1. Briefing: Evaluation & Management - The Basics Date: 20 March 2007
Time: :50
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2. Principles of Documentation Key Componenents 1995 vs. 1997
Objectives
Principles of Documentation
Key Componenents
1995 vs. 1997
The Differences – Patients and Services
Review
Questions
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3. Medical Record Documentation
The medical record should be complete and legible
The documentation of each patient encounter should include:
Reason for the encounter & relevant history, physical examination findings and prior diagnostic test results
If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred
Past and present diagnoses should be accessible to the treating and/or consulting physician
Appropriate health risk factors should be identified.
The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented
The CPT and ICD-9-CM codes reported should be supported by the documentation in the medical record
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4. Medical Record Documentation
DoD uses 1995 vs.1997 Guidelines
Medical record facilitates
The ability to evaluate and monitor
Communicate and provide continuity of care
Accurate and timely claims review and payment
Workload capture
Utilization review and quality of care evaluations
Collection of data
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5. Medical Record Documentation
What Payers Want & Why
The site of service
The medical necessity and appropriateness of the diagnostic and/or therapeutic services provided
That services provided have been accurately reported
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6. Medical Record Documentation
What MHS Wants and Why
The site (MEPRS) of service
The provider of service
The medical necessity and appropriateness of the diagnostic and/or therapeutic services provided
That services provided have been accurately reported
Let me repeat that last bullet….. That the services have
been accurately reported
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7. Medical Decision Making Additional Components Include Counseling
Three Key Components
History
Examination
Medical Decision Making
Additional Components Include
Counseling
Coordination of care
Nature of presenting problem
Time - Key or controlling factor when visit consists predominantly of counseling and coordination of care
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8. Require all 3 Key Components:
Three Key Components
Require all 3 Key Components:
New Patient Office or Outpatient Services
Initial Office or Outpatient Consultation Services
Initial Observation Care Services
Initial Hospital Care Services
Observation or Inpatient Care Services Admit/Discharge Same Date
Initial Inpatient Consultation Services
Emergency Department Services
Require 2 of 3 key Components:
Established Patient Office or Outpatient Services
Subsequent Hospital Care Services
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9. Expanded Problem Focused Detailed Comprehensive
Three Key Components
History
Problem Focused
Expanded Problem Focused
Detailed
Comprehensive
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10. History of Present Illness (HPI) Review of Systems (ROS)
Three Key Components
History
Chief Complaint (CC)
History of Present Illness (HPI)
Review of Systems (ROS)
Past Family, Medical and Social History (PFSH)
A single statement may be used in both areas negating
the need for a physician to repeat themselves.
Notation made in the HPI follows logically the system
was reviewed and should be given credit in the ROS.
Example: Patient presenting with abdominal pain, complains of nausea
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11. The medical record should clearly reflect the chief complaint Example:
Three Key Components
Chief Complaint (CC)
The medical record should clearly reflect the chief complaint
Example:
“Follow-up for hypertension”
“Complaining of left ear pain”
“Annual physical exam”
Chief Complaint easily inferred
Patient complaining of “productive cough, nasal drainage, and headache.”
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12. History of Present Illness (HPI):
Three Key Components
History of Present Illness (HPI):
Location – arm, ankle, throat, abdomen)
Quality – sharp, shooting, aching, fullness
Severity – mild, or on a scale of 1 to 10
Duration – started three days ago, yesterday
Timing – after eating, in the morning
Context – pain happens while standing, “when I move like this”
Modifying factors – better when heat is applied
Associated signs and symptoms – coughing causes chest pain
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13. Three Key Components Brief HPI
Example: Patient complaining of right arm pain (location) for three days (duration)
Example: Patient seen today for COPD, stable, and well controlled diabetes mellitus type II (2 chronic conditions)
Note: 95 vs. 97 Guidelines
Extended HPI
Example: Patient complaining of a sharp (quality) left arm (location) pain for two days (duration), feels better when heat is applied (modifying factor)
Example: Patient here today for a follow-up of stable hypertension, controlled hypothyroidism and moderately controlled diabetes mellitus, type I (three chronic conditions)
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14. Review of Systems (ROS):
Three Key Components
Review of Systems (ROS):
Constitutional symptoms (fever, weight loss, etc.)
Eyes (blurred vision, contacts, strain)
Ears, Nose, Mouth, Throat (nose bleed, ear pain)
Cardiovascular (Edema, syncope, palpitations)
Respiratory (SOB, cough, chest pain)
Gastrointestinal (Appetitive, bloating)
Genitourinary (Frequency, burning, hematuria)
Musculoskeletal (Joint pain, swelling or stiffness)
Integumentary (Skin and/or breast) – (Rashes, itching, peeling)
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15. Review of Systems (ROS): Neurological (Headaches, tremors, seizures)
Three Key Components
Review of Systems (ROS):
Neurological (Headaches, tremors, seizures)
Psychiatric (Attitude, insomnia)
Endocrine (Excessive hunger or thirst, thyroid problems)
Hematologic/Lymphatic (Anemia, bruising or bleeding problems)
Allergic/Immunologic (Allergy symptoms or reactions, immune problems)
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16. Review of Systems (ROS) Problem Pertinent Extended Complete
Three Key Components
Review of Systems (ROS)
Problem Pertinent
Extended
Complete
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17. Review of Systems (ROS)
Three Key Components
Review of Systems (ROS)
Problem Pertinent – directly related to the HPI
Example: A patient complaining of ear pain denies history of otitis media (ENT)
Extended – directly related to the HPI and additional systems
Example: A patient complaining of ear pain denies any history of ottis media, dizziness, or nausea
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18. Review of Systems (ROS)
Three Key Components
Review of Systems (ROS)
Complete ROS – directly related to the HPI plus all additional body systems
Example: A patient complaining of abdominal pain and chest pain reports no fever or chills (Constitutional), no respiratory (Respiratory), no previous cardiac problems (Cardiovascular), minor abdominal pain in the past (Gastrointestinal), all other systems negative
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19. Past Family and/or Social History (PFSH)
Three Key Components
Past Family and/or Social History (PFSH)
Past history – illness, injuries, operations, may also include, immunizations, allergies
Family history – hereditary diseases or current health status of family members
Social history – age appropriate review of past and current activities and may include employment history, sexual history, extent of education
Interval History – any changes since last seen by physician
Example: “stopped smoking,” “appetite has decreased”
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20. Past Family and Social History (PFSH): Pertinent PFSH
Three Key Components
Past Family and Social History (PFSH):
Pertinent PFSH
At least one specific item from any of the three history areas must be documented for a pertinent PFSH
Complete PFSH
At least one specific item from two of the three history areas must be documented for a complete PFSH, established patient
At least one specific item from each of the three history areas must be documented for a complete PFSH, new patient
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21. Three Key Components Brief (1-3) None Prob pert One PROBLEM FOCUSED
HPI (history of present illness)
_Location _Severity _Timing _Mod/Fact _Quality _Duration _Context _Assoc S/S
Brief
(1-3)
Extended
(4 or more)
ROS (review of systems)
_Const _ENT _Endo _Eyes _GI _GU _Hem/Lymph _Integ/Skin _Resp _Card/Vasc _Musculo _Neuro _All/Lymph _Psych _All others negative
Pertinent to problem
(1 system)
(2-9 sys)
Complete
(10 or more sys) or
(All others neg)
PFSH
_Past
_Family
_Social
Established/
Subsequent
None
Two or three
New/Initial
Prob pert
One- Two
Three
Circle the entry farthest to the right for each history area. To determine history level, draw a line down the column with the circle farthest to the left
EXP PROB
FOCUSED
DETAILED
COMPREHENSIVE
Brief
(1-3)
None
Prob pert
One
PROBLEM
FOCUSED
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22. Three Key Components Examination
Problem Focused – a limited examination of the affected body area or organ system
Expanded Problem Focused – a limited examination of the affected body area or organ system and any other symptomatic or related body area(s) or organ system(s)
Detailed – an extended examination of the affected body arear(s) or organ system(s) ans any other symptomatic or related body area(s) or organ system(s)
Comprehensive – a general multi-system examination, or complete examination of a single organ system and any other symptomatic or related body area(s) or organ system(s)
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23. General Multi-System Exam Single Organ System Exam Cardiovascular Exam
Three Key Components
Examination
General Multi-System Exam
Single Organ System Exam
Cardiovascular Exam
Ear, Nose and Throat Exam
Eye Genitourinary Exam (Breaks out male and female)
Hematologic/Lymphatic/Immunologic Exam
Musculoskeletal Exam
Neurological Exam
Psychiatric Exam
Respiratory Exam
Skin Exam
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24. Three Key Components Exam – Body areas Exam – Organ systems
Head, including the face
Neck
Chest, including the breasts and axillae
Abdomen
Genitalia, groin, buttocks
Back
Each extremity
Exam – Organ systems
Eyes
Ears, nose, mouth, and Throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
Neurological
Psychiatric
Hematologic/Lymphatic
Immunologic
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25. 1995 vs. 1997 1995 criteria (Examination) Body areas:
Head, including the face
Neck
Chest, including breasts and axillae
Abdomen
Genitalia, groin, buttocks
Back/Spine
Each extremity 
Organ systems:
Constitutional
Eyes
Ears, nose, mouth and throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
Neurologic
Psychiatric
Hematologic/lymphatic/immunologic 
1997 criteria (Examination) Organ systems/Body areas combined:
Constitutional
Cardiovascular
Chest/Breasts
Eyes
Ears, nose, mouth, and throat (ENMT)
Gastrointestinal
Genitourinary-Male
Genitourinary-Female
Integumentary/Skin
Lymphatic
Musculoskeletal
Neck
Neurologic
Respiratory
Psychiatric
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26. Three Key Components Examination
Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented. A notation of “abnormal” without elaboration is insufficient
Abnormal or unexpected findings of the examination of any asymptomatic body area(s) or organ system(s) should be described
A brief statement or notation indicating “negative” or “normal” is sufficient to document normal finding related to unaffected area(s) or asymptomatic organ systems(s)
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27. General Multi-System Exam
Three Key Components
General Multi-System Exam
Problem Focused – one to five elements identified by a bullet in one or more organ system(s) or body area(s)
Expanded Problem Focused - at least six elements identified by a bullet in one or more organ system(s) or body area(s)
Detailed – at least six organ systems or body areas. For each system or area selected, performance and documentation of at least two elements identified by a bullet is expected Alternatively, a detailed examination may include performance and documentation of at least twelve elements identified by a bullet in two or more organ systems or body areas
Comprehensive – should include at least nine organ systems or body areas. For each system/area selected, all elements of the examination identified by a bullet should be performed, unless specific directions limit the content of the examination. For each area/system, documentation of at least two elements identified by a bullet is expected
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28. Single Organ System Exams
Three Key Components
Single Organ System Exams
Problem Focused – one to five elements identified by a bullet, whether in a box with a shaded or unshaded border
Expanded Problem Focused – at least six elements identified by a bullet, whether in a box with a shaded or unshaded border
Detailed – examinations other than the eye and psychiatric examinations should include performance and documentation of at least twelve elements identified by a bullet, whether in a box with a shaded or unshaded border
Eye and psychiatric examinations should include the performance and documentation of at least nine elements identified by a bullet, whether in a box with a shaded or unshaded border
Comprehensive – should include all elements identified by a bullet, whether in a shaded or unshaded box. Documentation of every element in each box with a shaded border and at least one element in each box with an unshaded border is expected
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29. 1995 vs. 1997 Exam – 1995 vs. 1997 1995 guidelines 1997 guidelines
Prob. focused: 1 body area or organ system
Exp. Prob. focused: 2-7 areas or systems (limited exam)
Detailed: 2-7 areas or systems (extended exam)
Comprehensive: 8 or more areas or systems
1997 guidelines
Prob. focused: 1-5 elements
Exp. Prob. Focused: 6-12 elements
Detailed: at least 12 elements in 2 or more systems
Comprehensive: At least two bullets in each system
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30. Medical Decision Making (MDM) Straightforward Low Complexity
Three Key Components
Medical Decision Making (MDM)
Straightforward
Low Complexity
Moderate Complexity
High Complexity
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31. Complexity and Medical Decision Making:
Three Key Components
Complexity and Medical Decision Making:
Amount (number) of diagnoses or treatment options
And/or complexity of data to be reviewed
Risk of complications and/or morbidity or mortality
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32. Complexity and Medical Decision Making:
Three Key Components
Complexity and Medical Decision Making:
● Number of Diagnoses or Management Options
Assessment, clinical impression, or diagnosis
Self-limited or minor: stable, improved or worsening
Est. problem: improved, well controlled, resolving or resolved; or inadequately controlled, worsening, or failing to change as expected
New problem: no additional work up planned /additional work up planned
Initiation of, or changes in, treatment
Referrals, consultations requested or advice sought
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33. Complexity and Medical Decision Making:
Three Key Components
Complexity and Medical Decision Making:
Amount and/or Complexity of Data to Be Reviewed
Diagnostic test/procedure ordered, planned, scheduled, or performed
Review lab, radiology and/or other diagnostic tests.
Acceptable documentation: “WBC elevated” or “chest x-ray unremarkable”
Report signed and dated
Obtain old records/obtain additional history from other sources
“Old records reviewed” or “additional history obtained from family” without elaboration is insufficient
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34. Complexity and Medical Decision Making:
Three Key Components
Complexity and Medical Decision Making:
Risk of Significant Complications, Morbidity, and/or Mortality
Comorbidities/underlying diseases or other factors
Surgical or invasive diagnostic procedure ordered, planned or scheduled
Surgical or invasive diagnostic procedure performed
Referral or decision to perform urgent surgical or invasive diagnostic procedure
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35. Documentation of an Encounter Dominated by
Three Key Components
Documentation of an Encounter Dominated by
Counseling or Coordination of Care
Should include the total length of time of the encounter and the record should describe the counseling and/or activities to coordinate care
Three questions must be answered “yes” to base your visit on time
Does the documentation reveal total time?
Does documentation describe the content of counseling or coordinating care?
Does documentation reveal that more than half of time was counseling or coordinating care? (Are the History, Exam, and Medical Decision Making documented?)
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36. The Differences New Patient:
CPT describes a New Patient as one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years
Established Patient:
CPT describes an Established Patient as one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years
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37. The Differences Follow-Up Visit:
A patient, whether new or established in your clinic, who is being seen for an illness or injury for which they have previously been seen and who has not yet been released from care
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38. The Differences Consult vs. Referral
Consultation: Services provided by a physician whose opinion or advice is requested by another provider or appropriate source
Referral: Transfer of the total or partial/specific care of a patient from one physician to another
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39. A clear, concise medical record E/M levels based on the components
Review
A clear, concise medical record
E/M levels based on the components
Requirement for levels/services
Validate services rendered in the event of an audit
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40. E&M – The Basics
Resources:
Ingenix Coding Lab: Understanding E&M Coding
CMS 1995 Documentation Guidelines for Evaluation and Management Services
CMS 1997 Documentation Guidelines for Evaluation and management Services
2007 CPT by AMA