1. PHYSICIAN NETWORK SERVICES
E&M overview
Physician Network Services
Coding Compliance Education

2. E&M overview Chief Complaint History:
Should be clearly stated in every encounter
History:
HPI: - History of Present Illness:
Location, Duration, Quality
Context, Modifying Factors, Associated signs & Symptoms
ROS: - Review of Systems:
It is a Q&A format
Relevant to the chief complaint
ROS reviewed and negative, as long as positive/negative pertinent ROS are documented

3. Documentation Example
E&M overview
HPI: - History of Present Illness:
Element
Definition
Documentation Example
Location
Place, whereabouts
Pain in groin
Quality
Characteristics, grade
Burning pain in groin
Severity
How hard it is to endure
Hx of mild burning pain in groin become more intense, and/or pain scale
Duration
Length of time
Hx of mild burning pain in groin become more intense for last 2 wks
Timing
Regulation of occurrence
Intermittent groin pain, more intense and frequent last 2 wks
Context
Circumstances of occurrence
Hx of groin pain …..since the patient bent down to pick up trash
Modifying Factors
Altering elements; condition
Hx of groin pain ….. Has been taking Motrin 800 mg bid with some relief
Signs/Symptoms
Significantly related to the presenting problem, CC
Hx of groin pain …. States he had a feeling of bowel and bladder urgency twice this week, OR no other sx noted

4. E&M overview ROS: - Review of Systems:
The following systems are recognized
Constitutional
Musculoskeletal
Eyes
Integumentary
Ears, Nose, Mouth, Throat
Neurological
Cardiovascular
Psychiatric
Respiratory
Endocrine
Gastrointestinal
Hematologic/Lymphatic
Genitourinary
Allergic/Immunologic

5. E&M overview PFSH – Personal Family Social History Past History
Past experiences with illnesses, operations, injuries, treatments, current medication, allergies, etc.
Family History
Family history of illness and diseases; hereditary
Social History
Age appropriate review of past and current activities; drugs/alcohol, marital status, occupation, exercise, etc.

6. E&M overview
PFSH
Terms not acceptable under the E&M documentation guidelines are:
Non-contributory, non-pertinent and negative.
Could be acceptable if they are followed by a statement such as:
“PFS history was reviewed and was not contributory or pertinent to the chief complaint or negative for any medical or social problems”.

7. Expanded Problem Focused
E&M overview
History Determination
E/M Level
Type of History
Needed Elements
99201 / 99212
Problem Focused
HPI: 1-3 elements
ROS: None
PFSH: None
99202 / 99213
Expanded Problem Focused
ROS: 1 Pertinent
99203 / 99214
Detailed
HPI: >4 or 3+ chronics
ROS: 2-9
PFSH: 1 Pertinent
99204/99205/99215
Comprehensive
ROS: 10+
PFSH: Initial-3 Est-2

8. E&M overview Physical Examination
Following the 1995 E&M documentation guidelines
Includes organ systems and body areas
The physical examination should support the medical necessity stated by the chief complaint
Volume of documentation will not necessarily support the level of service billed

9. E&M OVERVIEW Body Areas and Organ Systems Body Areas Organ Systems
Head and face
Neck
Chest, including breasts and axillae
Abdomen
Genitalia, buttocks and groin
Back and spine
Each extremity
Constitutional
Eyes
Ears, nose mouth and throat
Cardiovascular
Respiratory
Gastroenterology
Genitourinary
Musculoskeletal
Skin
Neurologic
Psychiatric
Hematologic, lymphatic, immunologic

10. Organ Systems/ Body Areas
E&M overview
Examination
E/M Level
Type of Exam
Organ Systems/ Body Areas
99201 / 99212
Problem Focused
1 Organ System /
Body Area
99202 / 99213
Expanded Problem Focused
2-4 Organ Systems/ Body Areas
99203 / 99214
Detailed
5-7 Organ Systems/ Body Areas
99204/
Comprehensive
8 Organs Systems Only

11. E&M overview Medical Decision Making: Problem/diagnosis categories
New and established problems different complexity
Data:
Labs, radiology, procedures ordered and/or reviewed
Independent review of tests
Decision to request records
Review and summary of old records
Risk:
Presenting problem
Diagnostic procedure
Management options selected

12. E&M overview MDM Determination E/M Level Type of MDM Needed Elements
99201 / 99202/99212
Straight-Forward
Dx: 0-1 point
Data: 0-1 point
Risk: Minimal
99203 / 99213
Low Complexity
Dx: 2 points
Data: 2 points
Risk: Low
99204/ 99214
Moderate Complexity
Dx: 3 points
Data: 3 points
Risk: Moderate
99205/ 99215
High Complexity
Dx: 4 or more points
Data: 4 or more points
Risk: High

13. Expanded Problem Focused
Bring It Together
Code Determination- Meet all 3 requirements
E/M Level
New
History
Exam
MDM
99201
Problem Focused
Straight-Forward
99202
Expanded Problem Focused
99203
Detailed
Low
99204
Comprehensive
Moderate
99205
High
You cannot code higher than your lowest met requirement

14. Expanded Problem Focused
Bring It Together
Code Determination- Meet 2 of 3 requirements
E/M Level
Est
History
Exam
MDM
99212
Problem Focused
Straight-Forward
99213
Expanded Problem Focused
Low
99214
Detailed
Moderate
99215
Comprehensive
High
You cannot code higher than your lowest met requirement

15. E&M overview Billing based on time
A level of service can be determined based on time if more than 50% of the visit is spent coordinating care (inpatient only), and/or counseling (face-to-face)
The total time must be recorded as well as a statement that more than 50% of the visit was counseling (face-to-face) or coordination of care (inpatient only)

16. E&M overview Billing based on time Examples
More than half of this 30 minute visit was spent in counseling discussing ……
Spent more than half of this 45 minute visit discussing the management of John’s asthma at school. Obtained mother’s permission to discuss with school nurse and physical education instructor. Given prescriptions for inhalers to remain at school, home, and day care. Discussed plan for severe SOB
Level of service: (New patient) or (Established patient)
10/15 minutes spent counseling patient on….
Discussed the advisability of ENT referral for the evaluation of recurring tonsillitis. Mom agrees that more aggressive treatment or surgery should be explored
Total time: 15 minutes Counseling: 10 minutes
Level of service: (established patient)

17. E&M overview Level 5 To bill a level 5 for a new or established visit
The E&M documentation guidelines must be met
Meet the medical necessity and
The condition(s) should have the acuity and high risk to pose a threat to life

18. E&M overview Most common findings Incomplete documentation
Missing Chief Complaint
A component of the E/M was not documented (New patients)
Provider’s signature is missing or illegible
Capturing of Review of Systems
Physical Examination and Medical Necessity
Diagnosis (specificity and priority)
Missing Documentation of Orders
Proper documentation for level 5
Preventive vs. Sick Visits

19. E&M overview
QUESTIONS?

20. DOCUMENTATION GUIDELINES
Non-Physician Provider Practice Guidelines
Direct billing: a service is provided entirely by the mid-level provider (i.e. new problem, physician is not in the office suite, new patient).
Incident-to billing: is billing under the supervising physician’s name as long as the mid-level provider is seeing an existing patient for an established problem, and the supervising physician has established a plan of care and he/she is in the office suite.

21. DOCUMENTATION GUIDELINES
Incident-to services
Medicare “incident-to” supervision guidelines must be met:
The physician must be present in the office suite providing direct supervision.
The physician must see all new patients and establish a plan of care.
The Non-Physician Provider follows established patients and provides services that are part of the physician’s plan of care for the patient.

22. DOCUMENTATION GUIDELINES
Incident-to services
Medicare “incident-to” supervision guidelines must be met:
The physician sees established patients when they present with new problems.
The physician provides subsequent services that reflect his/her continuing active participation in and management of the course of treatment.

23. DOCUMENTATION GUIDELINES
When Non-Physician Provider bills Medicare under his/her own billing number, he/she must document the service provided and sign the documentation indicating his/her responsibility for the service
Billing for other insurance carriers
When Non-Physician Provider bills under the provider number of the supervising physician, the physician may be required to co-sign the patient services indicating they accept the responsibility for the service.

24. DOCUMENTATION GUIDELINES
INCIDENT-TO DECISION MAKING
NO YES
NO YES NO
Non-physician practitioner provides services
Was the physician in the suite?
Use the non-physician practitioner’s provider number
Was the problem new?
This service should qualify for incident-to billing
Allow fees at 85% of the fee schedule
Use the physician’s provider number on the claim

25. DOCUMENTATION GUIDELINES
Signature requirements
Situation
Performed by:
Signature requirement:
Ancillary Staff
Must be signed by supervising provider
Incident to
NPP
(Non-Physician Practitioner)
May be signed by the NPP or the supervising physician
Split/Shared:
Office/Clinic setting
Must meet incident-to
NPP and Physician
Hospital Inpatient/
Outpatient/ED setting
Must be signed by billing provider

26. DOCUMENTATION GUIDELINES
QUESTIONS?