least two body areas/organ systems

Decision Making Straightforward Low Complexity Moderate Complexity #Diagnostic/treatment options (0 -1) Amt./complexity of data (0 -1) Risk (minimal) Low Complexity #Diagnostic/treatment options (2) (2) Risk (low) Moderate Complexity #Diagnostic/treatment options (3) Amt./complexity of data (3) Risk (moderate) High Complexity #Diagnoses/mgmt options (4) Amt./complexity of data (4) Risk (high)

CPT MDM Guidelines (Medicaid) Complexity measured by: # of possible diagnoses and/or the number of management options that must be considered. Amount/complexity of records, tests, other information that must be obtained, reviewed, and analyzed. Risk of significant complications, morbidity, mortality, as well as co-morbidities, associated with the patient’s presenting problem(s), the diagnostic procedure(s) and/or the possible management options.

Decision Making Example Vaginal Discharge Exam New problem, additional workup planned Lab is ordered (4) Review/order tests in 8xxxx series (1) Moderate decision making Undiagnosed new problem with uncertain prognosis Prescription drug management Prescription written Decision Making level = Moderate (2 0f 3) Extensive # Diagnosis/treatment options Minimal amount of data to be reviewed Table of risk - Moderate

Level Assignment Example History = Detailed Physical exam = Expanded Problem Focused Decision Making = Moderate Level = 99202, new patient If established patient = 99214

Contributing Factors Presenting Problem Time Minimal Self-Limited/Minor Low Severity Moderate Severity High Severity Time FACE-TO-FACE Time is a key factor ONLY when: Counseling or coordination of care takes up OVER 50% of the total visit time

Counseling/Coordination of Care Main factor determining code when takes up MORE than 50% of the total visit time Documentation: Total visit time Time spent in Counseling/Coordination of Care Face to face Subject/ content Code level is based on the total visit time not just the time spent in counseling

Counseling Examples Established patient, 20 minute visit to follow-up on oral contraceptive use NP 99213 RN 99211 (MA 99213) 15 minutes of a 20 minute visit spent counseling the patient on alcohol and cigarette use during pregnancy

Definitions New patient Established patient Has not received face-to-face services from ANY provider in the agency Within past 3 years (AMA) Established patient Has received face-to-face services from

Selecting a Level of E/M Identify Place of service (POS) = where (office) Type of service (TOS) = what (Problem/Preventive) Status of Patient = who (New/Established) Determine the extent of history - physical exam - decision making - counseling Must consider all factors, and make sure adequate DOCUMENTATION in chart to justify code.

Office 99201-99215 Report Problem visit (vs. Preventive visit) 99201-99205, 99212-99215 performed by MD,DO,NP,PA,CNS 99211 - Ancillary staff i.e. RN, LPN, CNA MD/NP must be in the clinic Report only 1 E/M per day Report diagnostic tests, studies, procedures separately

Office 99201-99215 (Medicaid) 99201-99205, 99212-99215 may be performed by any staff of a “certified family planning clinic”. Staff may be MD, NP, PA, RN, CMA or unlicensed personnel acting in a coordinated manner to provide the service(s). Other reporting requirements are the same as other providers

Preventive Medicine Services

Preventive Medicine 99381-99397 Routine management of patients without presenting problems, i.e. annual, routine, well child exams Performed by MD, DO,NP,PA,CNS Includes other clinic staff if Medicaid Codes New/established patients Age Not used for scheduled follow-up visits for specified problems