1. Evaluation & Management Services Evaluation & Management Services July 7, 2009 Brenda Edwards, CPC, CPC-I, CEMC Coding & Compliance Specialist KaMMCO

2. Medical Record Documentation Medical Record Documentation  Records pertinent facts, findings and observations about an individual’s health history including past and present illnesses, examinations, tests, treatments and outcomes  Chronologically documents the care of the patient  Is an important element contributing to high quality care.

3. Golden Rule of Coding: If it is not documented, it is not done and therefore not billable! it is not done and therefore not billable!

4. Accuracy is of the Utmost Importance Legibly document what you have done. Legibly document what you have done. Something that may seem trivial for you to document could be the reason you could bill a higher level of service. Something that may seem trivial for you to document could be the reason you could bill a higher level of service.

5. Principles of Documentation Principles of Documentation  Complete and legible  At least two patient identifiers  The reason for the encounter  Relevant history, physical examination findings and prior diagnostic test results  Assessment, clinical impression or diagnosis and plan for care included  Appropriate health risk factors identified as well as the patient’s progress, response to and changes in treatment and revision of diagnosis should be documented  The CPT and ICD-9 codes submitted must be supported by the documentation in the medical record

6. Evaluation & Management Services Evaluation & Management Services  An E&M (evaluation & management) service is any non-procedural service provided to a patient. Office visit, hospital admission, subsequent days, discharge, ER visits and nursing home services are all examples of E&M services  Documentation guidelines for E&M services were first introduced by the Health Care Finance Administration and the AMA in 1995.

7. Documentation Guidelines New patients vs. established patient New patients vs. established patient New patient - One who hasn’t been seen by any provider of the same practice (same tax id) in the past 3 years New patient - One who hasn’t been seen by any provider of the same practice (same tax id) in the past 3 years Established patient – May be “new” to the provider but not “new” to the practice Established patient – May be “new” to the provider but not “new” to the practice

8. Evaluation & Management Services Three components to an E&M visit Three components to an E&M visit History History History of Present Illness (HPI) History of Present Illness (HPI) Review of Systems (ROS) Review of Systems (ROS) Past, Family, Social History (PFSH) Past, Family, Social History (PFSH) Exam Exam Medical Decision Making (MDM) Medical Decision Making (MDM)

9. Assignment of the E&M Code  Based on the documentation by the provider, the level of the E&M service is determined by the level of history, exam and MDM  New patient office visits, must all meet 3 out of 3 levels of the History, Exam and MDM  Example: History was comprehensive, exam was detailed and MDM was moderate, the criteria only a 99203 was met – only 2 out of the 3 levels for a 99204 were met

10. 3 of 3 versus 2 of 3  3 of 3 means each required element (History, Exam & MDM) are at least the same level or higher (can only code as high as the lowest level of the three that is documented)  New patient office visit, ER, Inpatient H&P or consult require 3 of 3  Detailed history, detailed exam and detailed MDM = Detailed new patient encounter  Problem Focused HPI, detailed exam and detailed MDM = Detailed established patient encounter  Established patient only requires 2 of 3  Example: History was comprehensive, exam was detailed and MDM was moderate, the criteria only a 99203 was met – only 2 out of the 3 levels for a 99204 were met

11. 99201, 99241, 99212 99202, 99242, 99213 99203, 99243, 99214 99204, 99244, 99215 HPIBrief (1-3) Brief (1-3) Extended (4+) Extended (4+) ROSN/A1 SystemExtended (2-9) Complete (10+) PFSHN/A Pertinent (1-3) Complete (3) Type of History Problem Focused ExpandedDetailedComprehensive

12. History Elements Chief Complaint is a clear and concise statement in the patient’s own words and documented by the provider Chief Complaint is a clear and concise statement in the patient’s own words and documented by the provider 3 Major sections of the Encounter 3 Major sections of the Encounter History History Includes chief complaint (CC), history of present illness (HPI), review of systems (ROS) and past medical, family and social history (PFSH) Includes chief complaint (CC), history of present illness (HPI), review of systems (ROS) and past medical, family and social history (PFSH) Exam Exam Medical Decision Making Medical Decision Making The provider’s “thought” process on paper The provider’s “thought” process on paper

13. History of Present Illness  The medical record should clearly reflect the chief complaint (the reason the patient came through the door)  History of present illness can either be brief (1-3 elements) or extended (4+)  Location  Quality  Severity  Duration  Timing  Context  Modifying Factors  Associated Signs and/or Symptoms

14. Review of Systems Constitutional Constitutional Eyes Eyes ENT ENT Cardiovascular Cardiovascular Respiratory Respiratory Gastrointestinal Gastrointestinal Genitourinary Genitourinary Musculoskeletal Integumentary Neurological Psychiatric Allergic/Immunologic Endocrine Hematologic/Lymphatic  Review of systems is the patient ’ s positive and pertinent negative response to a series of questions.

15. Past, Family & Social History  Can be obtained once in the medical record and then referred to at subsequent visits, with additions or changes added, as encountered  Must be initialed and dated to validate review by provider

16. Examination  Problem focused (examination of the affected body area)  Expanded problem focused (2-4 body areas/systems)  Detailed (5-7 body areas/systems)  Comprehensive (8+ body areas/systems)

17. Medical Decision Making Medical decision making is the provider’s “thought process” Medical decision making is the provider’s “thought process” Hardest element to translate into an audit form Hardest element to translate into an audit form The reason for encounter typically dictates the level of service selected The reason for encounter typically dictates the level of service selected

18. Medical Decision Making  Based on  Complexity of the diagnosis/management options  Amount of complexity of data reviewed  Risk to the patient Documentation of the MDM is hardest to quantify Putting provider’s “thought process” on paper

19. Medical Decision Making Levels of Risk (examples are not all inclusive) Levels of Risk (examples are not all inclusive) Minimal risk Minimal risk Sunburn, common cold, something a patient might not typically see a doctor for. Sunburn, common cold, something a patient might not typically see a doctor for. Low risk Low risk Well controlled hypertension, ankle sprain, cystitis Well controlled hypertension, ankle sprain, cystitis Moderate Risk Moderate Risk Exacerbation (mild) COPD, undiagnosed breast lump, pneumonia Exacerbation (mild) COPD, undiagnosed breast lump, pneumonia High Risk High Risk Severe exacerbation of COPD, acute renal failure, abrupt change in neurological status Severe exacerbation of COPD, acute renal failure, abrupt change in neurological status

20. Medical Decision Making  To qualify for a given level of decision making, 2 of the 3 elements must be met or exceeded  Example: A patient has stable diabetes, stable hypertension and stable COPD (2 or more stable chronic conditions-moderate), the provider orders lab (minimal) and continues the patient on current medication regimen (moderate) the level of Medical Decision Making is moderate

21. Time Based Visits  Provider must document amount of time related to counseling (more than 50%) and total time spent with patient  Provider must document subject matter discussed, the more detailed the better Example: 99213=a provider typically spends 15 minutes face-to-face. If more than 8 minutes was spent counseling the patient on a new diagnosis of hypertension, then the visit can be coded based on time, regardless of the complexity of the history, exam or MDM Example: 99213=a provider typically spends 15 minutes face-to-face. If more than 8 minutes was spent counseling the patient on a new diagnosis of hypertension, then the visit can be coded based on time, regardless of the complexity of the history, exam or MDM

22. The Hospital Card

23. History & Physical (99221-99223) 3 of 3 elements need to be met 3 of 3 elements need to be met No other E&M services provided on the same day (ER or office visit) if the admission is known No other E&M services provided on the same day (ER or office visit) if the admission is known Date of H&P should match date of admission to the floor Date of H&P should match date of admission to the floor

24. Subsequent Visits 99231-99233 2 of 3 elements need to be met 2 of 3 elements need to be met Review of medical record, reviewing results, changes in pt status since last assessment, examination Review of medical record, reviewing results, changes in pt status since last assessment, examination Time can be spent face to face or on the unit or floor Time can be spent face to face or on the unit or floor

25. Discharge 99238 & 99239 Must be a face to face encounter Must be a face to face encounter Time must be documented Time must be documented 99238 30 minutes 99238 30 minutes 99239 Greater than 30 minutes 99239 Greater than 30 minutes Preparation of discharge instructions, medications and/or placement arrangements Preparation of discharge instructions, medications and/or placement arrangements If a patient was seen in the AM and dies in the afternoon (without provider present) cannot be billed as a “discharge”. Only subsequent care provided in the AM encounter. If a patient was seen in the AM and dies in the afternoon (without provider present) cannot be billed as a “discharge”. Only subsequent care provided in the AM encounter.

26. Newborn Care  Initial assessment of newborn Initial treatment of a normal newborn, born in the hospital Initial treatment of a normal newborn, born in the hospital Subsequent visits Subsequent visits Evaluation of a normal newborn, per day Evaluation of a normal newborn, per day Discharge is the same as inpatient (99238 or 99239) Discharge is the same as inpatient (99238 or 99239) No charges are done by SFHC provider for NICU babies followed by a pediatrician No charges are done by SFHC provider for NICU babies followed by a pediatrician Can bill for “normal” newborn care on day 1 if baby was “healthy” and complications arise on day 2 that warrant pediatrician involvement. Documentation should support the change in billing Can bill for “normal” newborn care on day 1 if baby was “healthy” and complications arise on day 2 that warrant pediatrician involvement. Documentation should support the change in billing Circumcision is separately billable by performing provider Circumcision is separately billable by performing provider

27. Hospital Consultations  Entire care of patient is not assumed  In order to bill must have 3 “R”s in writing  Request for an opinion Render your opinion Render your opinion Reply back to requesting provider of findings or recommendations Reply back to requesting provider of findings or recommendations

28. Concurrent Care Patient is managed by multiple providers/specialties Patient is managed by multiple providers/specialties Each can bill for their services, if specific conditions are being followed by each provider Each can bill for their services, if specific conditions are being followed by each provider Can’t bill for “courtesy visits” Can’t bill for “courtesy visits”

29. Emergency Room Visits 5 levels of services that follow standard billing guidelines for a new patient (3 of 3 elements) 5 levels of services that follow standard billing guidelines for a new patient (3 of 3 elements) Procedures done during the visit are separately billable with supporting diagnoses Procedures done during the visit are separately billable with supporting diagnoses No card required No card required Billing is done off of dictated ER report Billing is done off of dictated ER report

30. OB H&P and Delivery No card required if normal delivery and aftercare No card required if normal delivery and aftercare Subsequent days may be billed if diagnosis supports additional care and treatment for complications/conditions Subsequent days may be billed if diagnosis supports additional care and treatment for complications/conditions Management of a patient admitted for observation is separately billable (premature contractions, injury or accident) Management of a patient admitted for observation is separately billable (premature contractions, injury or accident)

31. Critical Care Can be performed in any setting (inpatient, ER or office) Can be performed in any setting (inpatient, ER or office) Not billed just because a patient is in the ICU Not billed just because a patient is in the ICU Time-based codes-documentation of time is required Time-based codes-documentation of time is required Direct delivery of medical care for a critically ill or injured patient Direct delivery of medical care for a critically ill or injured patient Time spent providing critical care is based on total time spent engaging in work directly related to the individual patient Time spent providing critical care is based on total time spent engaging in work directly related to the individual patient

32. Critical Care Physician is not required to be at constant bedside, but may be involved in patient care decisions on the same floor or unit Physician is not required to be at constant bedside, but may be involved in patient care decisions on the same floor or unit Time spent outside the unit or floor may not be reported as critical care since the physician is not immediately available to the patient Time spent outside the unit or floor may not be reported as critical care since the physician is not immediately available to the patient Involves high complexity decision making to assess, manipulate and support vital system functions to prevent further life threatening deterioration of the patient’s condition Involves high complexity decision making to assess, manipulate and support vital system functions to prevent further life threatening deterioration of the patient’s condition

33. Assistant Surgery Billable by Resident if not related to rotation or covering rotation for another resident Billable by Resident if not related to rotation or covering rotation for another resident Hospital card required (mainly for tracking) Hospital card required (mainly for tracking) Billing is done from surgery report and surgeon’s billing Billing is done from surgery report and surgeon’s billing Charge is typically 25% of the surgeon’s fee Charge is typically 25% of the surgeon’s fee Billable by Resident if rotation service but established patient of the resident is the recipient of the surgery Billable by Resident if rotation service but established patient of the resident is the recipient of the surgery

34. Outpatient Procedures Billable by the Resident if not related to rotation or covering rotation for another Resident Billable by the Resident if not related to rotation or covering rotation for another Resident Hospital card required (mainly for tracking) Hospital card required (mainly for tracking)

35. Questions