1. Evaluation and Management (E/M) Services

2. General Documentation Guidelines
The documentation of each patient encounter should include:
The reason for encounter and relevant history, physical examination findings, and prior diagnostic test results
An assessment, clinical impression, or diagnosis
Plan for care
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

3. Key Components of an E/M Service
History
Physical Examination
Medical Decision Making

4. Key Components of an E/M Service
Three out of three key components required (History, Physical Exam, Medical Decision Making):
New Patient Office Visits ( )
Outpatient Consultations ( )
Initial Hospital Care ( )
Inpatient Consultations ( )
Emergency Room Visit ( )
**Please note: Only 2 out of 3 PFSH required

5. Key Components of an E/M Service
Only two out of the three components required (History or Physical Exam AND Medical Decision Making):
**Please note: Medical Decision Making must be counted as one of the key components when determining code level.
Established Patient Office Visits ( )
Subsequent Hospital Care ( )

6. History – Key Component #1
Chief Complaint (CC) – Required for EVERY note
History of Present Illness (HPI)
Review of Systems (ROS)
Past, Family and Social History (PFSH)

7. HPI Elements
Location: Where do the patient's symptoms occur?  Head, shoulders, knees, toes etc.
Quality:  Includes a description of the type of pain: burning, stabbing, dull, achy, radiating, throbbing, etc. Describe a sore throat as scratchy
Severity: Patient's symptoms (getting better or worse, increasing or decreasing, pain scale of 1-10).  The patient might be feeling well
Duration: Any description about the duration of the length of the patient's symptoms, illness or condition. For ex. history of mild burning pain in the groin that has become more intense and frequent for the last two weeks
Timing:  Is it intermittent, continuous, constant, upon awakening or after exercising
Context:  Where the patient is and what the patient does when the symptoms or signs begin for ex. after slipping on ice, playing sports, sitting in chair or in relation to another illness or surgery
Modifying factors:  Any treatment prescribed by a physician or tried by the patient without physician direction. Things that make it better or worse.
Associated signs and symptoms: Other findings that the patient presents with, related or unrelated to today's chief complaint.  Positive complaints

8. Case Study – History of Present Illness (HPI)
CC: Chest pain
The patient is a 68 year old male who presents with chest pain (location) which began approximately two hours ago (duration). The pain is described as crushing (quality) and 8/10 (severity). He states the pain has been constant (timing) and has also had nausea and shortness of breath (associated signs and symptoms). He has no known heart disease . Pain improved following administration of IV morphine (modifying factors).

9. Case Study – History of Present Illness (HPI)

10. Review of Systems (ROS)
A review of systems is an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced.
Constitutional symptoms (ex. eating/sleeping well)
Eyes
Ears, Nose, Mouth, Throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary (skin and/or breast)
Neurological
Psychiatric
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic

11. Case Study – Review of Systems (ROS)
General – Positive for occasional fatigue, negative for fevers or chills Cardiovascular – Intermittent lower extremity edema, no orthopnea or paroxysmal nocturnal dyspnea Pulmonary – Negative for cough, hemoptysis or pleuritic chest pain All other systems were reviewed and are negative

12. Case Study – Review of Systems (ROS)
Positive and pertinent negative responses should be documented in the patient’s medical record. In addition the statement “all other systems reviewed and are negative” is the only acceptable verbiage that can be used to qualify for a complete ROS

13. Past, Family and Social History (PFSH)
PFSH consists of a review of 3 areas:
Past medical history - personal illnesses, injuries operations and medication
Family history - review of family medical illnesses (hereditary & potential risks)
Social history - age appropriate review of past and current activities (drinking, smoking, employment, marital status, education)

14. Case Study – Past, Family and Social History
PMH: Hypertension, NIRDM, dyslipidemia, GERD and gout as well as a tonsillectomy over 25 years ago, NKDA FH: Father died at age 48 of acute MI, mother is still alive in her 90’s with Alzheimer’s disease, he has no siblings and on grown son in good health. SH: Patient quit smoking in 1978 after 15 year, 1 pack a day history. Drinks 2 to 3 martini’s per day. Lives with his wife of 35 years.

15. Case Study – Past, Family and Social History

16. Four History Types Problem focused (PF) Detailed
Expanded Problem Focused (EPF) Comprehensive

17. History
The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.
This may be included in the progress note (e.g.; ROS and PFSH reviewed and discussed with patient)
If the patient is unable to give a history, the practitioner must describe the patient’s condition or other circumstance which precludes obtaining a history.
Common examples include:
Altered mental status
Dementia
Urgency of the condition
A foreign language barrier does not qualify.

18. Physical Exam – Key Component #2
Body Areas
Head, including face
Neck
Chest, including breast and axillae
Abdomen
Genitalia, groin, buttocks
Back, including spine
Each extremity
Organ Systems
Constitutional, vital signs, general appearance
Eyes
Ears, nose, mouth, throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
Neurologic
Psychiatric
Hematologic/lymphatic/immunologic

19. Physical Exam Types Problem focused – 1 body area or organ system
Expanded problem focused – 2-4 body areas or organ systems
Detailed –5-7 body areas or organ systems
Comprehensive – 8 or more organ systems ONLY

20. Case Study – Physical Exam
Vitals: 180/75 General appearance: Anxious and agitated, well nourished white male looks stated age Eyes: Anicteric sclerae, moist conjunctiva with no lid-lag, PERRLA HENT: AT/NC, oropharynx clear with moist mucous membranes and normal hard/soft palate Neck: Trachea midline, supple, no thyromegaly or carotid bruits, no JVD Lungs: CTA in front with bibasilar posterior crackles worse on the left, normal respiratory effort CV: RRR, no MRGs, hyperdynamic PMI in midclavicular line Abdomen: Soft, non-tender, no masses or HSM, normal pulsatile abdominal aorta without bruits Ext: 1+ bipedal edema with symmetrically diminished pedal pulses, no digital cyanosis Skin: Normal temperature, turgor and texture, no rash, no ulcers or nodules Neuro: Cranial nerves II – XII grossly intact, symmetrically decreased light touch sensation in both lower extremities Psych: Appropriate affect, alert and oriented x 3

21. Physical Exam Types (continued)
Constitutional Eyes ENT RESP CV GI GU MS
Integumentary Neuro Psych Lymph

22. Medical Decision Making (MDM) – Key Component #3
Four levels of Medical Decision Making
Straightforward
Low Complexity
Moderate Complexity
High Complexity

23. Case Study – Medical Decision Making (MDM)
Assessment
Chest pain with high suspicion for unstable angina or acute MI
Sub-optimally controlled hypertension
Stable Diabetes
Plan
Follow results of cardiac enzymes ASAP
Admit to CCU with IV morphine as needed for pain
ASA
IV metoprolol
NTG drip
Heparin drip per protocol
Echocardiogram today
Sliding scale insulin
Monitor and control hypertension

24. Case Study – Medical Decision Making (MDM)
Chest pain with high suspicion for unstable angina or acute MI
Sub-optimally controlled hypertension
Stable diabetes

25. Case Study – Medical Decision Making (MDM)
Provider ordered and reviewed labs, EKG and chest

27. Case Study – Medical Decision Making (MDM)
Putting it all together

28. Selecting the Level of Service

29. E/M Coding Based on Time
In the case of visits which consist predominantly of counseling or coordination of care, time is the key or controlling factor to qualify for a particular level of E/M service.
Time spent counseling must be greater than 50% of the encounter.
Documentation Example: I spent ___ minutes total time with the patient and ___ minutes was spent counseling the patient regarding _________________ (add details of counseling)

30. Discharge Day Management
minutes or less
More than 30 minutes
Time must be documented when billing code 99239
Example: I spent approximately 40 minutes
performing these discharge day management
services. Education was given on the patient
diabetes, blood glucose goals and self-monitoring. In
addition we discussed diet and knowing when to administer insulin.

31. Discharge Day Management
Documentation should include:
Final examination of the patient (face to face time must be documented)
Discussion of the hospital stay even if the time spent by the physician on that date is not continuous
Instructions for continuing care to all relevant caregivers
Preparation of discharge records
Prescriptions
Referral forms
Signature

32. Consultation Documentation Requirements
Documentation should include the FOUR R’s:
Consultation REQUESTS are to be noted in the patient’s written record (who requested).
The REASON for the request must be noted.
RENDERING the service (History, Physical Exam and Medical Decision Making).
Consulting physicians must provide a written REPORT of findings back to the requesting entity.
Consultation Codes are not be used in these circumstances:
Transfer of care (physician has agreed to accept transfer of care prior to an initial evaluation)
A consultation initiated at the request of patient or family

33. Consultation Documentation Requirements
Acceptable Consultation Verbiage:
Patient sent by Dr. Doe for my evaluation of COPD (consult performed on an inpatient, with a report in the medical record)
Dear Dr. Primary, Thank you for requesting my opinion about Mr. Smith’s headaches. I think it’s all in his head! (Request documented, opinion rendered, letter serves as the report)
Dear Dr. Bones, at your request, I have evaluated Ms. Hip’s medical condition prior to her surgery. I find her medical problems to be ABC. She is cleared for surgery. (Request documented, opinion rendered, letter serves as the report)

34. Diagnosis Coding
Support the medical necessity and level of service coded
Must be supported by documentation
Should be coded to the highest degree of specificity
If no definitive diagnosis, must code based on signs and symptoms
Cannot code “rule out” diagnosis
Should not be assigned when a diagnosis is mentioned in the history and is not addressed, except when care is affected or the diagnosis is actively treated by you
All diagnosis codes must be sequenced/linked (1,2,3, etc.) to the corresponding CPT code

35. Questions?