1. Webcast Session II An Introduction to Evaluation and Management (EM) Coding Accurate Coding for Evaluation and Management (EM) Services A webcast designed for headache and migraine specialists Presenters Stuart B. Black, MD American Headache Society (AHS) Sheila J. Madhani, MA, MPH, CCS-P MARC Associates
October 16, 2007

2. Goals Introduction to CPT EM codes
How to properly select the appropriate level of Medical Decision Making (MDM) for a specific EM encounter
Application of CPT coding guidelines and practices to clinical scenarios relevant to headache specialists

3. What Will We Discuss? Importance of accurate coding
Key components of EM codes
How to properly select the appropriate level of Medical Decision Making (MDM) for a specific EM encounter
General principles of medical record documentation
Clinical examples
Coding resources

4. Importance of Accurate Coding
Full and fair description of services provided
Avoid over-coding (fraud and abuse) and under-coding (not reporting all the services you have provided)
Improve quality of patient care

5. Importance of Accurate Coding
Physicians use EM codes to report professional services
Documentation in the medical record must support the EM code and ICD-9 code(s) submitted
Submitting a code that is not supported by documentation may be considered fraud

6. Key Components of EM Codes
Three key components must be considered and supported by documentation in the medical record before selecting a code
History
Examination
Medical decision making (MDM)

7. Key Components History
Summary
Elements
Problem Focused
Expanded Problem Focused
Detailed
Comprehensive
HPI
History of Present Illness
Brief
(1-3 elements)
Extended
(4 or more elements)
ROS
Review of Systems
None
Problem Specific
Complete
PFSH
Past Medical, Family and Social History
Pertinent

8. Key Components Physical Examination
Summary – 1997 Guidelines, Single System Specialty Exam, Neurological
Level of Exam
1997 Single Organ System
Problem focused
1-5 elements
Expanded Problem Focused
At least 6 elements
Detailed
At least 12 elements
Comprehensive
Perform all elements
Document all elements in
Constitutional
Eyes
Musculoskeletal
Neurological
Document 1 element in
Cardiovascular

9. How to properly select the appropriate level of Medical Decision Making (MDM) for a specific EM encounter

10. Medical Decision Making (MDM)
What is medical decision making (MDM)?
MDM refers to the complexity of establishing a diagnosis and/or selecting a management option
Of the three key components of EM, MDM is the most challenging to meet and document

11. Medical Decision Making (MDM)
MDM Factors
Factor #1: Number of diagnoses or management options
Number of possible diagnoses
Number of options that must be considered
Levels
Minimal
Limited
Multiple
Extensive

12. Medical Decision Making (MDM)
MDM Factors
Factor #2: Amount and/or complexity of data to be reviewed
Amount and/or complexity of medical records, diagnostic tests and/or other information that must be obtained, reviewed and analyzed
Levels
Minimal or none
Limited
Moderate
Extensive

13. Medical Decision Making (MDM)
MDM Factors
Factor #3: Risk of complications and/or morbidity or mortality
The risk of significant complications, morbidity and/or mortality associated with the patient’s presenting problem
The risk of comorbidities associated with the patient’s presenting problem
The risk of the diagnostic procedure(s) and/or the possible management options
Levels
Minimal
Low
Moderate
High

14. Medical Decision Making (MDM)
What are the different levels of MDM?
Straightforward
Low complexity
Moderate complexity
High complexity

15. Medical Decision Making (MDM)
How do I determine the level of MDM for a specific EM encounter?
The level of MDM is based on the level of complexity of the 3 factors of MDM
Number of diagnoses or management options
Amount and/or complexity of data to be reviewed
Risk of complications and/or morbidity or mortality

16. Medical Decision Making (MDM)
How do I determine the level of MDM for a specific EM encounter?
The level of MDM is based on the level of complexity of the 3 factors of MDM
#1 - Number of diagnoses or management options
#2 - Amount and/or complexity of data to be reviewed
#3 - Risk of complications and/or morbidity or mortality
Type of decision making
(Level of MDM)
Minimal
Minimal or None
Straightforward
Limited
Low
Low Complexity
Multiple
Moderate
Moderate Complexity
Extensive
High
High Complexity

17. Medical Decision Making (MDM)
The next few slides provide the following guidance
Issues to consider when determining the level of complexity of the 3 factors of MDM
Recommendations for documenting MDM
Based on 1997 EM Guidelines, Centers for Medicare and Medicaid Services (CMS)

18. Medical Decision Making (MDM)
Factor #1: Number of diagnoses or management options
Issues to consider
MDM is easier for a diagnosed problem than for an identified but undiagnosed problem
Problems which are improving are less complex than problems that are worsening or failing to change as expected
The need to ask advice from an outside source is an indication of complexity of diagnosis

19. Medical Decision Making (MDM)
Factor #1: Number of diagnoses or management options
Documentation recommendations
An assessment, clinical impression or diagnosis should be documented
Initiation of treatment or changes in treatment should be documented
Any referrals or consultations, advice sought should be documented

20. Medical Decision Making (MDM)
Factor #2: Amount and/or complexity of data to be reviewed
Issues to consider
The type of diagnostic testing ordered or reviewed
Decision to review old medical records and/or obtain history from a source other than the patient increases complexity
Discussion of contradictory or unexpected results with the physician who performed or interpreted test increases complexity

21. Medical Decision Making (MDM)
Factor #2: Amount and/or complexity of data to be reviewed
Documentation recommendations
Any of the following tasks should be documented
Any diagnostic services ordered, planned or scheduled
The review of lab, radiology and/or other diagnostic tests
Decision to obtain old records or obtain additional history from other sources that the patient
Relevant findings from the review of old records and/or additional history
Discussion of diagnostic tests with the physician who performed them
The direct visualization and independent interpretation of an image, tracing or specimen

22. Medical Decision Making (MDM)
Factor #3: Risk of significant complications, morbidity, and/or mortality
Issues to consider
Risk associated with the presenting problem
Risks associated with the diagnostic procedure(s)
Risks associated with the possible management problems

23. Medical Decision Making (MDM)
Factor #3: Risk of significant complications, morbidity, and/or mortality
Documentation recommendations
Any of the following risks should be documented
Comorbidities/underlying diseases
Surgical or invasive diagnostic procedures ordered, planned or scheduled at the time of the EM
Any invasive or surgical diagnostic procedure performed at the time of the EM encounter
The referral for or decision to perform a surgical or invasive diagnostic procedure on an urgent basis

24. Medical Decision Making (MDM)
Risk Table
CMS has developed a risk table to help determine the level of medical decision making for a specific EM encounter (minimal, low, moderate, high)
Table includes common clinical scenarios
Table provides an assessment of risk in 3 categories
Presenting problem(s)
Diagnostic procedure(s) ordered
Management options selected
Highest level of risk in any 1 category determines the overall risk

25. Centers for Medicare and Medicaid Services (CMS), Documentation Guidelines for EM, 1997.

26. Key Components Medical Decision Making (MDM)
Table of Risk
For headache specialists the most important risk categories are:
Number of treatment options
The levels of risk complications and/or morbidity or mortality

27. Medical Decision Making (MDM)
Table of Risk Comparison – elements relevant to headache specialists extracted from Table of Risk
Number of Treatment Options
Risk of Complications
Minimum
Rest
One self limited or minor problem
Low
Over the counter drugs
Stable chronic illness
Moderate
Prescription drug management
One or more chronic illnesses with mild exacerbation
High
Drug therapy requiring intensive monitoring for toxicity
One or more chronic illnesses with severe exacerbation

28. Medical Decision Making (MDM)
MDM scoring system
Methodology to determine level of MDM developed by private organizations
There are several systems currently in use
Based on a point system that takes qualitative information collected by the provider and translates it into quantitative data
More points; higher level of service
Example that follows was developed by the American Health Information Management Association (AHIMA)
In general scoring systems are not part of any CMS guidelines or recommendations

29. Medical Decision Making (MDM)
MDM scoring system example
Factor 1: Number of Diagnoses or Treatment Options (more than 1 may apply)
Number of Diagnoses or Treatment Options
Points
Self limited or minor 1
Established problem; stable
Established problem; worsening 2
New problem; no additional workup 3
New problem (to examiner); additional workup 4

30. Medical Decision Making (MDM)
MDM scoring system example
Factor 2: Amount/Complexity of Data Reviewed (more than 1 may apply)
Data Reviewed
Points
Order/review clinical lab tests 1
Order/review from radiology services
Order/review from medical services
Discussion of tests results with performing provider
Decision to obtain old records/history/discuss case with provider 2
Independent visualization of image, tracing or report

31. Medical Decision Making (MDM)
MDM scoring system example
Factor 3: Risk of significant complications
Minimal
Low
Moderate
High

32. Medical Decision Making (MDM)
MDM scoring system example
Straightforward
Low Complexity
Moderate Complexity
High Complexity
Diagnosis/
Management Options
<=1 2 3
>=4
Amount/Complexity of Data
Risk
Minimal
Low
Moderate
High

33. Medical Decision Making (MDM)
Summary
Number of diagnoses or management options
Amount and/or complexity of data to be reviewed
Risk of complications and/or morbidity or mortality
Type of decision making
(Level of MDM)
Minimal
Minimal or None
Straightforward
Limited
Low
Low Complexity
Multiple
Moderate
Moderate Complexity
Extensive
High
High Complexity

34. Choosing an appropriate level of EM service
Based on Key Components
The three key components must be considered and supported by documentation in the medical record before selecting a code
History
Examination
Medical decision making (MDM)

35. Choosing an appropriate level of EM service
New patient, office/outpatient and office consultations
You must meet or exceed ALL of the requirements to qualify for a particular level of an EM service
Established patient, office/outpatient
You must meet or exceed 2 out of the 3 requirements to qualify for a particular level of an EM service

36. Summary New Patient – Office/OP (3 out of 3) Code History Exam
Medical Decision Making
99201
Problem focused
Straightforward
99202
Extended problem focused
99203
Detailed
Low complexity
99204
Comprehensive
Moderate Complexity
99205
High Complexity

37. Summary Office or other Outpatient Consultation (3 out of 3) Code
History
Exam
Medical Decision Making
99241
Problem focused
Straightforward
99242
Extended problem focused
99243
Detailed
Low complexity
99244
Comprehensive
Moderate Complexity
99245
High Complexity

38. Summary Established Patient – Office/OP (2 out of 3) Code History Exam
Medical Decision Making
99211
Minimum services; Physician not required
99212
Problem focused
Straightforward
99213
Extended Problem Focused
Low complexity
99214
Detailed
Moderate Complexity
99215
Comprehensive
High Complexity

39. Time
Time determines the level of E/M service when counseling and/or coordination of care dominate (> 50%) the encounter
Counseling and coordination is separate from the history, physical exam and medical decision making
More common scenario for headache specialists
The extent of counseling and/or coordination of care must be documented in the medical record independent of the three key components

40. Documentation General Principles of Medical Record Documentation¹
Medical record should be complete and legible
The documentation of each patient encounter should include:
Reasons for the encounter and relevant history, physical examination findings and prior diagnostic test results;
Assessment, clinical impression or diagnosis;
Plan for care; and
Date and legible identity of the provider
If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred
¹ 1997 EM Guidelines, Centers for Medicare and Medicaid Services (CMS)

41. Documentation General Principles of Medical Record Documentation¹
Past and present diagnoses should be accessible
Appropriate health risk factors should be identified
Patients progress and response to changes in treatment should be included
CPT and ICD-9 codes submitted should be supported by documentation in the medical record
¹ 1997 EM Guidelines, 1997 EM Guidelines, Centers for Medicare and Medicaid Services (CMS)

42. Documentation Elements of a consultation
There are three documented elements that comprise a consultation
A written request, asking a question, for specific advice or specific management direction in the care of a patient
Documentation of the patient evaluation
A specific written response i.e. the answer to the question, as simple as “Yes, the patient didn’t have a PE and you may proceed with the surgery”
The unspoken fourth component- all of the above must materially contribute to the evaluation and/or management of the patient or the consult is not medically necessary

43. Clinical examples

44. Case #1 – History (HPI, ROS, PFSH)
70 yr old man with hx of DM. 6 months ago developed herpes zoster; right V1 distribution. After Rx of acute zoster developed constant, deep burning pain in V1 (R) with tic like pain and pain to light touch. Also developed severe (R) hemicranial headaches Under care of PCP; pain refractive to Rx. Referred to H/A Specialist for consult.

45. Case #1 Level of Care Physical Exam Diagnosis
99241?, 99242?, 99243?, 99244?, 99245?,
99201?, 99202?, 99203?, 99204?, 99205?
Physical Exam
Examination 23 bullets: BP 150/85; pulse 82 regular RR16. Carotids full. Pt did appear to be in acute distress with pain in V1 distribution of R trigeminal nerve. No skin lesions present.
M/S & Symbolic Function intact. CN; Normal except for extreme pain to touch (R) V1 area of face. Motor, Coordination, Gait, Reflexes WNL. Sensation otherwise intact
Diagnosis
1.History of Acute Herpes Zoster ; 2. Post Herpetic Neuralgia
3. Trigeminal Neuralgia; 4. New onset right hemicranial persistent headache; 5. Diabetes Mellitus - currently well controlled on oral medication
Complexity of Data Reviewed
1.Reviewed all records from consulting PCP and prior Neurologist; 2. Personal discussion with consulting Physician; 3. Reviewed all prior lab values; 4. Reviewed prior Ct and MRI of Head; 5. Reviewed all prior treatments
Risk
Risk of Presenting Problem:
Minimal?; Self Limited or Minor?; Low severity?; Moderate severity?
High severity?
Risk of Management Options?; Risk of Diagnostic Procedures?

46. Case #1
Pre-service
Reviewed all the patient’s referral records. Reviewed the medical history form completed by the patient, vital signs, additional information obtained by PA. Personal communication with referring physician
Intra-service
Comprehensive H&P performed
Reviewed relevant data, risks, and explained clinical features of Post Herpetic Neuralgia
Discussed diagnostic and therapeutic options
Discussed recommended treatment plan
Medical Decision Making
Number of Diagnoses or Treatment Options > 4
Amount / Complexity of Data Reviewed > 4
Using the Table of Risk:
“Acute or chronic illnesses or injuries that pose a threat to life or bodily function, e.g.. multiple trauma, acute MI, pulmonary embolus, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure”
“Drug therapy requiring intensive monitoring for toxicity” .

47. Case #1
Post-service
Complete medical record documentation and send written report to referring physician
Post 1st visit communicate with referring doctor and treat any treatment failures or AE’s if need
Receive and respond to any interval testing results or correspondence
Revise treatment plan if necessary and communicate with patient as necessary
The level of care would meet CPT criteria for an Office Consultation It includes a comprehensive H & P and MDM of high complexity. There has been no transfer of care.

48. Case #2 – History (HPI, ROS, PFSH)
27 year old woman, established pt, seen in follow up B/O MOH. Post hospital visit following detoxification week ago. Detailed review of post hospital instructions; discussed all medications; discussed Dx and risks of MOH; discussed situation with family and importance of family support. Scheduled for support group.

49. Case #2 Level of Care Physical Exam Diagnosis
99212; 99213; 99214; 99215; ; 99213; 99214; 99215
Physical Exam
BP 115/70; Pulse 65
Entire 30 minute encounter spent in Counseling and Coordination of Care. More than 50% of the time spent in face – to –face discussion with patient and family.
Diagnosis
1. Migraine w/o aura; 2.Transformed migraine; 3. Medication Overuse Headache
Complexity of Data Reviewed
The encounter was a “counseling visit”. A detailed and concise overview of the medical problem and current treatment plan was discussed with the patient and her family. Current and future care including the diagnoses, treatments, prognosis, risks, and management options discussed.
Risk
The risks of noncompliance reviewed at length.
The risks of the overall presenting problem reviewed.
The risk of not monitoring medication therapy reviewed.
Reviewed risk of morbidity; prolonged functional impairment.

50. Case #2
Pre-service
Reviewed medical record and hospitalization in detail before encounter with patient and her family.
Intra-service
Counseling and Coordination of care comprised more than 50% of the encounter; in fact it comprised 100% of the encounter. This was “face - to – face time with the patient and family. Although time is not taken into account as a factor for determining the level of E/M care for most medical encounters, time is often the key or controlling factor in selecting the level of service in headache management.
When counseling and Coordination of care is the CPT determining factor, there is no consideration of the extent of the history, the exam, the medical decision making required, or the nature of the presenting problem.

51. Case #2 Intra-service (cont.)
The time spent in Counseling/Coordination of care is the sole determinant of the E/M code.
Counseling is defined as a discussion with the patient and/or family or other care giver concerning: diagnostic results, prognosis, risks and benefits of treatment, instructions for management, compliance issues, risk factor reduction, patient and family education.
Coordination is defined as discussions about the patient’s care with other providers or agencies. Time is defined in the CPT codebook. For an established patient: =10min; 99213= 15 min; = 25 min; = 40 min.

52. Case #2
Post-service
The Physician must document the total length of time of the visit / encounter. In addition, the description of the counseling and / or activities involved in coordinating care must be documented.
The physician also must document that more than 50% of the encounter was involved in Consultation and / or Coordination of care. The E/M code for this visit would be Consultation and Coordination of care is a major factor in the management of headache patients.

53. Coding resources

54. Coding resources American Headache Society (AHS)
AHS’s Headache Coding Corner
American Medical Association
CPT-related resources
Centers for Medicare and Medicaid Service (CMS)
Evaluation and Management Services Guide
1997 Documentation Guidelines for Evaluation and Management Services

55. Thank You
The American Headache Society thanks you for your participation.
Please contact American Headache Society (AHS) headquarters for further information: or