1. Evaluation & Management Services

2. What is documentation and why is it important?
Medical record documentation is required
for reporting pertinent findings, facts and observations about a patients health history.
The medical record documents patient care showing the chronology of treatment, communication between physicians, quality of care, and collection of data.

3. General principles of documentation
Medical record should be complete and legible.
Documentation should include:
Chief complaint
Exam and Diagnostic Test results
Assessment
Plan

4. 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

5. 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 list “Instructions for selecting a Level of E/M Service”

6. 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

7. STEP ONE - HISTORY

8. History Definitions Chief complaint (CC)
Reason for the visit
History of present illness (HPI)
chronological description of the development of the patient’s illness from the 1st sign and/or symptom to the present.
Review of systems (ROS)
is an inventory of body systems obtained through a series of questions asked by the physician seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced
Past, Family, Social, History (PFSH)

9. History Definitions - Cont Past, Family, Social, History (PFSH)
The PFSH consists of a review of one or more of the following three areas of the patient’s history:
Past History (P)
Family History (F)
Social History (S)
The PFSH is considered to be interval history for subsequent inpatient visits.
Interval history - any new history information obtained since the last “physician-patient” encounter

10. 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)
FOR A NEW PATIENT.

11. 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

12. Elements of History HPI
Location
Quality
Severity
Duration
Timing
Context
Modifying factors
Associated signs and symptoms

13. Elements of History - HPI
Location – place, whereabouts, site, position. Where on the body is the patient experiencing signs or symptoms? (e.g., pain in groin)
Quality – A description, characteristics, or statement to identify the type of sign or symptom. (e.g., burning pain in groin)
Severity – Degree, intensity, ability to endure. (e.g., History of mild burning pain in groin that has become more intense)

14. Elements of History - HPI
Duration – Length of time. How long has patient been experiencing the signs or symptoms? (e.g., History of intermittent mild burning pain in groin that has become more intense and frequent for the last two weeks)
Timing – Regulation of occurrence. A description of when the patient experiences signs or symptoms (e.g., history of intermittent mild burning in groin that has become more intense and frequent for the last two weeks).

15. Elements of History - HPI
Context – Circumstances, cause, precursor, outside factors. A description of where the patient is or what the patient does when the signs or symptoms are experienced (e.g., history of intermitted mild burning pain in groin that has become more intense and frequent for the last two weeks since the patient bent down to pick up son and continues to feel intense pain when bending).

16. Elements of History - HPI
Modifying Factors – Elements that change, alter or have some effect on the complaint or symptoms (e.g., history of intermittent mild burning pain in the groin that has become more intense and frequent for last two weeks since the patient bent down to pick up son; continues to feel intense pain when bending. Patient currently on Motrin 800 mg BID for past 3 weeks without relief)
Associated Signs and Symptoms – Factors or symptoms that accompany the main symptoms. What other factors does patient experience in addition to this discomfort/pain? (e.g., Shortness of breath, light-headedness, nausea/vomiting)

17. Elements of History - ROS
Constitutional (e.g., fever, weight loss/gain, lack of appetite)
Eyes
Ears, nose, throat, mouth
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary (skin and/or breast)
Neurological
Psychiatric
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic

18. Documentation Example of ROS
Patient denies loss of consciousness. He has not had any bowel or bladder problems. All other systems are negative.

19. Evaluation of Sample ROS
Patient denies loss of consciousness or bowel/bladder problem. All other systems are negative.
Neurological = loss of consciousness
Gastrointestinal = no bowel Program
Genitourinary = no bladder problems
All other neg

20. Element of History - Past/Family/Social History - (PFSH)
Past History: the patient’s history of illnesses, operations, injuries, treatments, medications.
Family History: a review of medical events in the patient’s family, including diseases which may be hereditary or place the patient at risk.”
Social History: Contains marital status and/or living arrangements; current employment; occupational history; use of drugs, alcohol and tobacco; level of education, sexual history; or other relevant social factors.

21. Body Areas vs. Organ Systems
The exam components are divided up between body areas and organ systems. These can be combined when counting elements for exam.
ORGAN SYSTEMS
Constitutional (vitals & general
appearance)
Eyes
ENT, mouth
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
Neurologic
Psychiatric
Hematologic/Lymphatic/Immunologic
BODY AREAS
Head, incl. Face
Neck
Chest, incl. Breasts &
axillae
Abdomen
Genitalia, groin, buttocks
Back, incl. Spine
Each extremity

22. History CASE STUDY
New patient is complaining of a white vaginal discharge for the past 2 days with a heavier flow in the morning. There is no change with Monistat. Patient denies itching burning with urination or fever. Patient has had 2 sexual partners in the past 60 days

23. History CASE STUDY What is the patient’s CC ?
Vaginal Discharge
What are the patient’s Elements of HPI?
Location - vaginal
Duration - past 2 days
Timing - a heavier flow in the morning
Modifying factor - There is no change with Monistat
What is the Level of HPI?
Ans: Detailed
CASE STUDY
New patient is complaining of a white vaginal discharge for the past 2 days with a heavier flow in the morning. There is no change with Monistat. Patient denies itching burning with urination or fever. Patient has had 2 sexual partners in the past 60 days

24. History CASE STUDY What is/are the ROS? What is the Level of ROS?
Integumentary - itching
Genitourinary - burning with urination
Constitutional - fever
What is the Level of ROS?
Ans: Detailed
What is/are the patient’s PFSH
PH (past history) – N/A
FH (family History) - N/A
SH – (social history) - Patient has had 2 sexual partners in the past 60 days
What is the Level of PFSH?
CASE STUDY
New patient is complaining of a white vaginal discharge for the past 2 days with a heavier flow in the morning. There is no change with Monistat. Patient denies itching burning with urination or fever. Patient has had 2 sexual partners in the past 60 days

25. History CASE STUDY ANSWER/EXPLANATION
History Level = Detailed (3 of 3) CC
HPI = Extended (4+ elements)
ROS = Extended (3 elements)
PFSH = Pertinent (1 element)
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)

26. STEP TWO – EXAMINATION Performed by Physician

27. 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

28. 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

29. Physical Exam Example Vaginal Discharge Exam
Constitutional
BP, temp, pulse
Genitourinary
Examination of external genitalia
Examination of cervix
What is the Level of the Physical Exam?
ANS: Problem Focused = (At least two body areas/organ systems)
CASE STUDY
New patient is complaining of a white vaginal discharge for the past 2 days with a heavier flow in the morning. There is no change with Monistat. Patient denies itching burning with urination or fever. Patient has had 2 sexual partners in the past 60 days

30. STEP THREE MEDICAL DECISION-MAKING

31. MEDICAL DECISION-MAKING
MDM refers to the complexity of establishing a diagnosis and/or selecting a management option.
MDM is the function of 3 variables
Number of diagnoses and/or management options
Amount &/or complexity of data that must be obtained, reviewed &/or analyzed
Risk of significant complications, morbidity &/or mortality

32. Number of Diagnosis and/or Management Options
Self Limited or Minor; stable, improving, worsening x1
Established Problem*; stable, improved
Established Problem*; worsening X2
New Problem*; no workup planned X3
New Problem*; addl. workup planned x4
Total Diagnosis or management options

33. Amount and/or Complexity of Data
Documentation should include:
Diagnostic service:
Ordered, planned, scheduled or performed
Review of tests results
Simple notation or initialing & dating
Decision to obtain old records or additional History
Relevant findings from review of old records
Discussion of results with performing physician
Direct visualization and interpretation

34. Risk of Complications, Morbidity and/or Mortality
Refers to patient’s level of risk at the visit
Sources of risk
Presenting problem
Diagnostic procedures ordered
Management options selected
Illustrated by clinical examples in “Table of Risk”

35. Documented Example of MDM
A/P (assessment/plan): By history, suspect possible herniated disk. Patient will be referred for MRI scan. Prescribe Motrin 800 mg, tid with food, Vicodin for pain.

36. Evaluation of MDM
Number of dx/tx options = new problem with addl workup
Amt/complexity of data = ordered MRI
Risk = prescription management
A/P: By history, suspect possible herniated disk. Patient will be referred for MRI scan. Prescribe Motrin 800 mg, tid with food, Vicodin for pain.

37. 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)

38. Decision Making Straightforward Low Complexity
minimal number of diagnoses or management options considered.
little, if any, amount or complexity of data reviewed.
minimal risk of complications or morbidity or mortality (expectation of full recovery without functional impairment).
Low Complexity
limited number of diagnoses or management options considered.
limited amount and complexity of data reviewed.
low risk of complications or morbidity or mortality (uncertain outcome or increased probability of prolonged functional impairment.

39. Decision Making Moderate Complexity High Complexity
multiple number of diagnoses or management options considered.
moderate amount and complexity of data reviewed.
moderate risk of complications or morbidity or mortality (uncertain
outcome or increased probability of prolonged functional impairment or
high probability of severe prolonged functional impairment).
High Complexity
extensive number of diagnoses or management options considered
extensive amount and complexity of data reviewed
high risk of complications or morbidity or mortality (uncertain
outcome or increased probability of prolonged functional impairment
or high probability of severe prolonged functional impairment) .

40. 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.

41. Table of Risk Examples Presenting Problem
Minimal – One self-limited or minor problem.
Low – Two or more minor problems, one stable chronic illness, acute uncomplicated illness.
Moderate – Chronic illness with exacerbation, two of more stable chronic illnesses, undiagnosed new problem with uncertain prognosis, acute illness with systemic pneumonitis, acute complicated injury
High – Chronic illness with severe exacerbation, acute or chronic illness that poses threat to life, abrupt change in neurologic status.

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

43. Level Assignment EXAMPLE/CASE STUDY CPT BOOK
History = Detailed
Physical Exam = Problem Focused
Decision Making = Moderate
What is the code for a New & Established Patient?
ANSWER
Level = 99203, new patient
If Established Patient = 99214

44. 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

45. Consultation Code Selection

46. Definition of Consultation
“A type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.”
Payment for consultation is often significantly higher than other E/M service

47. Consultation vs. Referral
Requires a physician request for an opinion or advice.
Request and reason for consult must be documented.
Evidence of opinion and/or advice communicated back to requesting physician.
UPIN is required.
Referral:
Is a transfer of care for treatment of a specified problem.
Is for a known problem.
Physician plans to manage the patient’s care and treatment.
No report to referring physician is required.

48. Four Elements That Distinguish A Consultation
A type of service provided by a physician whose opinion or advice regarding evaluation and/or management of an unknown or uncertain problem is requested by another physician or appropriate source.
The written or verbal request for a consultation must be documented in the medical record.
The consulting physician may initiate diagnostic or therapeutic services at the consultation or subsequent visit.
The consulting physician’s opinion and any services ordered or performed must be:
a) Documented in the medical record; and
b) Communicated by written report to the requesting physician or other appropriate source.

49. Types of Inpatient Consultations
Initial Inpatient
No difference in new or established
Reported one time during hospital stay
Requires 3 of 3 key components be documented
Follow-up Inpatient
Used to complete an initial consultation
Complete initial consult, initiated by consulting physician
Subsequent consult, initiated by attending physician
Requires 2 of 3 key components be documented

50. 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

51. 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

52. 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

53. 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.

54. Office 99201-99215 Report Problem visit (vs. Preventive visit)
, performed by MD, 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

55. 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

56. Preventive Medicine Services

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

58. CASE STUDY
Susan Johnson was referred to Dr. Jones’ office for her opinion of Susan’s chronic low back pain radiating to the leg. Dr. Jones took a detail history, performed a detailed examination, and medical decision making was of low complexity.
99243

59. CASE STUDY
Michael, age 38, scheduled an annual physical exam with Dr. Graves. He has been Dr. Graves’ patient for 15 years and had his last annual physical 2 years ago.
First - 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
99395

60. CASE STUDY
A 2-year-old boy with bacterial pneumonia is hospitalized and has had 5 days of antibiotic therapy. Today the child developed a fever of F with a mild rash on his torso. In a subsequent hospital visit, the attending physician performed a problem-focused history and examination. The MDM complexity was low.
99231