1. Provider Evaluation & Management Training Christi Wesson, Assistant Director Misty Skelton, Assistant Director VMG Coding and Charge Entry 1

2. NP Billing  There are separate rules for billing Nurse Practitioner’s and nonbilling Nurse Practitioners.  Non Billing Nurse Practitioners can not bill for any services. The attending can only reference their ROS, Past, Family and Social history in order to bill. 2

3. Non Billing Acknowledgement 3

4. NP BILLING  NP billing for the admission service (this includes admission H&P’s)  According to the Vanderbilt Bylaws NP’s can not bill without the attending provider seeing the patient(except for CNM).  Prior to billing the attending will need to document his own note or countersign stating that he saw the patient and agrees with the NP’s note.  The preceptor will also need to review 20% of NP charts.  See next slides for appropriate Countersignature. 4

5. NP Countersignature For Reviewing 20% of the NP’s notes. For billing a shared visit and then documenting Key findings. 5

6. NP Billing cont.  Nurse Practitioners can bill and see patients for consults and consulting subsequent visits.  The attending does not have to attest or document a note prior to billing for these services.  These services are not shared visits.  If the attending and NP both document a note these can not be combined in order to bill.  Billing Nurse Practitioners can bill for procedures if it is within their scope of practice.  Critical Care cannot be a shared service. 6

7. Evaluation & Management Coding  3 Key Components in an E&M service  History  Exam  Medical Decision Making  The level of service selected is based on the extent of the history &/or exam, and the complexity of the medical decision making required and documented by the provider. 7

8. Elements of History  Chief Complaint (CC)  History of present illness (HPI)  Review of systems (ROS)  Past medical, family, social history (PFSH) 8

9. History of Present Illness  Location – Where is the pain/problem?  Quality – What type of pain? (throbbing, constant, improving, worsening, acute, chronic)  Severity – How bad is the pain? (scale of 1-10, functional status, compared to other types of pain)  Timing – When did you first experience the problem? Specific time of day? Nocturnal?  Duration – How long do the symptoms last? (Onset 3 days ago, since last Monday, yesterday)  Context – What are you doing when the problems occurs? Associated with meals, exercise, or stress?  Modifying factors – What have you tried to alleviate the problem? Medications? What changes/alters the complaint?  Associated signs and symptoms – What else is bothering you when this occurs? (Fever w/ chills, headache w/ blurry visions, diaphoresis w/ chest pain) 9

10. History of Present Illness cont.  Tip – 4 HPI needed for admits & consults levels 3-5  Tip – If any part of the history is unobtainable, you can document history unobtainable due to ______ (state the reason) Ex: pt intubated & sedated 10

11. Review of Systems (ROS) An inventory of body systems obtained through questions seeking to identify signs and/or symptoms which the patient has or has had.  Constitutional symptoms (e.g. fever, weight loss)  Eyes  Ears, Nose, Mouth, Throat  Cardiovascular  Respiratory  Gastrointestinal  Genitourinary  Musculoskeletal  Integumentary (including breasts)  Neurological  Psychiatric  Endocrine  Hematologic/Lymphatic  Allergic/Immunologic

12.  May be recorded by ancillary staff or on a form completed by the patient  Provider must document that he/she reviewed and confirmed information recorded by others.  If unable to obtain, document why  Pertinent positives and negatives must be referred to in the notes Review of Systems (ROS)

13. Unacceptable (ROS) statements  Review of system: negative  Review of system: None  Review of system Non-contributory  Review of system: unremarkable  Review of system: Full ROS was notable only for the findings listed in the HPI  10 point review of systems was completed and is negative unless otherwise stated  Review of systems per HPI otherwise negative

14. Acceptable (ROS) statements  Review of systems are obtained based on medical necessity. Systems with pertinent positive or negative responses must be individually documented.  Example:  Review of (# of systems reviewed) system is negative except for: MSK: chronic back pain that is flaring, no HSM  Review of (# of systems reviewed) system is negative except as discussed per HPI  Document all pertinent positive and negative findings and document “All other systems reviewed and negative”

15. Past, Family & Social History  Past (past illness, injuries, operations, treatments, current medications, allergies)  Family (medical events of patient’s family, hereditary disease)  Social (living arrangements, level of education) Tip: DON’T use “noncontributory” Can use negative, but must document negative for what 15

16. Physical Exam Findings Body Areas (7)  Head including face  Neck  Chest, including breast  Abdomen  Genitalia, groin  Back including spine  Each extremity Organ Systems (12)  Constitutional  Eyes  ENMT  Cardiovascular  Respiratory  GI  GU  Musculoskeletal  Skin  Neuro  Psych  Hem/Lymph/Immo

17.  Examples of Organ system exam:  Constitutional: Vital signs and general appearance  Eyes: Pupils: size, shape, equality, reaction to light & accommodation  ENMT: Sinus tenderness, pharynx, tonsils  Cardiovascular: Thrill, Rhythm, Sounds, Murmur, Edema  Respiratory: Breath Sounds, Wheeze, Spoken or Whispered voice.  GI: Hepatomegaly, Splenomegaly, Bowel sounds, bruits, rubs  GU: Examination of Bladder, Palpation of kidney -enlargement, CVA tenderness Physical Exam Findings

18.  Examples of Organ system exam:  Musculoskeletal: ROM (range of motion), Strength, Stability, Gait  Skin: Color, texture, lesions, moles, birthmarks, rashes, dermatitis, dermatoses, hyperhidrosis, actinic damage, ulcers  Neuro: Sensory examination, Reflex Examination  Psych: hallucinations, delusions, obsessions, compulsions, Time, place, person  Hem/Lymph/Immo: Palpable cervical, axillary, inguinal nodes 18

19. Medical Decision Making  2 of the 3 elements must be met or exceeded  Number of Diagnoses/Treatment Options  Amount & Complexity of Data  Level of Risk 19

20. Number of Diagnoses/Treatment Options  Each encounter should have an assessment/plan and diagnosis that is documented  Self limited/minor = 1  Est problem: stable/improved = 1  Est problem: worsening = 2  New problem: no work-up = 3  New problem: add work-up = 4 20

21. Amount & Complexity of Data  If a diagnostic service is ordered, planned, reviewed, or performed at the time of the E/M encounter, the type of service should be documented  Lab Test (80000 series) = 1  X-Ray (70000 series) = 1  Medical Test (90000 series) = 1  Discuss test with performing physician = 1  Independent review of images, testing or specimen = 2  Decision to obtain old records and/or hx from someone other than patient =1  Review/summarize old records and/or obtain hx from someone other than patient = 2 21

22. Table of Risk  Highest level of risk in any category determines the level of risk  Presenting Problem  Diagnostic Procedure  Management Options 22

23. Score Sheet – Table of Risk 23

24. Score Sheet – Type of Decision Making To qualify for a given type of decision making, 2 of the 3 elements in the table must be either met or exceeded. Type of Decision Making Str. ForwardLowModerateHigh # of Dx or Mgmt Options 0 or 1234+ Amount & Complexity of Data 0 or 1234+ Overall RiskMinimalLowModerateHigh 24

25. Evaluation & Management Services Inpatient Consultation (3 out of 3) LevelHXPEMDMTime 99251Problem Focused Straightforward20 99252Expanded PF Straightforward40 99253Detailed Low55 99254Comprehensive Moderate80 99255Comprehensive High110 Initial Hospital Care (3 out of 3) 99221Detailed/ Comprehensive Straightforward/ Low 30 99222Comprehensive Moderate50 99223Comprehensive High70 Subsequent Hospital Care (2 out of 3) 99231Problem Focused Straightforward/ Low 15 99232Expanded PF Moderate25 99233Detailed High35 25

26. Questions 26