Once you have identified the place of service, type of service, and patient status, you are ready to locate the information in the medical record that identifies the key components of the service.
The ROS may be asked by the physician, nurse, or by means of a questionnaire filled out by the patient or ancillary personnel. Regardless ofhow the information is obtained, before the information can qualify as an ROS, the physician must review the information and document the review in the medical record. The documentation includes both positive responses and pertinent negative responses related to the HPI.
The PFSH is a review of the past, family, and social history of the patient. Some encounters do not include any PFSH elements, whereasother encounters contain an extensive review of all elements.
The history is the subjective information the patient provides the physician, and the examination is the objective information the physician gathers. The examination is the findings that the physician observes during the encounter. The physician documents the examination in the medical record
1. Problem focused: Examination is limited to the affected BA or OS identified by the CC. It involves 1 OS or BA.2. Expanded problem focused: A limited examination of the affected BA or OS and other related BAs or OSs. It involves a limited examination of 2–7 BAs or OSs.3. Detailed: An extended examination of the affected BAs or related OSs. It involves an extended examination of 2–7 BAs or OSs.4. Comprehensive: This is the most extensive examination; it encompasses at least 8 OSs. For the purposes of this text, body areas will be counted for a comprehensive examination, although many coders only count organ systems
The key component of MDM is based on the complexity of the decision the physician must make regarding thepatient’s diagnosis and care.
None – Problem Focused None - Expanded problem focused 1 - Detailed 2-3 - Comprehensive
ScoringHPI – detailed (1)ROS – expanded problem focused (1)PFSH – Comprehensive (3)Level- expanded problem focused
Exam – Constitutional – no acute distressEndocrine – no thyromegalyLymphatic – no lymphadenopathyOphthalmologic – eyes: conjunctive are paleChest: barrel shapedRespiratory: rhonchi scattered in lung fields.Cardiac: regular rhythmExtremities – this exam is cardiovascular.Neurological: non focalOrgan systems documented: 7 Body area documented: 1Exam: Detailed
***When the Dr decides to treat the patient he discusses what he plans to do to the patient. He discusses how many illnesses the patient has. He also states what information he reviewed in order to make his decisions.
Number of dx: Peptic ulcer and tobacco abuseAmount and complexity of data to review: Blood workRisk to patient: Surgery required gastrectomy is needed. Recheck blood work to see if a partial or total Colonoscopy requested. Evaluate thyroid. Tobacco abuse affecting recoveryMedical decision making:
Low only need to have 2 of 3 for MDM
Evaluation and ManagementCall: 1-800-747-5150 (To listen and communicate)Access Code: 5328662
Objectives: At the end of the session the students will be able to:Perform diagnostic and procedural codingUnderstand the three factors upon which evaluation and managementcodes are based.Discuss the four contributing factorsReview the three key components of patient services Materials Required: The Next Step textbook CPT Code Book
The most often reported codesin the CPT manual are those inthe Evaluation andManagement (E/M) section.
BASICS THREE FACTORSThe codes in the E/M section arebased on three factors:1. Place of service2. Type of service3. Patient status
KEY COMPONENTSThe three key components are the history,examination, and medical decision-making complexity
Review of Systems (ROS).The ROS is an inventory of thebody systems obtained through aseries of questions.
Past, Family, Social History.The physician decides the extent of the PFSHbased on the needs of the patient.
History LevelsThe level is based on the extent of the history.1. Problem focused2. Expanded problem focused3. Detailed4. Comprehensive
ExaminationThe history is the subjective informationThe objective information is the findings of theexamination
S in regards to the SOAPnote is the subjectiveinformationO is the objectiveinformation in the SOAPnote
The following are the four levels of examinationbased on the extent of the examination:1. Problem focused: Examination is limited2. Expanded problem focused: A limited examination of the affected BA or OS and other related BAs or OSs.3. Detailed: An extended examination4. Comprehensive: This is the most extensive examination
Medical Decision Making ComplexityThe MDM is based on the complexity ofthe decision the physician must make
History: There are three elements of the history History of present illness, review of systems and personal family social history.History of present illness-Defined: The patient describes in his /her own words what happened tothem to bring them to see the doctor. For example when where and howthey got sick or injured. It is in the patient’s own words.PHI key concepts: There are 8 key concepts to look for in the history of presentillness.Location: where on the body is the problemQuality: Adjectives describing the pain: sharp, stabbing, throbbing, dullSeverity: on a scale of 1-10, the worse I ever hadDuration: I have had this problem for 2 weeks, Last night I got a feverTiming: When: In the morning I vomit, I fell in the afternoonContext: Under what circumstances did it occur: E Code!!!I fell, I was in a car accident, I was at work, I fell roller skatingModifying factors: What made the situation better or worse?I took a Tylenol for my headache, I wrapped my sprain ankleAssociated Signs and Symptoms: Fever with the cold, abrasions with the fracture
There are 4 types of history.Problem focusedExpanded problem focusedDetailedComprehensive1-3 elements is problem focused or expandedproblem focused4 or more elements is detailed or comprehensive.
Provider asks patient a series of questions (This is not aphysically exam).1. Constitutional2. Opthalmological (eyes)3. Otorhinolarynological (ENMT)4. Cardiovascular5. Respiratory6. Gastrointestinal7. Genitourinary8. Musculoskeletal9. Integumentary10. Neurological11. Psychiatric12. Endocrine13. Hematologic/Lymphatic14. Allergic/ Immunologic
None is problem focused1 is Expanded problem focused2-9 is detailed10 or more is comprehensive
Past, Family, Social HistoryThis is obtained by asking the patient a series of questions.Components: Are past illnesses. Operations, injuries,treatments and current medications discussed?Is the family history documented? We are looking for riskfactors.If it says non- contributory, it is still documented.Are social activities and employment documented?Each component is worth one point.
Case 1-11 The history section onlyHistory of Present Illness: She has been having problems with recurrentpeptic ulcer disease despite therapy with Zantac and Prilosec. She hasundergone recent endoscopies, which revealed a large ulcer that wasreported to be benign. The patient also noted to have a slightly elevatedCEA of 11. On June 30, the patient underwent laparoscopy which turnedout to be normal as well as benign. There were no signs oflymphadenopathy.Past Surgical history: Hysterectomy and Tubal ligationThe patient has never had a problem with anesthesia or surgery.Social History: Positive for smoking. The patient denies alcohol abusedand smokes 1 pack per day.Family History: Negative for colonic carcinoma, premature coronary arterydisease, but positive for severe peptic ulcer disease in her mother.Allergies: noneReview of systems; melena, hematochezia and hematemesisHPI – location peptic ulcerReview of systems: Gastrointestinal -ulcerPFSH – Personal – endoscopies, past surgical historySocial history – smokerFamily – mother positive for ulcer disease and negative for colon cancer
ScoringHPI – detailed (1)ROS – expanded problem focused (1)PFSH – Comprehensive (3)Level- expanded problem focused
Doctor physically examines the patient by touching thepatient.Problem focused exam – looks only at the problemExpanded problem focused – looks at 2-7 body systems.It looks at the problem and few related organ systemsDetailed looks at 2-7 organ systems -It looks at theproblem and more organ systemsComprehensive looks at 8 organ systems
Constitutional is worth one point regardless of the number of constitutional elementsexamined.Constitutional elementsBlood pressure pulse respiration temperatureHeight weight general appearanceBody areasHead neck chest – chest wall abdomen-exteriorGenitalia – groin back each extremityOrgan systems1.Ophthalmologic – eyes, pupils examined – PERRlA2. Otolaryngologic – ears nose mouth and throat.3. Cardiovascular - heart, arteries and veins – heart sounds, regular rate and rhythm, pulses present in extremities, edema4. Respiratory – how the lungs and respiratory track work, no abnormal lung sounds no rales and no crackles5. Gastrointestinal – how the internal organs of the abdomen work – bowel sounds present, bowel sounds absent.6. Genitourinary – urination frequency or burning, discomfort during sex, erectile disfunction7. Musculoskeletal – bones and muscles; reflexes present, bones intact8. Integumentary – skin: rashes, abrasions, lacerations, lesions9. Neurologic – nerves, cranial nerves intact, oriented times 3 = oriented to person place and time.10. Psychiatric – emotional stability –11. Hematologic/Lymphatic/Immunologic – no lymphadenopathy
Read case 1-11 the physical exam section only.When assessing the physical exam only read the physical exam section.Exam: demonstrates a slender Hispanic female in no acute distress. She isuncomfortable however, because of epigastric discomfort. Her neck issupple. There is no thyromegaly or regional lymphadenopathy. Nosubclavicular lymph nodes.ENT: within normal limits.EYE: Sclera anicteric. Conjunctive are pale.Fundoscopic exam shows no AV nicking, hemorrhages exudates orpapilledema. Chest is barrel shaped without dullness to percussion but with rhonchiscattered throughout the lung fields. Prolonged expiratory phase wasnoted.Cardiac exam: Regular rhythm. Distant heart sounds; 1/6 systolic ejectionmurmur at the base. Abdomen is soft and tender to palpation; Epigastric area without reboundtenderness or guarding. Liver span is 7 cm edge at right costal margin. Aorta diameter is normal. Extremities upper and lower leg show no edema and swelling.Neurological exam is non-focal.
Exam – Constitutional – no acute distress (No points…no work involved)Endocrine – no thyromegalyLymphatic – no lymphadenopathyOphthalmologic – eyes: conjunctive are paleChest: barrel shapedRespiratory: rhonchi scattered in lung fields.Cardiac: regular rhythmExtremities – this exam is cardiovascular.Neurological: non focalOrgan systems documented: 7Body area documented: 1Exam: Detailed
Medical Decision Making There are 4 types of medical decision making. Straight Forward Low Complexity Moderate Complexity High Complexity Items we look at 3 things for medical decision making. Number of diagnosis or management options. Amount and complexity of data to be reviewed Risk of complication or death if not treated.
No of dx: How many problems does the patient have? How can we care for the patient.Amount and complexity of data reviewed: How many x-rays were reviewed? Was blood work reviewed or ordered? Was other information needed to make a decisionRisk of complication or death if the patient is not treated Minimal – one minor self limited dx – insect bite Low- one stable chronic illness Acute uncomplicated illness Moderate – one or more chronic illness Two stable chronic illness Undiagnosed new problem Acute illness with systemic symptoms Acute complicated illness High - one or more chronic illnesses with sever manifestations Acute or chronic illness that pose a threat to life An abrupt change in neurological status. Such as stroke, cva,
The key component ofMDM represents the Afor assessment in theSOAP note.
Case 1-11Non healing peptic ulcer disease. Patient’s doctor increased her Prilosecto 2 a day and continues Zantac at the present dose. In fact, one mightincrease it to 300mg bid if necessary. There is certainly a need to rule outZollinger-Ellison and hyperparathyroidism as the source of the patient’snon healing ulcer. C- Terminal PTH along with ionized calcium. Onemight plan parahyperthyroidectomy simultaneous with gastrectomy ifthe patient has high PTH, which I suspect is the case. Although in thecase of treatment with H2 blockers and Prilosec a gastrin level might beelevated. Any how we will check it and make sure that it is not extreme.If the gastrin level is high one might consider complete gastrectomyrather than a partial one of the presumption of Z-E syndrome. Thepatient will be evaluated after results of the tests are available andscheduled for surgery. Elevated CEA is bothersome. She has not hadcolonoscopy for some time and it should be evaluated again during thesame admission. The patient will be sent to Dr. Dawson. I am concernedwith her pulmonary status. She is advised to curtail her cigaretteconsumption to as low as possible and switch to low tar nicotinecigarettes in the interim. Once she is admitted, therapy with betaagonists and Atrovent will be immediately initiated and the patient willbe started on incentive spirometry.
Number of dx Peptic ulcer and tobacco abuseAmount and complexity of data to review Blood workRisk to patient Surgery required gastrectomy is needed. Recheck blood work to see if a partial or total Colonoscopy requested. Evaluate thyroid. Tobacco abuse affecting recoveryMedical decision making:
Putting it all togetherOutpatient Consultation (POS, TOS, PT STAT)Hx: Expanded Problem FocusedExam: DetailedMedical decision making: Low
POS TOS PATIENT STATUS New Patient EstablishedHX EXAM MDMProblem Problem StraightFocused Focused ForwardExpand Prob. Expand Prob. LowFocused FocusedDetailed Detailed ModerateComprehensive Comprehensive High
Lesson TipsPractice exercise in the “The NextStep” textbook and workbook forChapters 1Use the Evolve website for codingpractice – https://evolve.elsevier.com
SummaryToday we learned the three factors upon whichevaluation and management codes are basedWe discussed the four contributing factorsWe learned the three key components of patientservicesWe practiced some basic coding exercises fromthe power point.
Next Steps:We meet at the same time next weekRead Chapter 2 Medicine to preparefor next week.Work through as many of theexercises as possible