1. From Registration to Accounts Receivable – The Whole Can of Worms 2007 UBO/UBU Conference 1 Briefing: Evaluation & Management - The Basics Date:20 March 2007 Time:1400 - 14:50

2. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2 Objectives Principles of Documentation Key Componenents 1995 vs. 1997 The Differences – Patients and Services Review Questions

3. 2007 UBO/UBU Conference From Registration to Accounts Receivable 3 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 Medical Record Documentation

4. 2007 UBO/UBU Conference From Registration to Accounts Receivable 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

5. 2007 UBO/UBU Conference From Registration to Accounts Receivable 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

6. 2007 UBO/UBU Conference From Registration to Accounts Receivable 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

7. 2007 UBO/UBU Conference From Registration to Accounts Receivable 7 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

8. 2007 UBO/UBU Conference From Registration to Accounts Receivable 8 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

9. 2007 UBO/UBU Conference From Registration to Accounts Receivable 9 Three Key Components History – Problem Focused – Expanded Problem Focused – Detailed – Comprehensive

10. 2007 UBO/UBU Conference From Registration to Accounts Receivable 10 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

11. 2007 UBO/UBU Conference From Registration to Accounts Receivable 11 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 Example: – Patient complaining of “productive cough, nasal drainage, and headache.”

12. 2007 UBO/UBU Conference From Registration to Accounts Receivable 12 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

13. 2007 UBO/UBU Conference From Registration to Accounts Receivable 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)

14. 2007 UBO/UBU Conference From Registration to Accounts Receivable 14 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)

15. 2007 UBO/UBU Conference From Registration to Accounts Receivable 15 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)

16. 2007 UBO/UBU Conference From Registration to Accounts Receivable 16 Three Key Components Review of Systems (ROS) – Problem Pertinent – Extended – Complete

17. 2007 UBO/UBU Conference From Registration to Accounts Receivable 17 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

18. 2007 UBO/UBU Conference From Registration to Accounts Receivable 18 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

19. 2007 UBO/UBU Conference From Registration to Accounts Receivable 19 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”

20. 2007 UBO/UBU Conference From Registration to Accounts Receivable 20 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

21. 2007 UBO/UBU Conference From Registration to Accounts Receivable 21 Three Key Components HPI (history of present illness) _Location _Severity _Timing _Mod/Fact _Quality _Duration _Context _Assoc S/S Brief (1-3) Extended (4 or more) 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) Extended (2-9 sys) Complete (10 or more sys) or (All others neg) PFSH _Past _Family _Social Established/ Subsequent None Complete Two or three New/Initial None Prob pert One- Two Complete 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 DETAILEDCOMPREHENSIVE Brief (1-3) Prob pert One PROBLEM FOCUSED None

22. 2007 UBO/UBU Conference From Registration to Accounts Receivable 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)

23. 2007 UBO/UBU Conference From Registration to Accounts Receivable 23 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

24. 2007 UBO/UBU Conference From Registration to Accounts Receivable 24 Three Key Components Exam – Body areas – 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

25. 2007 UBO/UBU Conference From Registration to Accounts Receivable 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

26. 2007 UBO/UBU Conference From Registration to Accounts Receivable 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)

27. 2007 UBO/UBU Conference From Registration to Accounts Receivable 27 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

28. 2007 UBO/UBU Conference From Registration to Accounts Receivable 28 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

29. 2007 UBO/UBU Conference From Registration to Accounts Receivable 29 1995 vs. 1997 Exam – 1995 vs. 1997 – 1995 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

30. 2007 UBO/UBU Conference From Registration to Accounts Receivable 30 Three Key Components Medical Decision Making (MDM) – Straightforward – Low Complexity – Moderate Complexity – High Complexity

31. 2007 UBO/UBU Conference From Registration to Accounts Receivable 31 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

32. 2007 UBO/UBU Conference From Registration to Accounts Receivable 32 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

33. 2007 UBO/UBU Conference From Registration to Accounts Receivable 33 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

34. 2007 UBO/UBU Conference From Registration to Accounts Receivable 34 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

35. 2007 UBO/UBU Conference From Registration to Accounts Receivable 35 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?)

36. 2007 UBO/UBU Conference From Registration to Accounts Receivable 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

37. 2007 UBO/UBU Conference From Registration to Accounts Receivable 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

38. 2007 UBO/UBU Conference From Registration to Accounts Receivable 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

39. 2007 UBO/UBU Conference From Registration to Accounts Receivable 39 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

40. 2007 UBO/UBU Conference From Registration to Accounts Receivable 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