1. From Registration to Accounts Receivable – The Whole Can of Worms 2007 UBO/UBU Conference 1 Briefing:Advanced E&M, Validating the Level Date:20 March 2007 Time:1510-1600

2. 2007 UBO/UBU Conference From Registration to Accounts Receivable 2 Objectives Understand Evaluation and Management Services Identify critical components of E&M Understand significance of each component Recognize intent and purpose for levels of service Learn how to apply to services rendered

3. 2007 UBO/UBU Conference From Registration to Accounts Receivable 3 Overview Documentation Evaluation and Management Factors Evaluation and Management Codes Review Summary

4. 2007 UBO/UBU Conference From Registration to Accounts Receivable 4 Documentation Requirements Principles of Documentation – The medical record should be complete and legible – The documentation of each patient encounter should include: Date Signature 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, as well as revision of diagnosis should be documented – The CPT and ICD-9-CM codes reported should be supported by the documentation in the medical record – The documentation should support the intensity of the patient’s evaluation and/or treatment, including thought process, and the complexity of the medical decision making

5. 2007 UBO/UBU Conference From Registration to Accounts Receivable 5 Documentation Requirements Evaluating Your Documentation – Reason for the patient encounter – Services provided correctly documented – Clear explanation of medical necessity of the level of E&M, diagnostic and therapeutic procedures (to include support services and supplies) – Assessment of patient’s condition – Patient’s progress/results of treatment – Patient plan of care – Patient’s condition, reasonable medical rationale for setting of service – Documentation supports the care given – Medical record is legible and comprehensible

6. 2007 UBO/UBU Conference From Registration to Accounts Receivable 6 Documentation Requirements SOAP Format: – ( S)ubjective: Chief complaint and the history of the present illness, review of systems and relevant past, family and or social history – (O)bjective: Physical evaluation examination and the diagnostic evaluation – (A)ssesment: Complexity of medical decision making – (P)lan: Complexity of medical decision making

7. 2007 UBO/UBU Conference From Registration to Accounts Receivable 7 Documentation Requirements SNOCAMP Format: – (S)ubjective: Chief complaint and the history of the present illness, review of systems and relevant past, family and or social history – (N)ature of presenting problem: Chief complaint and the history of the present illness, review of systems and relevant past, family and or social history – (O)bjective: Physical evaluation examination and the diagnostic evaluation – (C)ounseling and/or coordination of care: – (A)ssessment: Complexity of medical decision making – (M)edical decision making: Complexity of medical decision making – (P)lan: Complexity of medical decision making

8. 2007 UBO/UBU Conference From Registration to Accounts Receivable 8 Documentation Requirements Considerations: – Under-documentation – Over-coding – Decision making a requirement – Encounter note stand alone entry – Deficiencies

9. 2007 UBO/UBU Conference From Registration to Accounts Receivable 9 Documentation Requirements Specific Pitfalls: – HPI: Documentation must be explicit as to the condition being treated, or actual signs and symptoms and the differential diagnosis as appropriate for the encounter, as well as any conditions the patient may have that complicates or affect medical care – Exam: Determined by the nature of the presenting problem, the documented HPI and additional history components Comprehensive exams not necessary for every patient unless clearly supported by medical necessity – Medical Decision Making: Reflective of: Hx and/or exam for the specific DOS Diagnosis and management options Complexity of data obtained, analyzed and reviewed Overall risks of presenting condition, comorbidities and complicating conditions

10. 2007 UBO/UBU Conference From Registration to Accounts Receivable 10 Evaluation & Management Factors Levels of Evaluation and Management: – Categories: Place of service (e.g. office or hospital) Type of service (e.g. critical care preventive medicine) – Further divided: Status of medical visit (e.g. new or established)

11. 2007 UBO/UBU Conference From Registration to Accounts Receivable 11 Evaluation & Management Factors Component Sequence and Code Selection: – Determine use of 95 or 97 guidelines – Complexity for the encounter suggested by the chief complaint will point directly at the level of medical decision making – When decision making at a certain level is required, the degrees of history and exam will follow – Safety in coding by decision making is that this component is the one most closely linked to medical necessity

12. 2007 UBO/UBU Conference From Registration to Accounts Receivable 12 Evaluation & Management Factors Seven Components – Three key History Examination Medical Decision Making – Four contributory Counseling Coordination of Care Nature of Presenting Problem Time

13. 2007 UBO/UBU Conference From Registration to Accounts Receivable 13 Evaluation & Management Factors Key Components: – History – Examination – Medical Decision Making

14. 2007 UBO/UBU Conference From Registration to Accounts Receivable 14 Evaluation & Management Factors Four contributory: – Counseling – Coordination of Care – Nature of Presenting Problem – Time

15. 2007 UBO/UBU Conference From Registration to Accounts Receivable 15 Evaluation & Management Factors History – Chief Complaint (CC) – History of Present Illness (HPI) – Review of Systems (ROS) – Past Family, Medical and Social History (PFSH)

16. 2007 UBO/UBU Conference From Registration to Accounts Receivable 16 Evaluation & Management Factors History: – Chief Complaint: Concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter. The CC is usually stated in the patient’s own words – The medical record should clearly reflect the chief complaint e.g. Patient complains of upset stomach, aching joints, and fatigue

17. 2007 UBO/UBU Conference From Registration to Accounts Receivable 17 Evaluation & Management Factors History Of Present Illness (HPI) – QUALITY - Adjective qualifier of the type of sign/symptom, usually not measurable in degrees – LOCATION - Where in/on the body the signs/symptoms occurred – SEVERITY - Ranking of symptom/pain, describe with adjectives – DURATION - Specific time period – TIMING - Specifics as to when symptoms/pain occur – CONTEXT - Circumstances surrounding the occurrence – MODIFYING FACTORS - Palliative steps, successful or not – ASSOCIATED SIGNS AND SYMPTOMS - Any symptom associated with the chief complaint

18. 2007 UBO/UBU Conference From Registration to Accounts Receivable 18 Evaluation & Management Factors History Of Present Illness (HPI): – Location (e.g. left, lower, Epigastric region) – Quality (e.g. sharp, dull, stabbing) – Severity (e.g. pain scale 5/10, severe, better) – Duration (e.g. two weeks, until today) – Timing (e.g. after meals, comes and goes) – Context (e.g. began during) – Modifying factors (e.g. feels better after applying ice) – Associated signs & symptoms (e.g. bloating, weakness) * 1997 guidelines allow chronic or inactive conditions for a brief HPI

19. 2007 UBO/UBU Conference From Registration to Accounts Receivable 19 Evaluation & Management Factors EXAMPLE – CC: A patient seen in the office complains of left ear pain – Brief HPI: Patient complains of dull ache in left ear over the past24 hours quality, location, and duration – Extended HPI: Patient complains of dull ache in left ear over the past 24 hours. Patient states he went swimming two days ago – Symptoms somewhat relieved by warm compress and ibuprofen Quality, location, duration, context, and modifying factors

20. 2007 UBO/UBU Conference From Registration to Accounts Receivable 20 Evaluation & Management Factors ROS: Inventory of body systems – For purposes of the ROS, the following systems are recognized: _ Const _ENT _Endo _Eyes _GI _GU _Hem/Lymph _Integ/Skin _Resp _Card/Vasc _Musculo _Neuro _All/Lymph _Psych _All others negative – Problem pertinent - System directly related to the problem(s) identified in the HPI – Extended- System directly related to the problem(s) identified in the HPI and a limited number of additional systems – Minimum of two documented systems – Complete ROS - System(s) directly related to the problem(s) identified in the HPI and all additional body systems – Those systems with positive or pertinent negative responses must be individually documented – Remaining systems a notation including all other systems are negative is permissible

21. 2007 UBO/UBU Conference From Registration to Accounts Receivable 21 Evaluation & Management Factors Case Example: – Chief Complaint: Earache – ROS: Positive for left ear pain. Denies dizziness, tinnitus, fullness, or headache – Problem pertinent– systems reviewed are directly related to the chief complaint Case Example: – Chief Complaint: F/u after cardiac cath. Patient states, “I feel great” – ROS: Patient states he feels great. Denies chest pain, syncope, palpitations, and shortness of breath. Relates occasional unilateral, asymptomatic edema of left leg – Extended- cardiovascular and respiratory systems are reviewed

22. 2007 UBO/UBU Conference From Registration to Accounts Receivable 22 Evaluation & Management Factors Case Example: – Chief Complaint: Earache – ROS: Constitutional: Weight stable, + fatigue Eyes: + loss of peripheral vision loss ENMT: no complaints Cardio: + palpitations; denied chest pain; denied calf pain, pressure, or edema Resp: + SOB on exertion GI: appetite good, denies heartburn and indigestion, + episodes of nausea Bowel movement daily; denies constipation or loose stools Urinary: denies incontinence, frequency, nocturia, pain, or discomfort Skin: + clammy, moist skin Neuro: + fainting; denies numbness, tingling, or tremors Psychiatric: denies memory loss or depression – Complete- inquired about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems

23. 2007 UBO/UBU Conference From Registration to Accounts Receivable 23 Evaluation & Management Factors Past Family and/Or Social History (PFSH) – Past- including experiences with illnesses, operations, injuries, and treatment – Family- including a review of medical events, diseases, and hereditary conditions that may place him or her at risk – Social- including an age appropriate review of past and current activities The social history of the mother can be taken into consideration for a newborn Types – Pertinent: history area directly related to the problem(s) identified in the HPI – Complete: review of areas 2 or 3 areas depending on category of E/M service

24. 2007 UBO/UBU Conference From Registration to Accounts Receivable 24 Evaluation & Management Factors 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

25. 2007 UBO/UBU Conference From Registration to Accounts Receivable 25 Evaluation & Management Factors Case example PFSH – Pertinent- review of history directly related to the problem(s) identified in the HPI Patient returns to office for follow-up of CABG Father died at age 61 following MI

26. 2007 UBO/UBU Conference From Registration to Accounts Receivable 26 Evaluation & Management Factors Example – C/O cough, sore throat, runny nose and sneezing for 2 days. No fever or sputum. Not a smoker. Babysat grandson last week who has strep throat. Chief Complaint: cough, sore throat, runny nose, sneezing Brief HPI: Context- following babysitting, exposure to strep Duration- Two days Problem pertinent ROS: Constitutional- fever Pulmonary- sputum – Two documented from different systems but both were problem pertinent Pertinent PFSH: Social History – not a smoker

27. 2007 UBO/UBU Conference From Registration to Accounts Receivable 27 Evaluation & Management Factors This record demonstrates the following key components – Chief complaint(s) documented Several symptoms – Brief HPI Described the chief complaint(s) Context and Duration – Problem Pertinent ROS The constitutional and pulmonary systems were documented Both directly relate to the chief complaint The EMDG states that the ROS that relates directly to the presenting problem is “pertinent” An extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number of additional systems- – Pertinent PFSH Included one area

28. 2007 UBO/UBU Conference From Registration to Accounts Receivable 28 Evaluation & Management Factors 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

29. 2007 UBO/UBU Conference From Registration to Accounts Receivable 29 Evaluation & Management Factors 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/Immun ologic

30. 2007 UBO/UBU Conference From Registration to Accounts Receivable 30 Evaluation & Management Factors 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)

31. 2007 UBO/UBU Conference From Registration to Accounts Receivable 31 Evaluation & Management Factors 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

32. 2007 UBO/UBU Conference From Registration to Accounts Receivable 32 Evaluation & Management Factors 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

33. 2007 UBO/UBU Conference From Registration to Accounts Receivable 33 Evaluation & Management Factors 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

34. 2007 UBO/UBU Conference From Registration to Accounts Receivable 34 Evaluation & Management Factors 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

35. 2007 UBO/UBU Conference From Registration to Accounts Receivable 35 Evaluation & Management Factors 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/immunol ogic 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 ***Examination elements are bulleted*** ***Offers general multi-system and single system examination elements***

36. 2007 UBO/UBU Conference From Registration to Accounts Receivable 36 Evaluation & Management Factors 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

37. 2007 UBO/UBU Conference From Registration to Accounts Receivable 37 Evaluation & Management Factors 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, b) 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

38. 2007 UBO/UBU Conference From Registration to Accounts Receivable 38 Evaluation & Management Factors 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

39. 2007 UBO/UBU Conference From Registration to Accounts Receivable 39 Evaluation & Management Factors 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

40. 2007 UBO/UBU Conference From Registration to Accounts Receivable 40 Evaluation & Management Factors 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?)

41. 2007 UBO/UBU Conference From Registration to Accounts Receivable 41 Evaluation & Management Factors Terms Commonly Used in E&M Codes: – Bullets: Under the 1997 guidelines each physical examination element is commonly referred to as a bullet – Interval history: Occurrence in a given area since the last visit – Prognosis: A forecast of the probable outcome of a condition or disease, and the prospects of recovery and disease residual, depending on the nature of the disease and the patients response to treatment – Morbidity: A diseased condition or state – Mortality: The condition of being mortal (death) – Chronic: An illness or disease of slow progression, or with little change – Acute: An illness or disease typically with severe symptoms, a rapid onset, and a short duration

42. 2007 UBO/UBU Conference From Registration to Accounts Receivable 42 Evaluation & Management Factors Modifiers used with E&M Codes – 21 - Prolonged evaluation and management services – 24 - Unrelated to evaluation and management services by the same physician during a postoperative period – 25 - Significantly separate, identifiable evaluation and management service by the same physician on the day of a procedure or other service – 27 - Multiple outpatient hospital E&M encounters on the same day – 32 - Mandated services – 52 - Reduced services – 57 - Decision for surgery

43. 2007 UBO/UBU Conference From Registration to Accounts Receivable 43 Evaluation & Management Office or Other Outpatient Services (new) E/M codeHistoryExamMedical decision making Counseling and coordination of care Nature of presenting problem (NOPP) 99201Problem Focused Problem Focused Straight- Forward Consistent with the NOPP and the patient’s and/or family’s needs Self-limited or Minor 99202Expanded Problem Focused Straight- Forward SameLow to Moderate Severity 99203Detailed Low Complexity SameModerate Severity 99204Comprehensive Moderate Complexity SameModerate to High Severity

44. 2007 UBO/UBU Conference From Registration to Accounts Receivable 44 Evaluation & Management Office and Other Outpatient Services (99211) – “Direct supervision” – Some Appropriate Uses of 99211 Requires Chief Complaint BP checks Weight Medication reactions Other services – Inappropriate uses of 99211 Telephone calls Prescription renewals Not medically indicated pulse, temperature or blood pressures

45. 2007 UBO/UBU Conference From Registration to Accounts Receivable 45 Evaluation & Management Office or Other Outpatient Services (established) E/M codeHistoryExamMedical decision making Counseling and coordination of care Nature of presenting problem (NOPP) 99212Problem Focused Problem Focused Straight- Forward Consistent with the NOPP and the patient’s and/or family’s needs Self-limited or Minor 99213Expanded Problem Focused Low Complexity SameLow to Moderate Severity 99214Detailed Moderate Complexity SameModerate Severity 99215Comprehensive High Complexity SameModerate to High Severity

46. 2007 UBO/UBU Conference From Registration to Accounts Receivable 46 Evaluation & Management Hospital Observation Services – 48-hour maximum stay – Admitting physician only – Do not use: When the patient is designated as observation status on one date and is subsequently admitted to the hospital on that same date

47. 2007 UBO/UBU Conference From Registration to Accounts Receivable 47 Evaluation & Management Initial Observation Care Services “Three key components must be met or exceeded” Code992189921999220 HISTORYDetailed or Comprehensive Comprehensive EXAMDetailed or Comprehensive Comprehensive MEDICAL DECISION MAKING Straightforward or Low ModerateHigh PRESENTING PROBLEMLow SeverityModerate SeverityHigh Severity

48. 2007 UBO/UBU Conference From Registration to Accounts Receivable 48 Evaluation & Management Observation or Inpatient Care Services “Three key components must be met or exceeded” Code992349923599236 HISTORYDetailed or Comprehensive Comprehensive EXAMDetailed or Comprehensive Comprehensive MEDICAL DECISION MAKING Straightforward or Low ModerateHigh PRESENTING PROBLEMLow SeverityModerate SeverityHigh Severity

49. 2007 UBO/UBU Conference From Registration to Accounts Receivable 49 Evaluation & Management Hospital Observation Services (99217-99220) – Things to remember……. Only the physician that admitted the patient into observation status can capture these codes All other physicians who see the patient in observation status must bill office and other outpatient service codes or outpatient consultation codes, as appropriate Initial observation care codes are for the initial day of care only. This is determined by calendar date, not 24 hour period Patient should not remain in observation status for greater than 48 hours Global surgical fees rules apply unless the criteria is met for modifiers 24, 25, or 57

50. 2007 UBO/UBU Conference From Registration to Accounts Receivable 50 Evaluation & Management Hospital Observation Services *99217- Discharge Day Management 8 hrs or less>8 hrs <24 hrs24 hrs or more 99218-99220 (observation care) 99234-99236 (observation or inpatient care) 99218-99220 (observation care) Same calendar date Admission paid Discharge not paid separately Same calendar date Admission and discharge included Same calendar date N/A Different calendar date Admission and discharge paid separately Different calendar date Use codes 99218-99220 Discharge is paid separately Different calendar date Admission and discharge paid separately

51. 2007 UBO/UBU Conference From Registration to Accounts Receivable 51 Evaluation & Management Hospital Inpatient Services – 99221-99233 – Initial hospital – Subsequent hospital Partial Hospital – Admitted to a facility – Mental Illness (diagnosis and treatment)

52. 2007 UBO/UBU Conference From Registration to Accounts Receivable 52 Evaluation & Management Hospital Inpatient Services – 99221-99223 – New or Established – Three key components – Includes: All E/M services provided in conjunction with the admission on the same date – Does not have to be the same date the patient was admitted to the hospital – E/M services provided on the same date, in sites other than the hospital, related to the hospital admission, should not be reported separately

53. 2007 UBO/UBU Conference From Registration to Accounts Receivable 53 Evaluation & Management Hospital Inpatient Care “Three key components must be met or exceeded” Code992219922299223 HISTORYDetailed or Comprehensive Comprehensive EXAMDetailed or Comprehensive Comprehensive MEDICAL DECISION MAKING Straightforward or Low ModerateHigh PRESENTING PROBLEMLow SeverityModerate SeverityHigh Severity

54. 2007 UBO/UBU Conference From Registration to Accounts Receivable 54 Evaluation & Management Hospital Inpatient Services *99238 (30 min or less) *99239 (>30 min): Discharge Day Management 8 hrs or less>8 hrs but <24 hrs24 hrs or more 99221-99223 (inpatient care) 99234-99236 (observation or inpatient care) 99221-99223 (inpatient care) Same calendar date Admission paid Discharge not paid separately Same calendar date Admission and discharge included Same calendar date N/A Different calendar date Admission and discharge paid separately Different calendar date Use codes 99221-99223 Discharge is paid separately Different calendar date Admission and discharge paid separately

55. 2007 UBO/UBU Conference From Registration to Accounts Receivable 55 Evaluation & Management Hospital Discharge Services- (99238-99239) – Time based – May include Final examination of patient Discussion of hospital course Instructions for continued care Preparing discharge records Writing prescriptions Writing referral forms – May also be reported for patients who expire during the hospital stay Perform final exam (pronouncing the patient is dead) Discuss the hospital stay with family members or others Prepare discharge records, such as discharge summary for the medical record

56. 2007 UBO/UBU Conference From Registration to Accounts Receivable 56 Evaluation & Management Consultations – Documentation should include: Request for the consult from the attending Attending provider document the need for a consult Consulted provider must provide written report – Inpatient: Request may be documented as part of a plan written in the attending provider’s progress notes Order in the hospital record Written request for a consultation – Outpatient: Request can be met by a reference in the medical record

57. 2007 UBO/UBU Conference From Registration to Accounts Receivable 57 Evaluation & Management Consultations – 99241-99245, 99251-99255, 99271-99275 – New or Established – Opinion/Advice – Written or Verbal – Appropriate source Physician Assistant Physical Therapist Insurance Company – May be reported by physicians in the same practice – Require all three key components

58. 2007 UBO/UBU Conference From Registration to Accounts Receivable 58 Evaluation & Management Office or Other Outpatient Consultations (99241- 99245) – Physician’s office – Observation patient – Emergency Department – Ambulatory Facility Initial Inpatient Consultations (99251-99255) – Admitted to an Inpatient facility – Only one per admission (by the consultant) *Require comprehensive history and exam – *99244 and 9245 (Office consultations) – *99254 and 9255 (Initial in-patient consultations)

59. 2007 UBO/UBU Conference From Registration to Accounts Receivable 59 Evaluation & Management Emergency Department Services (99281-99288) – 99288 – physician direction of EMS – typically bundled into ED E&M – Hospital-based facility – Used for unscheduled or episodic services – Must be available 24 hours a day – Three key components – New or Established – 99285 is unique…. Three key components required within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status – Specify the imposing constraints – Diagnosis should be indicative

60. 2007 UBO/UBU Conference From Registration to Accounts Receivable 60 Evaluation & Management Critical Care Services – 99289-99290 – during transport – not captured in MHS – 99291-99292 – Critically ill patient – Does not need to be continuous – Any location – Examples of bundled Services/Procedures Interpreting cardiac output measurements Gastric intubations Vascular access procedures Temporary transcutaneous pacing Ventilator management

61. 2007 UBO/UBU Conference From Registration to Accounts Receivable 61 Evaluation & Management Neonatal/Pediatric Critical Care – 99291-99292 Critical Care is provided to older than 24 months Critical Care is provided to neonates/pediatrics up through 24 months in an outpatient setting – 99293-99294 Pediatric: 29 postnatal days through 24 months – 99295-99296 Neonatal: Birth through 28 postnatal days 99295 may be reported with delivery and resuscitation codes – 99298-99300 LBW, VLBW, or who are not critically ill but require intensive observation

62. 2007 UBO/UBU Conference From Registration to Accounts Receivable 62 Evaluation & Management Other Services 99301-99350) – Not used by DoD Military Health System Prolonged Services (99354-99359) – Time must exceed the basic service by at least 30 minutes to qualify – 99354-99355 (face to face) Assigned for office/out patient facility Not assigned for inpatient – 99356-99357 (face to face) Not assigned for office/out patient facility Assigned for inpatient facility – 99358-99359 (w/out face to face) Appropriate for use in office/outpatient and inpatient facilities

63. 2007 UBO/UBU Conference From Registration to Accounts Receivable 63 Evaluation & Management Case Management & Care Plan Oversight – 99361-99362 Team Conferences Patient not present Interdisciplinary Team Time-based – 99371-99373 Telephone Calls Interaction between a privileged provider and a patient and/or guardian Medical decision making by a licensed provider directly responsible management of patient’s care – 99374-99380 Not currently used by the MHS Home health, hospice and nursing facility

64. 2007 UBO/UBU Conference From Registration to Accounts Receivable 64 Evaluation & Management Preventative Medicine Services (99381-99397) – Periodic preventive medicine evaluation and management services – Age and Gender appropriate Well baby check Well woman exam – New vs. Established – May be reported with a problem oriented E&M – Comprehensive hx/exam not synonymous Requires no chief complaint

65. 2007 UBO/UBU Conference From Registration to Accounts Receivable 65 Evaluation & Management Counseling and/or Risk Factor Reduction Intervention – Includes: Anticipatory guidance, risk factor reduction, intervention services – Do not use: Risk factor reduction interventions and counseling provided to patients with symptoms or illnesses – Time-Based – Individual vs. Group – 993401-99404: Individual Counseling – 99411-99412: Group Counseling – 99420: Administer and interpret health risk assessment

66. 2007 UBO/UBU Conference From Registration to Accounts Receivable 66 Evaluation & Management EXAMPLES: Couple is considering having a child and the lady’s nephew has Tay-Sachs If the couple had already had a child with Tay-Sachs, and were seeing a provider to learn more about the disease and how to manage their child, it would be education Discussion on having a prophylactic mastectomy as both the lady’s mother and sister had breast cancer is counseling Discussion on treatment options for a lady diagnosed with breast cancer is an office visit

67. 2007 UBO/UBU Conference From Registration to Accounts Receivable 67 Evaluation & Management Newborn Care (99431-99440) – Services in a variety of settings – Initial stabilization codes may be reported same day as initial E&M of infant admitted to critical care – Newborns admitted & discharged on same day should be reported with codes 99435 – NB care spanning more than one day should be reported with appropriate codes – Circumcision and other procedures are reported in addition to the admission and evaluation of the newborn

68. 2007 UBO/UBU Conference From Registration to Accounts Receivable 68 Review Selecting and E&M Code: – Identify place of service – Review guidelines for the category/subcategory – Determine: Complexity of medical decision making Exam History – Review code narratives for specific criteria – For billing: Select code that matches level of medical decision making, history, exam documented – For review of coding and documentation accuracy: Review decision making area to see if this is higher or lower than both other components – Higher: provider may be under-documenting – Lower: potential “stock” history or exams that bolster service levels – Use time as the determining factor: 50% counseling and coordination of care – Apply appropriate E&M modifiers

69. 2007 UBO/UBU Conference From Registration to Accounts Receivable 69 Review Important factors for assignment of E&M codes – 99211 – Medical decision making – Services requiring 3 of the 3 key components – Services that require comprehensive Hx & exam – 1995 vs. 1997 – Preventive medicine

70. 2007 UBO/UBU Conference From Registration to Accounts Receivable 70 Summary A clear, concise medical record E/M levels based on work performed and the complexity of the encounter Maximum RVU credit Validate services rendered in the event of an audit