1 The E&M Codes Using Dr. Quack’s Score Sheet to understand the Evaluation & Management Codes Using Dr. Quack’s Score Sheet to understand the Evaluation & Management Codes The updated score sheet can be found on pages 11 and 12 of The updated score sheet can be found on pages 11 and 12 of

2 The E&M Codes The Quack score sheet we are using today can be found on pages 11 and 12 of The Quack score sheet we are using today can be found on pages 11 and 12 of The score sheet has been updated from the hard copy mailed in early May…there was an omission in the history section (We can work around it today, however). The score sheet has been updated from the hard copy mailed in early May…there was an omission in the history section (We can work around it today, however).

3 The E&M Codes E&M coding is based on 3 key components: E&M coding is based on 3 key components: 1. History (There are 4 levels of complexity) 2. Examination (4 levels) 3. Decision Making (4 levels) First, the level of complexity of each of these components is determined. First, the level of complexity of each of these components is determined. Then the final level of service is determined, based on those levels of complexity. Then the final level of service is determined, based on those levels of complexity.

4 The E&M Codes Levels of service are scored differently for New vs. Established patients. Levels of service are scored differently for New vs. Established patients. For New Patients, the complexity of the History, History, Exam, and Exam, and Decision making Decision making …must all three be considered.

5 The E&M Codes For Established patients, only two of the three key components must be considered. For Established patients, only two of the three key components must be considered. However, it is best to ALWAYS consider Decision Making. However, it is best to ALWAYS consider Decision Making. THE RESULTING CODE MUST BE REASONABLE AND NECESSARY. The Decision Making Score helps assure that is the case. THE RESULTING CODE MUST BE REASONABLE AND NECESSARY. The Decision Making Score helps assure that is the case.

6 Key Component #1: History Made up of Made up of Chief Complaint Chief Complaint History of Present Illness (HPI) History of Present Illness (HPI) Review of Systems (ROS) Review of Systems (ROS) Past, Family, & Social History (PFSH) Past, Family, & Social History (PFSH)

7 Link on slides 1 & 4

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10 History of Present Illness Made up of Made up of Location [example: “od”, “os”, “ou”, “upper”…] Location [example: “od”, “os”, “ou”, “upper”…] Quality [“sharp”, “dull”, “stabbing”...] Quality [“sharp”, “dull”, “stabbing”...] Severity [“mild”, “severe”….] Severity [“mild”, “severe”….] Duration [“short”, “constant”, “hour or so”…] Duration [“short”, “constant”, “hour or so”…] Timing [“morning”, “nighttime”...] Timing [“morning”, “nighttime”...] Context [“driving”, “reading”…] Context [“driving”, “reading”…] Modifying Factors [“bright light”, “when tired”…] Modifying Factors [“bright light”, “when tired”…] Associated Signs & Symptoms [“headache”…] Associated Signs & Symptoms [“headache”…] OR Three Chronic or inactive conditions OR Three Chronic or inactive conditions 1.____________ [AMD…] 1.____________ [AMD…] 2.____________ [Cataract…] 2.____________ [Cataract…] 3.____________ [EBMD…] 3.____________ [EBMD…]

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12 Review of Systems Made up of Made up of Constitutional (weight loss, etc.) Constitutional (weight loss, etc.) Eyes Eyes Ears, Nose, Mouth, Throat Ears, Nose, Mouth, Throat Cardiovascular Cardiovascular Gastrointestinal Gastrointestinal Genitourinary Genitourinary Integumentary (skin, breast) Integumentary (skin, breast) Musculo-skeletal Musculo-skeletal Neurological Neurological Hematologic Lymphatic Hematologic Lymphatic Respiratory Respiratory Endocrine Endocrine Allergic Immunologic Allergic Immunologic Psychiatric Psychiatric All others negative (= 9) All others negative (= 9)

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16 Past, Family, Social History

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21 Key Component #2: Examination Made up of Made up of Acuity Acuity Adnexae, lids, lacrimal sys, pre-auriclar nodes Adnexae, lids, lacrimal sys, pre-auriclar nodes Cornea Cornea IOT IOT Confrontation Fields Confrontation Fields Conjunctiva, bulbar & palpebral Conjunctiva, bulbar & palpebral A/C A/C Retina, vessels, exudates, hemorrhages (dilated) Retina, vessels, exudates, hemorrhages (dilated) Ocular Motility Ocular Motility Pupil/Iris, APD Pupil/Iris, APD Lens Lens Disc, Cup, NFL (dilated) Disc, Cup, NFL (dilated) Systemic elements that briefly assess mental status or general constitution Systemic elements that briefly assess mental status or general constitution Oriented to time/location & mood Oriented to time/location & mood General Constitution General Constitution

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26 Key Component #3: Decision Making Made up of Made up of Diagnosis and Management Options Diagnosis and Management Options Data Complexity Data Complexity Risk Risk Very Important: Can be used to determine whether the ultimate level of service is truly “REASONABLE AND NECESSARY” Very Important: Can be used to determine whether the ultimate level of service is truly “REASONABLE AND NECESSARY”

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33 Am I Going to Need to Use One of These Forms For Every Exam? Nope. Once you’ve done a number of them, you’ll know intuitively what to bill on almost all of the more common diagnoses. Nope. Once you’ve done a number of them, you’ll know intuitively what to bill on almost all of the more common diagnoses. Keep the forms available for the unusual situations, however. Keep the forms available for the unusual situations, however. Now, for some examples…………. Now, for some examples………….

34 Example Case #1 24 YOWM scratched R eye with branch while mowing this morning; blurred vision, mild, scratchy red eye..

35 24 yowm scratched R eye with branch while mowing this morning; blurred vision, mild, scratchy red eye..

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39 mild corneal abrasion

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41 Example Case #2 F/U visit: 24 YOWM scratched R eye with branch while mowing yesterday; vision much better, no pain, little redness

42 F/U visit: 24 YOWM scratched R eye with branch while mowing yesterday; vision much better, no pain, little red

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46 mild corneal abrasion

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48 Example Case #3 67 YOBF c/o blurred VA OU, worse in pm when driving, gradual onset; glare & sun a problem.

49 67 YOBF c/o blurred VA OU, worse in pm when driving, gradual onset; glare & sun a problem.

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53 ns cataract OU

54 The E&M Codes For Established patients, only two of the three key components must be considered. For Established patients, only two of the three key components must be considered. However, it is best to ALWAYS consider Decision Making. However, it is best to ALWAYS consider Decision Making. THE RESULTING CODE MUST BE REASONABLE AND NECESSARY. THE RESULTING CODE MUST BE REASONABLE AND NECESSARY. The Decision Making Score helps assure that is the case. The Decision Making Score helps assure that is the case.

55 THE RESULTING CODE MUST BE REASONABLE AND NECESSARY. The Decision Making Score helps assure that is the case.

56 Example Case #4 68 YOBF c/o blurred VA OU, Hx cataract, dry AMD, Narrow angle, EBMD; 6 mo evaluation

57 68 YOBF c/o blurred VA OU, Hx cataract, dry AMD, Narrow angle, EBMD; 6 mo evaluation Cataract EBMD AMD Narrow Angle

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61 EBMD; AMD; Narrow angle Cataract

62 THE RESULTING CODE MUST BE REASONABLE AND NECESSARY. The Decision Making Score helps assure that is the case.

63 Example Case #5 Recently suffers constant, severe HA w/ vomiting; dizzyness; noticed he cannot see to the side OU when driving; Has not seen PCP in 20+ years

64 Recently suffers constant, severe HA w/ vomiting; dizzyness; noticed he cannot see temporally OU

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68 bitemporal heminopsia; swollen disks fields?; OCT? 2

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70 These same E&M codes are also used by cardiovascular surgeons, cardiovascular surgeons, neurosurgeons, and neurosurgeons, and other specialties that work with life-threatening situations. other specialties that work with life-threatening situations. ODs must keep the use of the 5 level codes in perspective, and use only when justified, which will be rarely, if ever, for most OD practitioners. Should an OD Bill a 5 Level E&M Code?

71 Previous recommendations from our Medicare carrier: Any 5 level code should include: At least one, preferably two, ancillary tests (fields, photos, OCT etc.), and At least one, preferably two, ancillary tests (fields, photos, OCT etc.), and Correspondence to the PCP, and Correspondence to the PCP, and Correspondence/referral to a tertiary provider. Correspondence/referral to a tertiary provider. Should an OD Bill a 5 Level E&M Code?

72 The E&M Codes Final outcome is based on what is clearly documented in the record. Final outcome is based on what is clearly documented in the record. If it wasn’t clearly documented in the record, auditors assume it wasn’t done. If it wasn’t clearly documented in the record, auditors assume it wasn’t done. Caveat: But never make changes to the record once it is completed. (i.e., never add or alter anything prior to an audit.) Caveat: But never make changes to the record once it is completed. (i.e., never add or alter anything prior to an audit.)

73 For All Patient Record Keeping You should have on hand You should have on hand A table of you office’s standard abbreviations available for audits. A table of you office’s standard abbreviations available for audits. A table of signatures (doctors and assistants) available for audits. A table of signatures (doctors and assistants) available for audits. Patient records must be signed (legibly, or at least should match the signature table) and must be dated. Patient records must be signed (legibly, or at least should match the signature table) and must be dated. Electronic signature okay, stamped signatures are not. Electronic signature okay, stamped signatures are not.

74 Decision Making Very Important: use Decision Making to determine whether the ultimate level of service is truly “REASONABLE AND NECESSARY ” Very Important: use Decision Making to determine whether the ultimate level of service is truly “REASONABLE AND NECESSARY ”

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80 mild corneal abrasion 111 0

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