1. Evaluation & Management Coding and Documentation 101 – the basics
Coding and Documentation 101-SAC
3/31/2017
Evaluation & Management Coding and Documentation 101 – the basics
Stephanie Ann Call, MD MSPH
VCU Internal Medicine Training Program
The Practice of Medicine Series

2. Learning Objectives
At the end of this session, residents will be able to
describe what medical documentation facilitates
identify three key components in selecting the levels of E/M services
select the appropriate level of an E&M service for a new and established patient in either the outpatient or inpatient setting
identify resources for compliance

3. Evaluation and Management (E&M) Documentation
One of most commonly billed procedures
May be billed for new or established patients
Includes office, hospital, nursing home visits, consultations, phone and overall management, ICU care, discharge planning
1995/1997 Medicare guidelines – can use both
Medicare Physician Guide: A Resource for Residents, Practicing Physicians, and Other Health Care Professionals –
Chapter 5 – E&M Documentation
Great references and resource lists

4. Why document? Medical /legal issues
To tell the story of the patient – communicate to others
To have the opportunity for reimbursement for the service provided
“E&M documentation is the pathway that translates a physician’s patient care work into the claims and reimbursement mechanism”
Medicare … “if it is not documented, it wasn’t done.”

5. What does documentation facilitate?
The ability to evaluate and plan the patient’s treatment
The ability to monitor patients health over time
Communication and continuity of care among healthcare professionals
Appropriate utilization review and quality of care evaluations
Collection of data for research and evaluation

6. General Principles of Documenting
Legibility – all documents MUST be legible
Defined as easily read by peers (other clinicians)
Required information:
Patient name, MR, date of service on each page
Date AND time (for inpatient)
Reason for encounter, relevant history, PE findings
Review of lab, x-ray data, other ancillary services
Assessment, clinical impression or diagnosis
Plan of care (including d/c plan if appropriate)
Legible identity of observer (authenticated)

7. General Principles of Documenting
If not documented, rationale for ordering diagnostics or ancillary services should be easily inferred
Past and present diagnoses should be accessible to physician – can be in chart
Appropriate health risk factors should be identified
Patient progress, response to and changes in treatment should be documented

8. General Principles of Documenting
Documentation should support the intensity of the evaluation or treatment, including thought processes and complexity of medical decision making
All entries should be dated and authenticated by physician signature
CPT and ICD-9-CM codes reported should reflect documentaton in the medical records

10. Components of an E&M service
Seven components use to define level of E&M service (exceptions to rule if predominantly counseling or coordination of care)
Key components
History
Examination
Medical Decision Making
Contributory components
Counseling
Coordination of Care
Nature of Presenting Problem
Time

11. Components of an E&M service
Seven components use to define level of E&M service (exceptions to rule if predominantly counseling or coordination of care)
Key components
History
Examination
Medical Decision Making
Contributory components
Counseling
Coordination of Care
Nature of Presenting Problem
Time
Used in selecting level of E/M service (some exceptions)

12. Determining Level of Service
Table to determine appropriate level of service based on documentation (as a reflection of complexity of care provided) in three key component areas
Each key component has graded levels
Different criteria for new patient vs established
Different criteria for inpatient vs outpatient
Procedure codes identified by tables – determine the level of service and amount of reimbursement (99201, 99202, 99203, etc)

13. Key Components
History
Physical Examination
Decision Making

14. History – elements (4) Chief complaint (CC)
Required for ALL levels of E/M coding
Reason for encounter
If follow up … “follow up for …”
NOT “routine f/u”
Must be documented by resident, NP, PA or attending
History of Present Illness (HPI)
Review of Systems (ROS)
Past, Family, Social History (PFSH)

15. History HPI elements Level of History Location Quality Severity
Duration
Timing
Context
Modifying Factors
Associated Signs and Symptoms
Level of History
Brief – status of 1-2 chronic conditions or 1-3 above
Extended – status of 3 chronic conditions or 4+ above

16. History Review of Systems (ROS)
Do not have to write a notation for all systems
Document the positive and pertinent negatives
“all other systems negative” – include number checked
Should have “usual” template
Level for ROS based on number of systems
Problem pertinent – related to problem only +/-
Extended – positive and pertinent responses for 2-9 systems
Complete ROS is 10+
ROS
Constitutional, eyes, ears, nose, throat, cv, respiratory, gi, gu, musculoskeletal, skin, neuro, psych, endo, heme, lymph, allergic, immunological

17. History Past, Family and Social (PFSH)
Past History – review of patient’s past illnesses, injuries, treatments
Includes major illness, injury, operations, prior hospitalizations, current meds, allergies
Social History – age appropriate review of past and current activities
May include marital status, living situation, employment and occupational hx, use of drugs/alcohol/tobacco, ed
Family History – review of medical events in family

18. History
PFSH
Pertinent – review of history area directly related to problem identified in HPI – at least one item from any of P, F, S
Complete – review of 2-3 PFSH areas if f/u visit, 3/3 areas if new patient

19. History – E/M levels Problem Focused Expanded Problem Focused Detailed
CC, 1-3 HPI elements
Expanded Problem Focused
CC, 1-3 HPI, problem pertinent system review (>1)
Detailed
CC, 4+ HPI, problem pertinent ROS additional ROS, pertinent PFSH (1 element)
Comprehensive
CC, 4+ HPI, complete ROS (10+), complete PFSH

20. Problem Pertinent >1
History
Type of History
HPI
ROS
PFSH
Problem Focused
Brief
N/A
Expanded Problem Focused
Brief
Problem Pertinent >1
Detailed
Extended
Extended
Pertinent
Comprehensive
Extended
Compete (10+)
Complete 2/3 or 3/3*

21. Exam
Organ systems
For a general multi-system exam
Body areas

22. Exam – Organ Systems Vital Signs, General Symptoms Eyes ENT CV
Respiratory GI GU
Musculoskeletal
Skin
Neurological
Psychiatric
Heme/Lymph/Immuno

23. Exam – Body Areas Head/face Neck Breast/Axillary Abdomen Genitalia
Back/spine
Extremity

24. Exam
Document specific abnormal and relevant negative findings of affected or symptomatic area
Document abnormal or unexpected findings of unaffected or asymptomatic areas
“abnormal” is insufficient
Templates ok
Reference cards, review sheets

25. Exam – levels (see p81 guide)
Problem focused
Limited to affected body area or organ system (1-6 elements)
Expanded Problem Focused
Affected system plus other symptomatic or related (6)
Detailed
Extended exam of affected area and other symptomatic or related organ system
Comprehensive
Multisystem exam (8-12) or complete single system

26. Medical Decision Making

27. Medical Decision Making - tips
TELL THE STORY
The medical record must clearly support all diagnoses reported on the claim
Document impressions, diagnoses, tests ordered and/or reviewed AND the plan of care
What is the complexity of care for this patient AT THIS TIME?
Is the patient improved, resolved, unresponding?

28. Medical Decision Making
Complexity of establishing a diagnosis
Four types/levels – guided by …
The number of diagnoses or management options
The amount or complexity of data ordered or reviewed
The risk of complications and morbidity/mortality

29. Medical Decision Making
4 levels
Straightforward
Low Complexity
Moderate Complexity
High Complexity
3 subcomponents
Diagnoses and Management Options
Amount and Complexity of Data
Risk of Complications

30. Decision Making
To qualify for a specific level of Decision Making, 2 of the 3 elements listed for that specific category must be met or exceeded
Diagnosed problems less complex than undiagnosed
Consider
How many diagnostic tests ordered
Did you request a consult

31. Diagnoses and Management Options
For established diagnosis
Improved, resolved, unresponding
If diagnosis not established
Possible, probable, rule out
Document treatment plan
Include medication changes
Therapies
Patient instructions, nursing instructions

32. Amount and complexity of data
Review and/or order of clinical lab and XR tests
Review and/or order of diagnostic tests
XR, scans, nuclear med, cardiac cath, echo, ekg, eeg, non-invasive vasc, PFTs
Document review of old records
Document information from family or caretaker
Summarize relevant findings, if any
If not, document fact that reviews done

33. Risk of complication
Minimal
Low
Moderate
High

34. Documenting Risk See tables on “risk” Make sure to document
Co-morbidities
Underlying diseases
Other factors increasing risk

35. Medical Decision Making
MDM - Level
Dx/Mgmt
Data
Risk
Straight-forward
Minimal < 2 elements
Minimal/none < 1 element
Minimal
Low
Limited elements
Limited elements
Moderate
Multiple elements
Multiple elements
High
Extensive > 7 elements
Extensive > 4 elements

36. What code do I choose?
Step 1: Is the patient New or Established, Inpatient or Outpatient?
New = 3 key components
Established = 2 of 3 key components
Step 2: What level of History and Exam was performed?
Use reference card for definitions
Step 3: Review the 3 subcomponents for Medical Decision Making
‘meets or exceeds’ is issue

37. What code do I choose?
Step 4: Compare your assessments against the requirements for a given level of service
May not match exactly
‘meets or exceeds’ is key phrase

38. New and Established Patients
3 of 3 Key Components
New patient office
Initial Inpatient Admission
Initial Consultation
2 of 3 Key Components
Established Office
Subsequent Inpatient care

39. Time
Choose code based on face-to-face time with the patient when OVER 50% of the visit was spent in counseling
Document the total time spent with the patient
Document the total time spent in counseling
Document the content of the counseling, and
Choose the level of E/M by the total amount of time

40. Other E&M Issues Consultations Incident to Shared visits
NPs, PAs, midwives, Clinical Nurse Specialists
Shared visits
Involves physician and non-physician practitioner
Prolonged services
Critical Care
Teaching Physicians (including GE exemption codes)

41. Learning Objectives At the end of this session, residents will
Be able to describe what medical documentation facilitates
Be able to identify three key components in selecting the levels of E/M services
Be able to select the appropriate level of an E&M service for a new and established patient in either the outpatient or inpatient setting
Be able to identify resources for compliance