Assigning E&M Codes

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Copyright 2006 American Health Information Management Association. All rights reserved.

Assigning Evaluat ion andManagement Code Levels

Practical Tools for Seminar Learning


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Disclaimer

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The American Health Information Management Association makes norepresentation or guarantee with respect to the contents herein and specificallydisclaims any implied guarantee of suitability for any specific purpose. AHIMA hasno liability or responsibility to any person or entity with respect to any loss ordamage caused by the use of this audio seminar, including but not limited to any

loss of revenue, interruption of service, loss of business, or indirect damagesresulting from the use of this program. AHIMA makes no guarantee that the useof this program will prevent differences of opinion or disputes with Medicare orother third party payers as to the amount that will be paid to providers of service.

How to earn one (1) CEU for participationTo earn one (1) continuing education unit, each participant must do the following:

Step 1: Listen to the seminar, via Webcast link, audio CD, or MP3.

Step 2: Complete the assessment quiz contained in this resource book.Use the included answer key. Do not returnthe quiz to AHIMA.Save it for your records.

Step 3: Fax or mail us the completed sign-in form from this resource book.

The fax number and address are located at the bottom of the form.

Step 4: Print the certificate of attendance for each listener. The certificate must be

retained by each participant as a record of their participation, along with a copyof their completed quiz.

After listening to the seminar, please let us know what you think, by completing our online

evaluation survey at http://campus.ahima.org/audio/fastfactsresources.htm


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Faculty

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Susan M. Hull, MPH, RHIA, CCS, CCS-P

Susan M. Hull, MPH, RHIA, CCS, CCS-P is a professional practice resources managerfor the American Health Information Management Association (AHIMA). In her role as

manager, Susan provides professional expertise to AHIMA members, the media, and

outside organizations on coding practice issues, and develops written products aimedat furthering the art and science of coding.

Susan has over 20 years experience in the HIM field. Before joining AHIMA in 2002,she served as Senior Executive Director for HMI Corporation where she oversawcoding reviews; chargemaster maintenance and development; and presented seminars

in outpatient, inpatient, and physician documentation and coding. Prior to this, sheworked in numerous HIM roles, including consultant, HIM department director, andHIM software developer and manager.

In addition to AHIMA, Susan is actively involved as a volunteer in the HIM profession.She has presented on timely HIM topics to the Health Information ManagementAssociations of California, Tennessee, and Southern Illinois, as well as the SouthernIllinois Healthcare Financial Management Association.

Susan received a bachelor of arts degree and a master of public health in HealthServices and Hospital Administration from the University of California, Los Angeles.


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Table of Contents

Disclaimer ..................................................................................................................... i

How to earn one (1) CEU for participation......................................................................... i

Faculty .........................................................................................................................ii

Basis for E&M level coding .............................................................................................. 1

New vs. established patients ........................................................................................... 1History ........................................................................................................................ 2

Review of systems.............................................................................................. 2

PFSH................................................................................................................. 3

Time as a determining factor........................................................................................ 4-5

Who may document ....................................................................................................... 5

Physical examination ................................................................................................... 6-7

Physical examination (1995 guidelines) ............................................................................ 7

Physical examination (1997 guidelines) ............................................................................ 8

Medical decision making ................................................................................................. 8

Categories of problems ....................................................................................... 9

Categories of data reviewed................................................................................ 9

Management options .........................................................................................10

Summary......................................................................................................................11

AHIMA Audio Seminars..................................................................................................12

About assessment quiz ..................................................................................................12

Thank you for attending (with link for evaluation survey) .................................................13

Appendix ..................................................................................................................14

Assessment Quiz

Continuing Education Credit and Compliance Sign-in Form

Certificate of Attendance and Quiz Completion

Quiz Answer Key


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Assigning E&M Code Levels

1

Notes Comments

Basis for E&M level coding

Evaluation and management levels areassigned based upon documentation of:

History

Physical examination

Medical decision making

In specific cases, time isthe determining factor

1

New vs. established patients

ANew patient has not received face-to-face

professional services from the provider or another

provider of the same specialty who belongs to the

same group w ith in the past 3 years.

AnEstablishedpatient has received face-to-face

professional services from the provider or another

provider of the same specialty who belongs to the

same group w ith in the past 3 years.

2


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2

Notes Comments

History

History of present illness

Seven parameters:

Location where i t is

Duration how long you have had it

Timing when it occurs

Context what you are doing when it occurs

Severity how bad is it

Modifying factors what makes it better or worse

Associated signs and symptom s what else doyou feel at the same time

3

History Review of systems

Constitutional

Eyes

ENT

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Musculoskeletal

Integumentary

Neurological

Psychiatric

Endocrine

Hematologic/lymphatic

Allergic/immunologic

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3

Notes Comments

History PFSH

Past history

Prior major il lnesses, injuries,hospitalizations and operations

Current medications

Allergies

Immunization status (age appropriate)

Feeding/dietary status (age appropriate)

Continued

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History PFSH

Family history Significant inherited conditions

Anything that m ight place the patient at risk

Social history Marital status/ living arrangements

Occupational history

Use of drugs, alcohol, tobacco

Educational history

Sexual history

(Continued)

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6

Notes Comments


Two sets of documentation guidelines forphysical exam ination

1995 guidelines better for general examination

1997 guidelines better for specialty exam ination

May use either, but must be consistent

w ithin a patient encounter

11

Physical exam ination

1995 and 1997 guidelines are availableon the CMS w eb site at:http:/ / new.cms.hhs.gov/M edlearnProducts/ 20_DocGuide.asp

Basically the only thing that is different isthe documentation guidelines for physicalexamination

(Continued)

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7

Notes Comments


1995 guidelines based on either body areas or organ systems

For purposes of examination, the following bodyareas are recognized: Head, including the face

Neck

Chest, including breasts and axi llae

Abdomen

Genitalia, groin, buttocks

Back, including spine

Each extremity

(Continued)

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Physical examination organ systems

Constitu tional (e.g.,vital signs, generalappearance)

Eyes

Ears, nose, mouth andthroat

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Musculoskeletal

Skin

Neurologic

Psychiatric

Hematologic/lymphatic/immunologic

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Notes Comments


1997 guidelines General multisystem examination

Single system (specialty) examination

Cardiovascular

Ears, Nose, Mouth and Throat

Eyes

Genitourinary (Female)

Genitourinary (Male)

Hematologic/Lymphatic/Immunologic

Musculoskeletal

Neurological

Psychiatric Respiratory

Skin

(Continued)

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Medical decision mak ing

The most difficult to quantify

Based upon nature of the presentingproblem, amount and complexity ofinformation that must be analyzed

Nature of the diagnosis and treatment plans

Risk of significant disability or impairmentif an error is made

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9

Notes Comments


Categories of problems

Minor or self-lim ited, stable, improv ing orworsening 1 point

Established problem, stable 1 point

Established problem, worsening 2 points

New problem, no addit ional workup 3 points

New problem, workup planned 4 points

(Continued)

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Categories of data reviewed

Order/ review cl inical laboratory tests 1 point

Order/ review radiology tests 1 point

Order/ review medicine tests 1 point

Discuss test results w ith performer 1 point

Obtain old records/ obtain history from thirdparty/ discuss case with provider 2 points

Independent review of images,tracing or report 2 points

(Continued)

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Notes Comments

Summary

Assignment of evaluation and managementcodes is based upon documentation ofhistory, physical examination and medicaldecision making in most cases

Guidelines apply to most evaluation andmanagement code sets

Time is determinant is select cases

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Summary

All criteria applied must be documented inthe medical record and readily available

Established patients require that two ofthree components meet the level to beassigned; new patients and ED patientsrequire that all be met

(Continued)

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Notes Comments

AHIM A Audio Seminars

Visit our Web sitehttp://campus.AHIMA.org

for updated information on thecurrent seminar schedule.While online, you can also register forlive seminars or order CDs andWebcasts of past seminars.

2006 American Health Information Management Association

Assessment

To access the assessment quiz that follows thisseminar, download the seminars resource book at

http://campus.ahima.org/audio/fastfactsresources.html

Your sign-in form and certificate of completion are also foundin the resource book.


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Notes Comments

Thank you for attending!

Please visit the AHIMA Audio SeminarsWeb site to complete your evaluationform online at:

http://campus.ahima.org/audio/fastfactsresources.html


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Appendix

Assessment Quiz

Continuing Education Credit and Compliance Sign-in Form

Certificate of Attendance and Quiz Completion

Quiz Answer Key


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Assessment Quiz Assigning Evaluation and Management Code Levels

ANSWERS to this quiz are found on the last page of the

seminar resource book, Practical Tools for Seminar Learning.

To earn continuing education credit of one (1) AHIMA CEU, Fast Facts Audio Seminar listeners must also completethis 10-question quiz. This CE credit is for attending the audio seminar AND completing this quiz. Please keep acopy of the completed quiz with your certificate of attendance. Do not send a copy to AHIMA .

1. For purposes of assigning evaluation andmanagement codes, an established patient is

one who __________.a. has been seen by the provider before

b. has received face-to-face professional servicesfrom the provider or other member of thesame specialty in the same group within thepast three years

c. has received professional services from theprovider or other member of the samespecialty in the same group within the pastthree years

d. has received face-to-face professional servicesfrom the provider or other member of the

same specialty in the same group within thepast year

2. Time is the determining factor in assigningevaluation and management codes when__________.

a. counseling consumes more than half the timeof the visit

b. the visit takes longer than usual

c. any time that the provider feels that it isappropriate

d. coding visits to patients in skilled nursingfacilities

3. For purposes of assigning evaluation andmanagement codes, which of the following is notconsidered counseling?

a. Advice re life style modification in combatingeffects of disease

b. Interactive psychotherapy

c. Discussion of medication administration andside-effects

d. Provision of educational resources

4. True or false? Only the physician may documenthistory, physical examination and medical

decision making.a. True

b. False

5. Which of the following statements re selection of

1995 vs. 1997 documentation guidelines is false?(answer choices are in next column)

a. Either may be chosen for a specific patient.

b. The physician must use the same set of

guidelines for all patients.

c. The 1995 guidelines are better to use forgeneral examinations.

d. The guidelines are available for download on

the CMS website.

6. A description of what you are doing when asymptom occurs is considered to bedocumentation of the __________ of thecomplaint.

a. context

b. timing

c. locationd. None of the above

7. True or false? Medical decision making is themost difficult of the three components ofevaluation and management coding to quantityas it can be somewhat subjective.

a. True

b. False

8. An established problem that is worsening isworth how many points in the medical decision

making process?

a. 1 point

b. 2 points

c. 3 points

d. 4 points

9. Elective major surgery without identified

significant risk is considered to be a __________level management option.

a. low

b. minimal

c. moderate

d. high

10. True or false? In assigning risk, pick the lowest

level in any of the three sections of data review,management options and nature of presentingproblem.

a. True

b. False

Do not send a copy of completed quizzes to AHIMA. Please keep them with your certificate of attendance, for yourrecords. Be sure to complete and send the seminar sign-in sheet found on the next page of this resource book.


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Certificate of Attendance

Fast Facts Audio Seminar

Assigning Evaluationand Management Code Levels

_____________________________________Name

_____________________________________AHIMA ID Number

_____________________________________Date Attended

_____________________________________

Anne M. WillmoreProject Manager

Distance Education

The American Health In formation Management Associationhas approved this program for one (1) continuing education unit.

Participant certifies that he or she has attended this audio seminarand completed the accompanying quiz.

Retain this certificate as evidence of participation.No record will be kept at AHIMA of your participation.


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Quiz Answer KeyFast Facts Audio Seminar: Assigning Evaluation and Management Code Levels

1: b; 2: a; 3: b; 4: false; 5: b; 6: b; 7: true; 8: b; 9: c; 10: false

Do not send a copy of your completed Fast Facts Audio Seminar quiz to AHIMA.Please keep it with your certificate of attendance, for your records.

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Assigning E&M Codes