1. Evaluation & Management Services

2. E/M Coding Key components Contributory factors History
Physical examination
Medical Decision making
Contributory factors
Nature of the presenting problem
Medical Necessity drives code selection
Extent of counseling
Coordination of care
Time

3. E/M Guidelines Medicare and Commercial Insurance Medicaid
CMS 1995 and 1997 E/M guidelines
Use either set
1997 approved by AMA
Medicaid
Does not use ‘95 or ‘97 guidelines
Uses AMA guidelines found in the CPT book
E/M Service Guidelines section in “Instructions for selecting a Level of E/M Service”

4. Medical Necessity
A service that is reasonable and necessary for the diagnosis and treatment of illness or injury, or to improve the functioning of a malformed body member
Government definition

5. History Definitions Chief complaint (CC)
Reason for the visit
History of present illness (HPI)
Chronological review of condition/complaint
Review of systems (ROS)
Inventory of systems through questions
Past, Family, Social, History (PFSH)

6. History Problem Focused Detailed
Chief Complaint  Chief Complaint
Brief HPI (1-3)  Extended HPI (4 or status of
No ROS chronic/inactive)
No PFSH  Extended ROS (2-9)
Expanded Problem  Pertinent PFSH (1)
Focused Comprehensive
Problem pertinent ROS (1) chronic/inactive)
No PFSH  Complete ROS (10)
ALL 3 elements must be  Complete PFSH (2 or 3
met: HPI,ROS,PFSH based on category of E/M)

7. CPT History Guidelines (Medicaid)
Problem focused: CC; brief HPI
Expanded problem focused: CC; brief HPI, problem pertinent ROS
Detailed: CC; extended HPI, problem pertinent ROS extended to include a review of limited number of additional systems; pertinent PFSH directly related to the patient’s problems
Comprehensive: CC; extended HPI, ROS which is directly related to the problem(s) identified in the HPI plus a review of all additional body systems; complete PFSH

8. History Example CC - Vaginal discharge
HPI - New patient is complaining of a white vaginal (location) discharge for the past 2 days (duration) with a heavier flow in the morning (timing). There is no change with Monistat (modifying factor).
ROS - Patient denies itching (integumentary), burning with urination (genitourinary) or fever (constitutional).
PFSH - Patient has had 2 sexual partners in the past 60 days (social)

9. History Example History Level = Detailed (3 of 3) CC
HPI = Extended (4+ elements)
ROS = Extended (3 elements)
PFSH = Pertinent (1 element)

10. Physical Exam Problem Focused Expanded Problem Focused Detailed
(95)<1 body area/
organ system
(97) 1-5 elements
Expanded Problem Focused
(95) 2-4 body areas/ organ systems
(97) elements
Detailed
(95) 5-7 body areas/organ systems
(97) 12 elements in 2+areas/systems
Comprehensive
(95) 8 organ systems
(97) General exam: Perform all elements document at least 2 elements in each of 9 areas/systems

11. CPT Physical Exam Guidelines (Medicaid)
Problem focused: limited exam of the affected body area or organ system
Expanded problem focused: limited exam of the affected body area or organ system and other symptomatic or related organ system(s)
Detailed: extended exam of the affected body area(s) and other symptomatic or related organ system(s)
Comprehensive: general multi-system exam or a complete exam of a single organ system

12. Physical Exam Example Vaginal Discharge Exam
Constitutional
BP, temp, pulse
Genitourinary
Examination of external genitalia
Examination of cervix
Physical Exam level = Expanded Problem Focused
At least two body areas/organ systems

13. Decision Making Straightforward Low Complexity Moderate Complexity
#Diagnostic/treatment options (0 -1)
Amt./complexity of data
(0 -1)
Risk (minimal)
Low Complexity
#Diagnostic/treatment
options (2)
(2)
Risk (low)
Moderate Complexity
#Diagnostic/treatment
options (3)
Amt./complexity of data (3)
Risk (moderate)
High Complexity
#Diagnoses/mgmt options (4)
Amt./complexity of data (4)
Risk (high)

14. CPT MDM Guidelines (Medicaid)
Complexity measured by:
# of possible diagnoses and/or the number of management options that must be considered.
Amount/complexity of records, tests, other information that must be obtained, reviewed, and analyzed.
Risk of significant complications, morbidity, mortality, as well as co-morbidities, associated with the patient’s presenting problem(s), the diagnostic procedure(s) and/or the possible management options.

15. Decision Making Example
Vaginal Discharge Exam
New problem, additional workup planned
Lab is ordered (4)
Review/order tests in 8xxxx series (1)
Moderate decision making
Undiagnosed new problem with uncertain prognosis
Prescription drug management
Prescription written
Decision Making level = Moderate (2 0f 3)
Extensive # Diagnosis/treatment options
Minimal amount of data to be reviewed
Table of risk - Moderate

16. Level Assignment Example
History = Detailed
Physical exam = Expanded Problem
Focused
Decision Making = Moderate
Level = 99202, new patient
If established patient = 99214

17. Contributing Factors Presenting Problem Time Minimal
Self-Limited/Minor
Low Severity
Moderate Severity
High Severity
Time
FACE-TO-FACE
Time is a key factor ONLY when:
Counseling or coordination of care takes up OVER 50% of the total visit time

18. Counseling/Coordination of Care
Main factor determining code when takes up MORE than 50% of the total visit time
Documentation:
Total visit time
Time spent in Counseling/Coordination of Care
Face to face
Subject/ content
Code level is based on the total visit time
not just the time spent in counseling

19. Counseling Examples
Established patient, 20 minute visit to follow-up on oral contraceptive use
NP 99213
RN (MA 99213)
15 minutes of a 20 minute visit spent counseling the patient on alcohol and cigarette use during pregnancy

20. Definitions New patient Established patient
Has not received face-to-face services from
ANY provider in the agency
Within past 3 years (AMA)
Established patient
Has received face-to-face services from

21. Selecting a Level of E/M
Identify
Place of service (POS) = where (office)
Type of service (TOS) = what (Problem/Preventive)
Status of Patient = who (New/Established)
Determine the extent of history - physical exam - decision making - counseling
Must consider all factors, and make sure adequate DOCUMENTATION in chart to justify code.

22. Office 99201-99215 Report Problem visit (vs. Preventive visit)
, performed by MD,DO,NP,PA,CNS
Ancillary staff i.e. RN, LPN, CNA
MD/NP must be in the clinic
Report only 1 E/M per day
Report diagnostic tests, studies, procedures separately

23. Office (Medicaid)
, may be performed by any staff of a “certified family planning clinic”. Staff may be MD, NP, PA, RN, CMA or unlicensed personnel acting in a coordinated manner to provide the service(s).
Other reporting requirements are the same as other providers

24. Preventive Medicine Services

25. Preventive Medicine
Routine management of patients without presenting problems, i.e. annual, routine, well child exams
Performed by MD, DO,NP,PA,CNS
Includes other clinic staff if Medicaid
Codes
New/established patients
Age
Not used for scheduled follow-up visits for specified problems