EHR Coding and Reimbursement

EHR Coding and Reimbursement
CHAPTER TWELVE TWO EHR Coding and Reimbursement

Guided Exercise 69: Calculating the E&M Code from an Encounter
Case Study Mary Williams is a 26-year-old female who was seen for stuffy sinus. The healthcare provider who entered the encounter data has not yet recorded the history of present illness or vital signs.

Step 1 Start Student Edition software. Click Select on Menu bar; then click Patient. In Patient Selection window, locate and click on Mary Williams. Figure 12-2: Select patient Mary Williams.

Step 2 Click Select on Menu bar; then click Existing Encounter. Select 5/28/ :45 AM Office Visit. Encounter note from that date will be displayed.

Step 3 Compare your screen to Figure 12-4. Exam was created using Adult URI List. Because we are going to be using information from encounter note to calculate E&M code, take time to look at encounter note in right pane of screen. Note History section contains a Review of Systems, but no HPI or social history.

Figure 12-4: Patient encounter note for May 28, 2012, displayed in right pane.

Step 3 (cont.) Not all of the note will fit in pane; you will need to use scroll bar on right to scroll downward to see rest of note (Figure 12-5).

Figure 12-5: Scrolled portion of patient encounter note with E&M button highlighted.

Step 4 Compare number of body systems in Physical Findings section of note with number of body systems in Review of Systems section. Locate and click on the button labeled “E&M” in Toolbar at top of screen. Icon resembles horseshoe magnet with lightning bolt.

Step 4 (cont.) Problem Screening checklist is displayed. Figure 12-6: Problem Screening checklist window.

Problem Screening Checklist Window
Problem Screening checklist (Figure 12-6) displays assessments in current encounter. Providers can add information for E&M calculator about each problem by checking boxes for active, chronic, new, or additional workup.

Drop-down list lets provider inform E&M calculator of problem status; this does not alter a problem status that has been recorded in Entry Detail Status field.

Step 5 We will explore effect of Problem Screening checklist later. Do not check any boxes at this time. Locate and click on OK button on bottom of Problem Screening for E/M window. Evaluation and Management Calculator window will be displayed (Figure 12-7).

Figure 12-7: E&M calculator for May 28, 2012, encounter.
E&M Calculator Window Figure 12-7: E&M calculator for May 28, 2012, encounter.

E&M Calculator Window Step 6
Fields in this screen will be explained in detail in Guided Exercise 70. For the moment, just calculate E&M code. If field labeled “Calculated E&M Code” displays “99212 Estab Outpatient Focused H&P—Straightforward Decisions,” you are ready to proceed.

E&M Calculator Window Step 6 (cont.)
If it is blank or contains a different code, locate area labeled “Patient Status” in upper right corner. If white circle next to “Existing” is empty, click it once with your mouse. It should then appear filled in center as shown in Figure 12-7 (circled in red).

Locate large button labeled “Calculate E&M Code” and click it. Compare your screen to Evaluation and Management Calculator window shown in Figure 12-7.

E&M Calculator Window Step 7
You are going to use E&M calculator window to help you understand CMS Documentation Guidelines for Evaluation and Management Services. Look at bottom of calculator window where there is a grid. Columns are labeled with terms such as HPI and ROS.

There are four rows representing the four levels discussed earlier. Each column lists levels relevant to that particular type of finding. Leave E&M calculator displayed as you read following section. Do not click any buttons until instructed to do so.

If you cannot complete reading in allotted time, simply repeat steps 1, 2, and 5 to invoke E&M calculator window again when you are ready to resume.

Levels of Key Components
History, examination, and medical decision making are the key components that determine level of E&M services. CPT-4 E&M code description lists the three key components and their levels. Key components each have levels of their own, which are determined separately.

Key Component: History
CC: acronym for Chief Complaint. A Chief Complaint is required for all levels of History. HPI: acronym for History of Present Illness. ROS: acronym for Review of Systems. PFSH: acronym for Past History, Family History, and Social History.

Step 8 Look at grid section of E&M calculator window shown in Figure 12-8. History section consists of four columns labeled HPI, ROS, PFSH, and Overall History. Each of the history elements (HPI, ROS, PFSH) has levels that will determine Overall History level.

Figure 12-8: E&M calculator with Show Column Details button highlighted.

Step 8 (cont.) If level in a column shown in bold type, then number of findings is sufficient to meet guidelines for level at which it appears. Look at column labeled “ROS.” Word “Pertinent” in first row is bold, meaning ROS has enough findings for level 1 but not enough for level 2, “Extended.”

Step 8 (cont.) History of Present Illness (HPI) is a chronological description of development of patient's present illness from first sign and/or symptom or from previous encounter to present. HPI includes the following characteristics.

Step 8 (cont.) Location Quality Severity Duration Timing Context Modifying factors Associated signs and symptoms

Step 8 (cont.) HPI has two named levels, brief and extended; levels are determined by quantity of findings. Brief: one to three items in the HPI. Extended: at least four items in the HPI or status of at least three chronic or inactive conditions. In this encounter, there are no findings for HPI; therefore, none of the levels are in bold type.

Step 9 E&M calculator will allow you to see which findings in encounter note were used to determine level. There are two ways to do this. First method is use button labeled “Show Column Details” (highlighted in Figure 12-8). Locate and click on button labeled “Show Column Details.” Drop-down list will appear.

Step 9 (cont.) Position mouse over ROS details in drop-down list (Figure 12-9); click mouse.

Figure 12-9: Show Column Details drop-down list.

Step 9 (cont.) Pane will open in upper portion of E&M calculator window to display findings that were recorded in encounter note for Review of Systems (ROS) (Figure 12-10).

Figure 12-10: ROS details in E&M calculator with Hide Details button highlighted.

Step 9 (cont.) Second method of displaying column details is to click mouse directly on column label, for example, “ROS” (circled in red in Figure 12-10). Using either method will change button label to “Hide Details.” Clicking Hide Details button will close detail pane and return to previous view.

Step 10 Review of Systems (ROS) level determined by number of systems reviewed; has three levels: Problem Pertinent: ROS inquires about system directly related to problems identified in HPI. Extended: ROS inquires about system directly related to problems identified in HPI and a number of additional systems. Extended level requires two to nine systems be documented.

Step 10 (cont.) Review of Systems (ROS) level determined by number of systems reviewed; has three levels (cont.): Complete: ROS inquires about systems directly related to problems identified in HPI plus all additional body systems. At least ten organ systems must be reviewed to meet requirement for Complete.

Step 10 (cont.) Compare your screen to Figure There is one finding shown in Figure 12-10; therefore, ROS is level 1—Pertinent. Close Details for ROS pane and return to previous view, by clicking button labeled “Hide Details” (highlighted in Figure 12-10). Be careful not to click Cancel button by mistake, because that will close E&M calculator instead of hiding Details of ROS.

Step 11 Past, Family, and/or Social History (PFSH) consists of review of three areas: Past history: patient's past experiences with illnesses, operations, injuries, treatments. Family history: review of medical events in patient's family, including diseases that may be hereditary or place the patient at risk. Social history: age-appropriate review of past and current activities.

Step 11 (cont.) PFSH level determined by number of findings in these three history types; has two levels: Pertinent: at least one item in any of PFSH area directly related to problems identified in the HPI. Complete: review of two or all three of PFSH history areas, depending on category of E&M service. Requires all three history areas for services that include comprehensive assessment of new patient or reassessment of existing patient. Review of two of three history areas is sufficient for other services.

Step 11 (cont.) Look at column under PFSH on screen. In this encounter, no PFSH was recorded.

Step 12 Key component History has four levels: Problem Focused Expanded Problem Focused Detailed Comprehensive Figure shows elements required for each level of history.

Step 12 (cont.) Level of History (shown in first column of table) is determined by levels of HPI, ROS, and PSFH elements. First column in Figure Level of History is comparable to column in E&M calculator grid labeled “Overall History.” Compare Figure to HPI, ROS, and PFSH columns on screen.

Figure 12-11: Table of Elements Required for Each Level of History.

Step 12 (cont.) Looking at chart in Figure 12-11, do you see why overall history is not level 1? It is because only ROS has been recorded, and HPI is required for level 1.

Key Component: Examination
Second key component is Physical Examination.

Examination guidelines defined for general multi-system exam and following 10 single-organ systems: Cardiovascular; Ears, Nose, and Throat Eyes; Genitourinary (Female or Male) Hematologic/Lymphatic/Immunologic Musculoskeletal; Neurological Psychiatric; Respiratory Skin

General multi-system examination or single-organ system examination may be performed by any physician, regardless of specialty.

Four levels of examination: Problem Focused: limited examination of affected body area or organ system. Expanded Problem Focused: limited examination of affected body area or organ system and any other symptomatic or related body areas or organ systems.

Four levels of examination (cont.): Detailed: extended examination of affected body areas or organ systems and any other symptomatic or related body areas or organ systems. Comprehensive: general multi-system examination, or complete examination of a single-organ system and other symptomatic or related body areas or organ systems.

See Figure for abridged example of Table of Elements of General Multisystem Examination. Individual elements of examination pertaining to a body area or organ system are identified by bullets. Locate bullets in second column of Figure

You may be familiar with concept of “the number of bullets required to meet a level of E&M coding.” This means how many findings in encounter note correspond to elements in guideline table with bullet characters printed next to them.

Step 13 Grid in E&M calculator window has only one column for Exam component. Locate and click on column labeled “Exam” (Figure 12-13). Pane displaying exam details will open in E&M calculator window. Look at “Summary details for Exam” pane.

Figure 12-13: Exam details of E&M calculator.

Step 13 (cont.) It has three columns labeled “CMS body systems,” “# of bullets,” and “Level 4 Met.” Each row under column labeled “# of bullets” has a pair of numbers. Locate row for Ears, Nose, Mouth, and Throat; you will see numbers 4:6. This means clinician examined four of six elements in that system.

Step 14 Compare your screen with table in Figure You will see screen has five elements with bullets documented in exam (four bullets in Ear, Nose, Mouth and Throat and 1 bullet in Respiratory). Examination is level 1, “Problem Focused Exam,” because there are only five bullets.

Step 14 (cont.) Exam level is not determined by number of findings but by number of bullets satisfied within a system/body area. Findings do not have to be abnormal; normal findings count as well. Think about Auto Negatives feature you used in previous exercises in context of this document guideline.

Key Component: Medical Decision Making
Medical decision making (MDM) refers to complexity of establishing diagnosis or selecting management option as measured by these elements: Number of possible diagnoses or management options that must be considered; this element has four levels.

Medical decision making (MDM) refers to complexity of establishing diagnosis or selecting management option as measured by these elements (cont.): Level determined by number and types of problems addressed during encounter, complexity of establishing a diagnosis, and management decisions that are made by clinician.

Medical decision making (MDM) refers to complexity of establishing diagnosis or selecting management option as measured by these elements (cont.): Level 1: Minimal Level 2: Limited Level 3: Multiple Level 4: Extensive

Medical decision making (MDM) refers to complexity of establishing diagnosis or selecting management option as measured by these elements (cont.): Amount or complexity of medical records, diagnostic tests, or other information that must be obtained, reviewed, and analyzed; four levels for this element:

Medical decision making (MDM) refers to complexity of establishing diagnosis or selecting management option as measured by these elements (cont.): Level 1: Minimal or None Level 2: Limited Level 3: Moderate Level 4: Extensive

Medical decision making (MDM) refers to complexity of establishing diagnosis or selecting management option as measured by these elements (cont.): Risk of significant complications, morbidity or mortality, as well as comorbidities, associated with patient's presenting problems, diagnostic procedures, or possible management options; four levels for this element:

Medical decision making (MDM) refers to complexity of establishing diagnosis or selecting management option as measured by these elements (cont.): Level 1: Minimal Level 2: Low Level 3: Moderate Level 4: High

Step 15 Locate and click on column labeled “Dx/Mgt (Figure 12-15). Dx/Mgt stands for Diagnosis and/or Management Options. Pane in E&M calculator window will display Details for Dx/Mgt pane.

Figure 12-15: Medical decision making—Details for Dx/Mgt.

Step 15 (cont.) Details pane has three columns labeled “Encounter findings,” “Complexity,” and “Prefix.” Complexity column displays level of complexity associated with finding. Prefix column contains a code or abbreviation if finding has a prefix. In this example, finding “ordered fluids” displays letter “O,” which stands for ordered.

Step 16 Remaining columns in E&M calculator window grid are concerned with MDM element of risk. Risk has its own table for calculating level of risk (shown later in Figure 12-18). Locate and click on column labeled “Problem Risk” (Figure 12-16).

Figure 12-16: Medical decision making—Details for Problem Risk.

Step 16 (cont.) E&M calculator window will display “Details for Problem Risk” pane. Details pane has three columns, labeled “Encounter findings,” “Risk,” and “Prefix.” Note that E&M calculator includes column measuring risk of tests, but none were ordered during this exam.

Step 17 Locate and click on column labeled “Mgt Risk” (Figure 12-17). Mgt is software abbreviation for management. E&M calculator window will display “Details for Mgt Risk” pane. Details pane has three columns, labeled “Encounter findings,” “Risk,” and “Prefix.”

Figure 12-17: Medical decision making—Details for Mgt Risk.

Step 17 (cont.) Risk level in this column is “minimal” because there is little risk involved when ordering fluids. Locate and click on button labeled “Hide Details” to return to E&M calculator screen. If you have difficulty locating button, refer to Figure

Step 18 E&M guidelines use a special table for calculating overall level of risk (Figure 12-18). Risk differs from the other two MDM elements in that risk level is highest level of any one column in the table. Table in Figure is used to help determine whether risk of significant complications, morbidity, or mortality is minimal, low, moderate, or high.

Step 18 (cont.) Because the determination of risk is complex and not readily quantifiable, table includes common clinical examples rather than absolute measures of risk. Locate column in E&M calculator window labeled “Overall Risk.” Notice that level of overall risk column is “low,” because that was level of the highest of the three risk elements, Problem Risk.

Determining the Level of Medical Decision Making
Four levels of Medical Decision Making Level 1: Straight forward Level 2: Low Complexity Level 3: Moderate Complexity Level 4: High Complexity Chart in Figure shows level of elements required for each level of medical decision making.

Figure 12-19: Table of elements required for each level of medical decision making.

Step 19 Compare chart in Figure to E&M calculator window. Locate column labeled “Overall MDM,” which is “low” or level 2.

Step 19 (cont.) Looking at columns for individual elements, note that those labeled “Dx/Mgt Options” and “Overall Risk” are also level 2. Even though there is no report for “Complexity of Data,” MDM level is set to highest of two out of three elements.

Other Components: Counseling, Coordination of Care, and Time
Time is considered the key or controlling factor to qualify for particular level of E&M services only when counseling or coordination of care dominates more than 50% of the encounter.

Step 20 In center of E&M calculator window are two fields related to time. First is check box used to indicate that counseling (or coordination of care) exceeded 50% of face-to-face time for visit. Second field used to enter total face-to-face time.

Step 20 (cont.) Face-to-face time incorporates total time both before and after visit. E&M calculator allows you to record amount of face-to-face time even when you are not using counseling time as a factor. It is a good practice to record face-to-face time for each encounter.

Step 20 (cont.) Click on down arrow button in field labeled “Total face-to-face or Floor time;” select 15 minutes from drop-down list (Figure 12-20). This will not change E&M code because time does not become a factor until it is more than half of face-to-face time.

Figure 12-20: Counseling and face-to-face time dropdown list.

Putting It All Together
Step 21 Chart in Figure shows E&M codes used for category of outpatient office visits. First column in Figure is CPT-4 code. Second column indicates if code is for new or established patient. Note that there are two groups of codes listed. First five codes are for new patients; five different codes are listed for established patients.

Figure 12-21: Relationship of key component levels determines E&M code.

Step 21 (cont.) Third column labeled “# of Key Elements Met” indicates how many key components determine E&M code. Blue, green, and lavender columns list levels of three key components: History, Exam, and Medical Decision Making. Level numbers under each key component are derived from individual tables in sections you have just completed.

Step 21 (cont.) Tables are: History—Figure 12-11 Exam—Figure 12-14 MDM—Figure 12-19 Final column lists number of minutes per type of visit used by E&M calculator.

Evaluating Key Components
E&M code level is determined by lowest level of key components considered. Scan down third column of Figure 12-21; note that number of key components for new patient is “All 3.” Notice for established patients it is “2 of 3.”

For established patient, the two key components with highest levels are considered and lowest level of the two determines E&M code. Compare E&M codes for new patient. Locate section of table in Figure for new patients.

What E&M code would be used when History is level 1 (Problem Focused), Exam is level 2 (Expanded Problem Focused), and MDM is level 2 (Low Complexity)? If you answered 99201, you are correct. E&M code for new patients is determined by all three elements.

Level of each of the key components is a combination of elements. To qualify for a given level of history, quantity and types of HPI, ROS, and PFSH must be met. To qualify for a given level of exam, number of “bulleted” items in appropriate number of body systems must be met.

Level of each of the key components is a combination of elements (cont.). To qualify for a given level of medical decision making, two of the three elements (number of diagnosis, amount of data, risk assessment) must be either met or exceeded.

Step 22 Click Cancel button to close E&M calculator window. You may exit Student Edition software without printing encounter this time because you have not made any changes to the note.

EHR Coding and Reimbursement

Similar presentations

Presentation on theme: "EHR Coding and Reimbursement"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

EHR Coding and Reimbursement

Similar presentations

Presentation on theme: "EHR Coding and Reimbursement"— Presentation transcript:

Similar presentations

About project

Feedback