Evaluation and
Management Coding
Or, This Means More Than It Used To!!!
Disclaimer• All CPT codes trademarked by the American Medical
Association. All rights reserved.• CARRIERS may differ on E&M auditing criteria--
see TRAILBLAZER. • This should not be the only source used for
coding and billing. All coding and billing decisions should be made on a case-by-case basis based upon documentation and insurance guidelines.
• All information contained herein is valid for the date of this seminar only. This presentation is based on national guidelines.
• Some E/M guidelines are very subjective and decisions about levels can be up to an individual auditor.
• This presentation is a summary only. For Medicare regulations, see http://www.cms.hhs.govor your local Medicare web site.
Agenda Common Oncology Issues
1995 versus 1997 Criteria
CMS Documentation Guidelines
Major Components
Consultations
Common Oncology Services
Strategies for Success
Common Problems in
Oncology Legibility
Knowledge of criteria
Consultations
Non-compliant forms
Templates same for everyone
Counseling
Mismatch of billed DOS and actual DOS.
Medical Records Salvo
“If it wasn’t written, it wasn’t done:
Caveats “If you can’t read it, it wasn’t done” “If you can’t find it, it wasn’t done” “If it is not filed in the record, it wasn’t done.” “If it was not ordered, it wasn’t necessary.”
Documentation Guidelines
General Principles (CMS) The medical record must be complete and
legible. The documentation of the each patient
encounter must include Reason for the encounter and relevant history,
physical, and prior health examination results; Assessment, clinical impression, or diagnosis; Plan for care; and, Date and legible identity of the observer.
CMS Documentation
Guidelines (cont’d) If not documented, the rationale for ordering
diagnostic and other ancillary services should easily be inferred.
Past and present diagnoses should be accessible to the treating and/or consulting physician.
Appropriate health risk factors should be identified.
The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented.
AND, the CPT and ICD-9-CM codes reported on the bill should be supported by the documentation in the medical record.
Source: CMS E/M Documentation Guidelines
Do your records meet these
standards?
1995 Versus 1997 Criteria for E&M
Only difference is the physical exam In 1997, single organ exams that do not really
apply to Oncologists, e.g. musculoskeletal, urologic.
1997 multi-system exam is much more detailed and is harder to get to a higher code, unless documentation is detailed.
1997 does give credit for partial exams of body areas or organ systems, which 1995 does not.
1995 is used most frequently by Oncologists. But, Medicare will use either.
See these at http://www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp
Driving Force of Practical E&M
“ NPP (the nature of the presenting problem)…is the indicator for selecting the appropriate level of medical care warranted by the severity of the patient’s illness.”
THE NATURE OF THE PRESENTING PROBLEM INDICATES THE LEVEL OF MEDICAL CARE AND CODING WARRANTED BY THE PATIENT’S ILLNESS. IT IS THE CPT CODING SYSTEM’S E&M VEHICLE FOR EVALUATING MEDICAL NECESSITY.
Practical E/M
Stephen R. Levinson, MD
Nature of the Presenting Problem
99231--Usually the patient is stable, recovering, or improving
99232--Usually the patient is responding inadequately to therapy or has developed a minor complication.
99233--Usually the patient is unstable or has developed a significant complication or new problem.
Medical Necessity (Trailblazer)
1. The guiding principle of Medicare is whether an item or service was “medically necessary”. For E&M, this means
Frequency of service/ intensity of service. Separate from whether criteria was met. Does the H&P meet the patient’s actual
needs at the time of service?
Medical Necessity (Trailblazer)
2. Information used by Medicare is contained within the medical record documentation of the history, physical, and medical decision-making. Medical necessity is based on these attributes:
Number, acuity, and severity of problems addressed in the E&M criteria.
The context of the service in terms of other services previously rendered for the same problem.
Complexity of documented co-morbidities that influence physician work.
Physical scope encompassed by the problems, i.e. number of physical systems affected by the problem.
Medical Necessity Tips (Trailblazer)
Identify presenting complaints and/or reasons for the visit. Demonstrate the history, physical and MDM
associated with each. Demonstrate how physician work was affected by
co-morbidities or chronic problems noted.
Ensure that the nature of the presenting problem is consistent with the level billed (99213 = low to moderate severity).
Become familiar with the clinical examples in CPT Appendix C.
Use Tools Not Rules!
Components of E&M Services
Major Components History Physical Medical Decision-making
Number of these: All three for consults, initial admissions, and
new patients 2 of 3 for established or follow up encounters.
Components of E&M Services
Other Components Counseling Coordination of Care Nature of Presenting Problem Time
The History Chief Complaint
History of Present Illness (HPI)
Review of Systems (ROS)
Past, Family, and Social History
History Chief Complaint--Brief statement,generally
in the patient’s own words or by the physician, conveying the reason for the visit to the physician. This can be documented by the patient, the nurse, or the provider.
Chief Complaint The medical record should clearly reflect
the chief complaint.
The chief complaint should be the reason that instigated today’s encounter.
This can include symptom, problem, condition, diagnosis, return to ordered by physician, or other factor that is the reason for the encounter.
Don’t say that patient in for “follow up” with no problem for which they need follow up.
History of Present Illness
HPI is a chronological narrative of the course of the patient’s presenting illness, from its initial date of diagnosis to the present visit. This should also include any complicating factors or co-morbidities. The HPI includes assessment and documentation of one to eight elements…
History of Present Illness (HPI)
Elements include: Location Quality Severity Duration Timing Context Modifying Factors Associated Signs and Symptoms
History of Present illness
Documentation of HPI BRIEF:1-3 elements of the HPI. EXTENDED: 4 or more elements of the HPI.
The specificity of the HPI can describe the medical necessity of why the patient is being seen and the level of service that may be billed.
Review of Systems
Documents the patient’s responses to a series of questions of their experiences, symptoms, or irregularities in fourteen medical systems. This can be current (since the last visit) or chronic but still a factor.
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 th information, there must be a notation supplementing or confirming information recorded by others.
Review of Systems
Systems to be documented (Count ‘em 14 systems) Constitutional Eyes Ear, Nose, Throat, Mouth Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary (includes breasts) Neurological Psychiatric Endocrine Hematological/lymphatic Allergic/immunologic
Review of Systems (ROS)
A problem pertinent ROS identified, through a series of questions, inquires about the system directly related to the problem
Extended ROS must identify the positive responses and pertinent negatives for at least (2) and not more than (9) systems
For a complete ROS, ten organ systems must be reviewed The attending physician may use “All other systems negative” when (2) pertinent positives and/or negatives are documented. In absence of such a notation, all systems must be documented. Oncologists miss this in their consults more than 50% of the time in my database.
If unable to obtain, document why, If the patient is unable to communicate due to mental state or language barrier “ROS unavailable due to …..” unconscious, intubated, poor historian, non-English speaking.
Review of Systems
Levels Problem pertinent = Review of systems
pertinent to the problem Extended =2-9 organ systems Complete = 10 organ systems
Review of Systems
Tips for ROS Can be documented by NP, RN, the patient on a form,
or from another MD’s history—but, should sign, confirm, and date or refer to it in dictation.
If available in the chart, can use former ones if referred to by date of exam--but it must be relevant to today’s service.
Can document positive response to (at least two) applicable systems and state all other (out of 14) systems are “non contributory”, but must be obvious that the questions were asked.
ROS should be in there for noted presenting problems.
Past, Family, Social History
What are they? PAST: Patient’s past experience with illnesses,
operations, injuries,medications (prescriptions, herbal, OTC), allergies, and treatments.
FAMILY: Medical events in the patient’s family that pose a risk to the patient and/or are related to the current illness or chief complaint.
SOCIAL: An age appropriate review of past and current activity which can include marital status, employment history, sexual history, living arrangements, smoking (primary and secondary), drinking, or exposure to environmental toxins.
Past, Family, Social History
Levels: Pertinent = At least one from any of these areas Complete:
For established patients in the office at least two of these.
For new patients and hospital patients, plus initial visits anywhere all three are necessary
Can refer to a prior assessment and state that it is unchanged. Again, this is questionable if it appears in every single visit.
Do not state that PFSH is ‘non-contributory’. State the actual status of question asked.
Use Of Forms (WPS)
In this era of needing to ensure services are accurately and thoroughly documented, there is a growing use of templates and/or checklists used by providers. Providers appreciate these helpful tools and aid because checklists help save time.
Examination templates and checklists are considered acceptable documentation. However, when using them they need to be used correctly. When a service is not documented properly on a checklist, medical necessity is unsubstantiated and the level of E & M service billed will be denied or downcoded.
Use Of Forms/ Templates (WPS)
A brief statement or notation indicating “negative” or “normal” is sufficient to document normal findings.
Abnormal findings must be described.
A key to any list symbols or abbreviations must be available to Medicare auditors as necessary.
Signatures and identification of providers is necessary on forms.
The History of Present Illness must be performed by the provider.
Use of Forms/ Templates (WPS)
The ROS and PFSH may be recorded by the ancillary staff or the patient on a form. The checklist must have a place for the physician or other provider to state they have reviewed it. The physician must make a notation supplementing or confirming the information recorded by others.
If the ROS or PFSH are unchanged from a previous encounter, it does not need to reiterated If the physician reviewed and updated the previous information, it may be noted by stating the date and location of these findings with a statement of update and/or a statement that all elements are unchanged.
Examination (1995)
Body Areas: Head including face Neck Chest including breasts and axillae Abdomen Back Genitalia, groin, and buttocks Each extremity
Can only be used in lower level visits.
Examination Organ Systems
Constitutional Eyes Ear, Nose, Throat, Mouth Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary (includes breasts) Neurological Psychiatric Endocrine Hematological/lymphatic Allergic/immunologic
Examination (1995)
Levels: Problem Focused = a limited exam of affected
body area or organ system. Expanded Problem Focused = a limited exam of
affected areas and other symptomatic or related organ systems (2-7 organ systems).
Detailed = an extended examination of affected areas and other symptomatic or related organs (2-7 organ systems).
Comprehensive = a general multi-system examination or a complete examination of a single organ system. Generally, this is 8-12 organ systems for a multi-system exam.
The Examination (1995)
Tips the Exam: It is preferable that a provider performs the exam as necessary
to ascertain abnormalities. But, Nurses and MAs can do constitutional as necessary.
The type of exam must be relevant to the diagnosis and the severity of the problem. Doing a comprehensive exam or having a template that does it can be a problem unless the patient actually needs the exam. Again, the Nature of Presenting Problem should drive the level of the exam.
The depth of the exam description can drive whether it is DETAILED OR EPF, both are 2-7 organ systems. ENTM must include the ears, nose, throat, and mouth. Lymph nodes must be include the entire system
Always examine systems most relevant to the presenting problem.
Medical Decision-Making
What is this? The number of possible diagnoses and
treatment options that must be considered in light of the presenting problem and HPI.
The amount or complexity of data considered, i.e. diagnostic tests, medical records, and/or other information obtained including from additional providers.
The risk of significant complications, morbidity, or mortality associated with the patient’s presenting problems, diagnostic procedures ordered, and/or possible or definite treatment options.
Medical Decision Making (MDM)
Four levels: Straightforward Low complexity Moderate complexity
complexity High
Dx./mgt. options
0-1 2 3 4
Amount of data
0-1 2 3 4
Overall risk Minimal Low Moderate High
Level of MDM Straightforward
9924199242
Low992219923199243
Moderate992229923299244
High992239923399245
Two of the three areas:Dx. Options, Amount of Data, and Risk Establish the MDM Level
Medical Decision-Making
Number of Diagnoses and Treatment Options Diagnosis (es) treated today are those counted. Patients with co-morbidities that impact current
treatment are more complex. These should be discussed.
For established diagnoses, it should be shown if they are worsening, improved, controlled or complicating.
The necessity to change the course of treatment must be documented. If the treatment is unchanged, this is a lower level of decision-making.
Referrals and consultations are a treatment option.
Number of
Diagnoses/Treatment Options This what diagnoses you considered in
making a decision for today’s encounters. Just because a patient has lots of diagnoses does not always put you at a higher level.
Improved, feeling well, or stable lower the intensity of the diagnosis criteria.
Consultations, review of information with other physicians to arrive at a treatment or diagnosis is considered higher level.
Amount or Complexity of Data
Reviewed Types of testing done and reviewed
dictates severity, i.e. a cardiac cath as opposed to a CBC.
Independent review of specimens and smears is more complex.
Review of old records or obtaining a history from someone other than the patient is a higher level, if new information is obtained.
Discussions of tests with the performing physician is considered more complex.
Medical Decision Making Data Elements
Amount and/or Complexity of data reviewedPoints are assigned to each section below based on the number of data items reviewed max = 4 pts
Points
Total
Review and/or order of clinical labs 1 1
Review and/or order of tests radiologic study, other non invasive diagnostic study
1
Discussion of diagnostic study w/interpreting MD 1
Decision to obtain old records and/or obtaining history from someone other than the patient
1
Review and summarization of old records or gathering data from source other than patient
2
Independent visualization of image, tracing or specimen itself
2 2
Total Points 3
Risk of Significant
Complications, Morbidity,
and/or Mortality Co-morbidities, complications, metastases
that complicate current decision should be documented.
Chemo, Radiation, surgery, and invasive testing decisions all increase the risk as these are risky procedures. These count as risky even if you are the ordering physician and are deciding upon those today.
Some Medical Oncology patients are high risk by virtue of their current diagnoses or treatment plan—but not all are.
Counseling/Coordination of
Care When counseling
dominates >50% of the visit, time may be used as the dominating factor---BUT READ THE FINE PRINT!
Counseling/Coordination of
Care Must document the following:
Total Visit Time 99214 = 25 minutes 99215 = 40 minutes
Time Spent Counseling Subject Matter of Counseling—diagnosis,
prognosis, code status, side effects, chemo options, etc.
This is incorrectly documented or under-billed in Medical Oncology.
Counseling/ Coordination of
Care
Counseling is a discussion with the patient and family concerning one or more of the following areas: Diagnostic results, impressions, and /or
recommended diagnostic studies; Prognosis, risks and benefits of management
(treatment) options; instructions for management and/or follow-up; importance of compliance with chosen management options;
Risk factor reduction; and patient family education
Putting it All Together: Office
VisitsKey Factors 2 of 3
Level 5 Level 4 Level 3
History• HPI• ROS• PFSH
• 4• 10• 2 of 3
• 4• 2• 1 of 3
• 1• 1• NA
EXAM ≥ 8 organ systems
a) An extended exam of affected area or b) 12 bullets (1997)
a) Limited exam of affected and related system or b) 6 bullets (1997)
MDM (2 of 3)• Dx/Tx Options• Data• Risk
High Complexity• Extensive• Extensive• High
Moderate• Multiple• Moderate• Moderate
Low Complexity• Limited• Limited• Low
Allowed Charges
Bell Curve 2007: Hem-Onc
99211 99212 99213 99214 992150.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
Office Visits Medicare 2007 Hematology-Oncology
Your MC %Your Provider %
Putting it All Together-- Consults
Key Factors 3 of 3
Level 5 Level 4 Level 3
History• HPI• ROS• PFSH
• 4• 10• All Three
• 4• 10• All Three
• 4• 2• 1 of 3
EXAM ≥ 8 organ systems
≥ 8 organ systems
a) An extended exam of affected area or b) 12 bullets (1997)
MDM (2 of 3)• Dx/Tx Options• Data• Risk
High Complexity• Extensive• Extensive• High
Moderate• Multiple• Moderate• Moderate
Low Complexity• Limited• Limited• Low
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CONSULT CHANGES FOR MEDICARE 2010
CMS has long had confusing rules relative to consults. So, the easiest way to deal with the problem is to eliminate them altogether. What this means is: New consults in the office will be coded as New Patients
(99201-99205). This means that no one in practice of your specialty has seen the patient at all for 36 months.
Established consults in the office will be coded as Established Patients (99212-99215)…this is not an exact match with consultation criteria.
Hospital consults will be coded as Admissions (99221-99223) with a new modifier (“AI”) signifying who was the admitting physician. There is no exact crosswalk of five levels to three.
TeleHealth consults are the exception. They have special G-codes.
53
Why?
Link to the Final RuleThe section showing the consultation changes can
begins on page 61767
http://edocket.access.gpo.gov/2009/pdf/E9-26502.pdf
53
54
New PatientsService
Performed
CPT Code
Documentation required
History/Exam/MDM
Problem Severity
Medicare
Consult level 1
99241(15 min)
PF/PF/Straightforward Self limited or minor
99201(10 min)
Consult level 2
99242(30 min)
EPF/EPF/Straightforward Low severity 99202(20 min)
Consult level 3
99243(40 min)
Detailed/Detailed/Low Moderate severity
99203(30 min)
Consult level 4
99244(60 min)
Comp./Comp./Moderate Moderate to high severity
99204(45 min)
Consult level 5
99245(80 min)
Comp./Comp./High Moderate to high severity
99205(60 min) 54
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Established Patients
ServicePerformed
CPT Code Documentation required(All 3 to 2 out of 3)
History/Exam/MDM
Problem Severity Medicare
Consult level 1 99241(15 min)
PF/PF/Straightforward Self limited or minor 99212(10 min)
Consult level 2 99242(30 min)
EPF/EPF/Straightforward or Low for 99213
Low severity 99213(15 min)
Consult level 3 99243(40 min)
Detailed/Detailed/Low or Moderate for 99214
Moderate severity 99213 or 99214(15-25 min)
Consult level 4 99244(60 min)
Comp./Comp./Moderate or High for 99215
Moderate to high severity
99214 or 99215(25-40 min)
Consult level 5 99245(80 min)
Comp./Comp./High Moderate to high severity
99215(40 min)
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Inpatient Consults
CPT Code History Exam MDMTraditional Medicare
99251(20 min)
PF Hx PF Exam SF MDM
99252(40 min)
EPF HX EPF Exam SF MDM
99253(55 min)
Det Hx Det Exam Low MDM 99221(30 min)
99254(80 min)
Comp Hx Comp Exam Moderate MDM
99222(50 min)
99255(110 min)
Comp Hx Comp Exam High MDM 99223(70 min)
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THE GOOD NEWS IS….
Your documentation only needs to match the code you are using…no need for all the complex consultation documentation!!!
Initial Hospital Visits regardless of reason are 99221-99223
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BUDGET NEUTRALITY???
Consult Code Maps to Percentage Mapped
2010 Price
99241($48.69)
9920199211
50%50%
$38.95$19.12
99242($91.61)
9920299212
50%50%
$67.44$38.95
99243($125.15)
9920399213
50%50%
$97.74$65.54
99244($185.38)
992o499214
50%50%
$151.48$98.46
99245($226.50)
9920599215
50%50%
$190.43$132.73
Source: CMS Website from Frank Cohen; 2010 NF RVUs; 2009 CF and GPCIs =1
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CPT RULE CHANGES 2010 Concurrent Care
“Concurrent care is provision of similar services (e.g. hospital visits) to the same patient by more than one physician on the same day. When concurrent care is
provided, no special reporting is required.”
Transfer of Care “Transfer of care is the process whereby a physician
who is providing management for all or some of a patient’s problems relinquishes this responsibility to another physician who EXPLICITLY agrees to accept this responsibility and, who from the initial encounter is not providing consultative services.”
“Consultation codes should not be reported by the physician who has agreed to accept the transfer of care before the initial evaluation, but are appropriate to report if the decision to accept the transfer of care cannot be made until after the initial consultation…”
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CPT CONSULTATIONS 2010
“A consultation is a type of evaluation and management service provided by a physician at the request of another physician or appropriate source to either recommend care for a specific condition or problem or determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition or problem.”
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CPT CONSULTATIONS
Evaluation and Management (E/M): Consultations: To clarify the two situations under which consultations may be reported, the Evaluation and Management (E/M) section subheading, "Consultations" has been revised. These situations are: 1) to provide opinion/services for a specific condition or problem, or 2) to allow a determination to be made on whether to accept the ongoing management of the patient's entire care or for the care of a specific condition or problem (i.e. transfer of care AFTER an evaluation of the patient's problem). CPT outlined that documentation of the written or verbal request for a consultation can be done by either the consultant or by the requesting physician or other appropriate source. You may remember that Medicare requires (until January 1) that BOTH the requesting and consulting physicians document the request. But, the request DOES need to be documented.
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CPT CHANGES FOR CONSULTATIONS 2010
Patients and/or families cannot initiate consultations.
Transfer of care definition in both office and hospital consults.
All admitting E/M services are bundled into an inpatient consultation on the date of admission.
Only one consult in the hospital or nursing facility stay. This includes inpatient and outpatient consultations.
Documentation: Request Opinion Written report
Allowed Charges
The Bell Curve
What can you do?o PEER REVIEW!
Physicians should use forms or software to audit their partners’ E&M. This works in two ways--improves understanding and brings pressure to change.
Read the E&M guidelines EVERY SIX MONTHS.
Read PRACTICAL E/M by Stephen Levinson.
Use templates, forms, and EMR algorithms wisely.
What can you do? Do not tolerate illegible notes.
Enlist support from these areas: Nurse Practitioners and PAs (for more efficiency in
your practice). Patient Surveys (Read and Sign Off) Past Reports (Refer back)
Blanks in dictation can be gaps in payment or liability issues.
Do not forget to document diagnoses.
Treat your medical records like your checkbook!
Contact Info Contact
[email protected] [email protected] 800-795-2633
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