Evaluation & Management

Coding and Documentation101 – the basicsStephanie Ann Call, MD MSPHVCU Internal Medicine Training

ProgramThe Practice of Medicine Series -

2009

Learning Objectives

At the end of this session, residents will be able to describe what medical documentation

facilitates identify three key components in

selecting the levels of E/M services select the appropriate level of an E&M

service for a new and established patient in either the outpatient or inpatient setting

identify resources for compliance

Evaluation and Management (E&M)

Documentation One of most commonly billed procedures May be billed for new or established

patients Includes office, hospital, nursing home

visits, consultations, phone and overall management, ICU care, discharge planning

1995/1997 Medicare guidelines – can use both

Medicare Physician Guide: A Resource for Residents, Practicing Physicians, and Other Health Care Professionals –http://www.cms.hhs.gov/MLNProducts/downloads/physicianguide.pdf Chapter 5 – E&M Documentation Great references and resource lists

Why document?

Medical /legal issues To tell the story of the patient –

communicate to others To have the opportunity for

reimbursement for the service provided “E&M documentation is the pathway

that translates a physician’s patient care work into the claims and reimbursement mechanism”

Medicare … “if it is not documented, it wasn’t done.”

What does documentation facilitate?

The ability to evaluate and plan the patient’s treatment

The ability to monitor patients health over time

Communication and continuity of care among healthcare professionals

Appropriate utilization review and quality of care evaluations

Collection of data for research and evaluation

General Principles of Documenting

Legibility – all documents MUST be legible Defined as easily read by peers (other

clinicians) Required information:

Patient name, MR, date of service on each page

Date AND time (for inpatient) Reason for encounter, relevant history,

PE findings Review of lab, x-ray data, other

ancillary services Assessment, clinical impression or

diagnosis Plan of care (including d/c plan if

appropriate) Legible identity of observer

(authenticated)

General Principles of Documenting

If not documented, rationale for ordering diagnostics or ancillary services should be easily inferred

Past and present diagnoses should be accessible to physician – can be in chart

Appropriate health risk factors should be identified

Patient progress, response to and changes in treatment should be documented

General Principles of Documenting

Documentation should support the intensity of the evaluation or treatment, including thought processes and complexity of medical decision making

All entries should be dated and authenticated by physician signature

CPT and ICD-9-CM codes reported should reflect documentaton in the medical records

Components of an E&M service

Seven components use to define level of E&M service (exceptions to rule if predominantly counseling or coordination of care) Key components

History Examination Medical Decision Making

Contributory components Counseling Coordination of Care Nature of Presenting Problem Time

Components of an E&M service

Seven components use to define level of E&M service (exceptions to rule if predominantly counseling or coordination of care) Key components

History Examination Medical Decision Making

Contributory components Counseling Coordination of Care Nature of Presenting Problem Time

Used in selecting level of E/M service (some exceptions)

Determining Level of Service

Table to determine appropriate level of service based on documentation (as a reflection of complexity of care provided) in three key component areas

Each key component has graded levels Different criteria for new patient vs

established Different criteria for inpatient vs

outpatient Procedure codes identified by tables –

determine the level of service and amount of reimbursement (99201, 99202, 99203, etc)

Key Components

History Physical Examination Decision Making

History – elements (4)

Chief complaint (CC) Required for ALL levels of E/M coding Reason for encounter If follow up … “follow up for …” NOT “routine f/u” Must be documented by resident, NP, PA

or attending History of Present Illness (HPI) Review of Systems (ROS) Past, Family, Social History (PFSH)

History HPI elements

Location Quality Severity Duration Timing Context Modifying Factors Associated Signs and Symptoms

Level of History Brief – status of 1-2 chronic conditions or 1-3

above Extended – status of 3 chronic conditions or

4+ above

History Review of Systems (ROS)

Do not have to write a notation for all systems Document the positive and pertinent negatives

“all other systems negative” – include number checked

Should have “usual” template Level for ROS based on number of

systems Problem pertinent – related to problem only +/- Extended – positive and pertinent responses for 2-9

systems Complete ROS is 10+

ROS Constitutional, eyes, ears, nose, throat, cv,

respiratory, gi, gu, musculoskeletal, skin, neuro, psych, endo, heme, lymph, allergic, immunological

History

Past, Family and Social (PFSH) Past History – review of patient’s past

illnesses, injuries, treatments Includes major illness, injury, operations,

prior hospitalizations, current meds, allergies

Social History – age appropriate review of past and current activities

May include marital status, living situation, employment and occupational hx, use of drugs/alcohol/tobacco, ed

Family History – review of medical events in family

History

PFSH Pertinent – review of history area

directly related to problem identified in HPI – at least one item from any of P, F, S

Complete – review of 2-3 PFSH areas if f/u visit, 3/3 areas if new patient

History – E/M levels

Problem Focused CC, 1-3 HPI elements

Expanded Problem Focused CC, 1-3 HPI, problem pertinent system

review (>1) Detailed

CC, 4+ HPI, problem pertinent ROS + 2-9 additional ROS, pertinent PFSH (1 element)

Comprehensive CC, 4+ HPI, complete ROS (10+),

complete PFSH

History

Type of History

HPI ROS PFSH

Problem Focused

Brief 1-3

N/A N/A

Expanded Problem Focused

Brief 1-3

Problem Pertinent

>1

N/A

Detailed Extended 4+

Extended 2-9

Pertinent 1

Comprehensive

Extended 4+

Compete (10+)

Complete 2/3 or 3/3*

Exam

Organ systems For a general multi-system exam

Body areas

Exam – Organ Systems

Vital Signs, General Symptoms Eyes ENT CV Respiratory GI

GU Musculoskeletal Skin Neurological Psychiatric Heme/Lymph/Immuno

Exam – Body Areas

Head/face Neck Breast/Axillary Abdomen Genitalia Back/spine Extremity

Exam

Document specific abnormal and relevant negative findings of affected or symptomatic area

Document abnormal or unexpected findings of unaffected or asymptomatic areas

“abnormal” is insufficient Templates ok Reference cards, review sheets

Exam – levels (see p81 guide)

Problem focused Limited to affected body area or organ system

(1-6 elements) Expanded Problem Focused

Affected system plus other symptomatic or related (6)

Detailed Extended exam of affected area and other

symptomatic or related organ system Comprehensive

Multisystem exam (8-12) or complete single system

Medical Decision Making

Medical Decision Making - tips

TELL THE STORY The medical record must clearly

support all diagnoses reported on the claim

Document impressions, diagnoses, tests ordered and/or reviewed AND the plan of care

What is the complexity of care for this patient AT THIS TIME?

Is the patient improved, resolved, unresponding?

Medical Decision Making

Complexity of establishing a diagnosis

Four types/levels – guided by … The number of diagnoses or

management options The amount or complexity of data

ordered or reviewed The risk of complications and

morbidity/mortality

Medical Decision Making

4 levels Straightforward Low Complexity Moderate Complexity High Complexity

3 subcomponents Diagnoses and Management Options Amount and Complexity of Data Risk of Complications

Decision Making

To qualify for a specific level of Decision Making, 2 of the 3 elements listed for that specific category must be met or exceeded

Diagnosed problems less complex than undiagnosed

Consider How many diagnostic tests ordered Did you request a consult

Diagnoses and Management Options

For established diagnosis Improved, resolved, unresponding

If diagnosis not established Possible, probable, rule out

Document treatment plan Include medication changes

Therapies Patient instructions, nursing

instructions

Amount and complexity of data

Review and/or order of clinical lab and XR tests

Review and/or order of diagnostic tests XR, scans, nuclear med, cardiac cath,

echo, ekg, eeg, non-invasive vasc, PFTs Document review of old records Document information from family

or caretaker Summarize relevant findings, if any

If not, document fact that reviews done

Risk of complication

Minimal Low Moderate High

Documenting Risk

See tables on “risk” Make sure to document

Co-morbidities Underlying diseases Other factors increasing risk

Medical Decision Making

MDM - Level

Dx/Mgmt Data Risk

Straight-forward

Minimal < 2

elements

Minimal/none

< 1 element

Minimal

Low Limited 3-4

elements

Limited 2

elements

Low

Moderate Multiple 5-6

elements

Multiple 3

elements

Moderate

High Extensive > 7

elements

Extensive > 4

elements

High

What code do I choose?

Step 1: Is the patient New or Established, Inpatient or Outpatient? New = 3 key components Established = 2 of 3 key components

Step 2: What level of History and Exam was performed? Use reference card for definitions

Step 3: Review the 3 subcomponents for Medical Decision Making ‘meets or exceeds’ is issue

What code do I choose?

Step 4: Compare your assessments against the requirements for a given level of service May not match exactly ‘meets or exceeds’ is key phrase

New and Established Patients

3 of 3 Key Components New patient office Initial Inpatient Admission Initial Consultation

2 of 3 Key Components Established Office Subsequent Inpatient care

Time

Choose code based on face-to-face time with the patient when OVER 50% of the visit was spent in counseling Document the total time spent with the

patient Document the total time spent in

counseling Document the content of the

counseling, and Choose the level of E/M by the total

amount of time

Other E&M Issues

Consultations Incident to

NPs, PAs, midwives, Clinical Nurse Specialists

Shared visits Involves physician and non-physician

practitioner Prolonged services Critical Care Teaching Physicians (including GE

exemption codes)

Learning Objectives

At the end of this session, residents will Be able to describe what medical

documentation facilitates Be able to identify three key

components in selecting the levels of E/M services

Be able to select the appropriate level of an E&M service for a new and established patient in either the outpatient or inpatient setting

Be able to identify resources for compliance