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Evaluation_and_Management[1]

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Evaluation_and_Management[1]

  1. 1. Building an E/M Code The Basics of Evaluation & Management Services Department of Revenue Integrity
  2. 2. Charting History  Medical records tell a story about a patient’s care and treatment. Whether it’s a fifteen minute consultation or a weeklong hospital stay, all of the time a patient is seen by someone in healthcare, is tracked.  Medical record documentation is required to record pertinent facts, findings and observations about an individual’s health history, including past and present illnesses, examinations, tests, treatments and outcomes.  It’s imperative that as coders, we read through the documentation and accurately pick up certain pieces so that we can determine a level of visit.  By laying brick upon brick, buildings are built. We do the same with our E/M codes by adding together elements from documentation to support a level of visit.
  3. 3. E/M Factors to consider Type of service (TOS) Visit, consult, observation? Place of service (POS) Emergency room, office, inpatient hospital, outpatient hospital, etc. Patient Status New vs. Established
  4. 4. Patient status  A coder should be able to determine from the medical record whether or not the patient is NEW or ESTABLISHED.  CPT defines a new patient as “one who HAS NOT received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.”  An established patient is “one has HAS received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.”  You’ll also notice in CPT that new patients require 3/3 key components, whereas established patients require 2/3. This determination is based on work performed and prior knowledge of the patient and their needs.
  5. 5. New patient visits
  6. 6. Established patient visits
  7. 7. Places of service  There are many different places of service for patients to be seen: Offices, hospitals (inpatient and outpatient), observation, emergency departments, nursing facilities, domicilaries, and patient’s homes.  By locating the place of service, it determines a certain range of codes and rules out a group that cannot be reported.
  8. 8. Components that make up E/M services  Key Components: History Examination Medical Decision Making  Contributory Components: Counseling Coordination of Care Nature of presenting problem (illness) Time
  9. 9. Key Components  History  Examination  Medical Decision Making Office or other outpatient services Hospital observation services Hospital inpatient services Consultations Emergency Department services, Nursing facility services, Domiciliary care services Home Care Services
  10. 10. Key Component: History  The history element is made up of four types of history:  Chief Complaint (CC)  History of Present Illness (HPI)  Review of Systems (ROS)  Past, Family & Social History (PFSH)
  11. 11. HISTORY: Chief Complaint (CC)  Defined as “a concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter, usually stated in the patient’s own words”.  A chief complaint must be present in all charts to count toward an E/M level of service.
  12. 12. HISTORY: Chief Complaint (cont.) Examples:  “Patient presents for follow-up of fracture care…”  “38-year old female is complaining of build-up of ear wax…”  “17-year old male was in high-speed MVA and is complaining of headache, neck pain and shoulder pain.”
  13. 13. HISTORY: History of Present Illness (HPI)  Defined as a “chronological description of patient’s present condition from time of onset to present”.  May not always include a timeline of events  May not be stated in the patient’s own words if unable to speak (i.e. CVA, trauma, etc.)  Clues can be given by family or other medical personnel present at scene if trauma  Includes eight description terms that may be met when calculating the HPI
  14. 14. HISTORY: HPI Descriptors  Location   Severity   Duration   Associated Signs/Symptoms   Quality   Context   Timing   Modifying Factors
  15. 15. HISTORY: HPI  Location  WHERE on the body the symptom is occurring  i.e. chest pain  i.e sore throat  i.e. knee swelling Some questions physicians will ask are:  Is the pain diffuse or localized?  Unilateral or bilateral?  Fixed or migratory?  If documented, give one point for location.
  16. 16. HISTORY: HPI  Severity  A rank of the symptom/pain on a scale from 1-10.  May also be described as severe, slightly, “worst I’ve ever had”, mild, moderate, increasing, decreasing, progressive, well.  If documented, give one point for severity.
  17. 17. HISTORY: HPI  Duration  Describes how long the symptom/pain has been present or how long it lasts when the patient has it  i.e. 20 minutes  i.e. 3 years ago  i.e. since last Friday  i.e. approximately two months ago  i.e. yesterday  If documented, give one point for duration.
  18. 18. HISTORY: HPI  Associated Signs/Symptoms  Describes the symptom/pain and other things that happen when this symptom/pain occurs.  i.e. chest pain leads to shortness of breath  Headache leads to visual disturbances  If documented, give one point for associated signs/symptoms.
  19. 19. HISTORY: HPI  Quality  Describes the character or type of the symptom/ pain  i.e. sharp  i.e. dull  i.e. burning  If documented, give one point point for quality.
  20. 20. HISTORY: HPI  Context  Describes HOW it happened; situation associated with the pain/symptom  i.e. exercise, dairy products, in an MVA, running down the steps, sitting in a chair  If documented, give one point for context.
  21. 21. HISTORY: HPI  Timing  Describes WHEN the pain/symptom occurs or establishes the onset for each symptom (why and when) and a rough chronology of the event(s) surrounding  If documented, give one point for timing.
  22. 22. HISTORY: HPI  Modifying Factors  Were medications taken to counter the effects of pain? Did the patient eat or lay down? What was done in an attempt to resolve the issue?  If documented, give one point for modifying factors.
  23. 23. HISTORY: HPI Types  There are two types of HPI and they factor into the E/M level. Notice once you have four elements of HPI, you’re now in the detailed range.  Be careful when counting these. Brief 1-3 elements Extended 4+ elements (’95) OR 3 chronic conditions (’97)
  24. 24. Example of History: HPI Patient complains of stabbing, intermittent chest pain which began eight hours ago while watching television. He rated the pain as 8/10 in severity and is worse with exertion. It is also associated with SOB and nausea.
  25. 25. Example Answer Patient complains of stabbing, intermittent chest pain which began eight hours ago while watching television. He rated the pain as 8/10 in severity and is worse with exertion. It is also associated with SOB and nausea. Timing Quality Location Duration Context Severity Modifying factor Associated S/S
  26. 26. HISTORY: Review of Systems (ROS)  An inventory of body systems obtained through a series of questions, seeking to identify signs and/or symptoms that the patient may be experiencing or may have experienced.  There are fourteen body systems/areas that are covered in this element.
  27. 27. HISTORY: ROS Constitutional (fever, weight loss, etc.) Musculoskeletal Eyes Integumentary (skin and/or breast) Ears, Nose, Throat Neurological Cardiovascular Psychiatric Respiratory Endocrine Gastrointestinal Hematological/lymphatic Genitourinary Allergic/ immunological
  28. 28. HISTORY: ROS Types  There are three types of ROS.  Problem focused is not relevant in ROS because to have 1 ROS element, you already are at the expanded problem focused history. Problem pertinent Focuses on sole problem Extended Inquires about the system directly related to the problem (2-9 systems) Complete Inquires about all systems (10+)
  29. 29. Example of History: ROS  Patient admits to lower back pain, loss of balance and dizziness. He denies nausea, vomiting, fever or chills. Also he denies abdominal pain, urinary frequency, and painful urination. He further denies chest pain, SOB and headaches. Does admit to fatigue and anxiety.
  30. 30. Example Answer  Patient admits to lower back pain, loss of balance and dizziness. He denies nausea, vomiting, fever or chills. Also he denies abdominal pain, urinary frequency, and painful urination. He further denies chest pain, SOB and headaches. Does admit to fatigue and anxiety. Musculoskeletal Neuro Gastro Constitutional Genitourinary Cardio Respiratory Hemat Psych
  31. 31. Checklist: ROS GEN c/o occ malaise and weight gain EYES No blurred vision CVS No CP, DOE, PND, orthopnea, syncope, palpitations RESP No cough, wheezing, hemoptysis, SOB GI No N/V/D/C, melena, heartburn, pain GU No dysuria, urgency, hesitancy, nocturia, incontinence SKIN No ulcers, itching, dryness, rash MUSC No joint pain, gait disturbance, cramps NEURO No confusion, memory loss, seizures, LOC, occ headache OTHERS Remaining systems are negative
  32. 32. HISTORY: PFSH  PFSH is an abbreviation for past, family and social history which make up the third part of the history element.  These three types of history paint a clearer picture for the physician to help narrow down a specific injury, alert the physician to a need for testing in a certain area, or provide background for medical decision making.
  33. 33. HISTORY: PFSH  Past history (patient’s past experiences with illnesses, operations, injuries and treatments)  Family history (a review of medical events in the patient’s family, including diseases which may be hereditary or place a patient at risk  Social history (age appropriate review of past and current activities) Social Family Past
  34. 34. HISTORY: PFSH Types  There are two types of PFSH.  Problem focused and expanded problem focused are not relevant as they don’t require any of the PFSH types for a certain level to be met. Pertinent At least 1 item from any of the three areas (must be directly related to HPI) Complete 2-3 areas
  35. 35. Example of History: PFSH  HPI: Coronary artery disease.  PFSH: Patient returns to office for follow up of CABG in 1992. Recent cardiac catheterization demonstrates 50% occlusion of vein graft to obtuse marginal artery.
  36. 36. Example Answer  HPI: Coronary artery disease.  PFSH: Patient returns to office for follow up of CABG in 1992. Recent cardiac catheterization demonstrates 50% occlusion of vein graft to obtuse marginal artery.  DIRECT RELATION TO HPI One element
  37. 37. PFSH Requirements NEW Pts:  At least one specific item from EACH of the history areas (past, family AND social history) must be documented for the following categories of E/M services to obtain a comprehensive PFSH. 3/3 Office or other outpatient svcs, new Hospital observation services Hospital inpatient services, initial Comprehensive NF assessments Domiciliary care, new pt Home care, new pt
  38. 38. PFSH Requirements EST Pts:  At least one specific item from TWO of the three history areas (past and family, family and social, or social and past) must be documented for a complete PFSH. 2/3 Office or other outpatient services, established Emergency Department Domiciliary care, est. Subsequent NF care Home care, est.
  39. 39. History Recap  Documentation requirements Level of Hx Problem Focused Expanded Problem Focused Detailed Comprehensive HPI 1-3 1-3 4+ 4+ ROS 0 1 2-9 10 PFSH 0 0 1 2/3
  40. 40. Important E/M rules to remember:  Levels do not crosswalk.  Some codes are based on time.  The chief complaint, ROS and PFSH may be listed as separate elements of history, or they may be included in the description of the HPI. Pay attention to only pull what is necessary as long as the documentation is provided.
  41. 41. Important E/M rules (cont.)  An ROS and/or a PFSH obtained during an earlier encounter doesn’t need to be re-recorded if there is evidence that a physician reviewed and updated the previous information.  This does NOT mean that copying/pasting is allowed by any physician.
  42. 42. Important E/M rules (cont.)  If the physician is unable to obtain history, from the patient or other source, the reason why should be listed.
  43. 43. Key Component: Examination  An examination is a thorough evaluation from head to toe of a patient, who is presenting with an illness/injury.  There are two kinds of acceptable examinations approved by CMS. They are the 1995 guidelines and the 1997 guidelines. They are made up of body areas and organ systems.
  44. 44. Examination BODY AREAS Head (including face) Neck Chest (breasts/axillae) Abdomen Genitalia, groin, buttocks Back, spine Each extremity
  45. 45. Examination ORGAN SYSTEMS Constitutional (e.g., vital signs, general appearance) Eyes Ears, nose, mouth, throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic/Lymphatic/ Immunologic
  46. 46. 1995 Guidelines:  The levels of E/M services are based on four types of examination that are defined as follows:  https://www.cms.gov/MLNProducts/Downloads/1995dg.pdf Problem focused Limited exam- affected body area or organ system Expanded problem focused Limited exam- affected body area or organ system & other symptomatic or related organ system(s). Detailed Extended exam- affected body area(s) and other symptomatic or related organ system(s). Comprehensive Multi-system exam or complete exam of a single organ system
  47. 47. 1997 Guidelines:  https://www.cms.gov/MLNProducts/Downloads/MASTER1.pdf • Problem Focused Examination-should include performance and documentation of one to five elements identified by a bullet (•) in one or more organ system(s) or body area(s). • Expanded Problem Focused Examination-should include performance and documentation of at least six elements identified by a bullet (•) in one or more organ system(s) or body area(s). • Detailed Examination--should include at least six organ systems or body areas. For each system/area selected, performance and documentation of at least two elements identified by a bullet (•) is expected. Alternatively, a detailed examination may include performance and documentation of at least twelve elements identified by a bullet (•) in two or more organ systems or body areas. • Comprehensive Examination--should include at least nine organ systems orbody areas. For each system/area selected, all elements of the examination identified by a bullet (•) should be performed, unless specific directions limit the content of the examination. For each area/system, documentation of at least two elements identified by a bullet is expected.
  48. 48. Differences in Exams: Problem focused one body area or organ system Problem focused 1-5 bulleted elements Expanded problem-focused 2+ body areas and/or organ systems Expanded problem focused 6-11 bulleted elements Detailed 5+ body areas and/or organ systems Detailed 12-17 bulleted elements for 2+ systems Comprehensive 8+ body areas and/or organ systems Comprehensive 18+ bulleted elements for 9+ systems 1995 guidelines 1997 guidelines
  49. 49. Key Component: MDM  The last piece that helps determine an E/M is the Medical Decision Making. This piece is a little bit more complex, but relevant to determining a level. Medical Decision Making Types Straight forward Low Moderate High
  50. 50. Complexity of MDM  Two of the three elements must be met or exceeded to qualify for a given type of MDM, or drop to the lowest. Number of diagnoses or management options Amount and/or complexity of data to be reviewed Risk of complications and/or morbidity or mortality Type of decision making Minimal Minimal or none Minimal Straightforward Limited Limited Low Low Multiple Moderate Moderate Moderate Extensive Extensive High High
  51. 51. Number of Dx or Mgmt Options  The number of possible diagnoses and/or the number of management options that must be considered is based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis and the management decisions made by the physician.
  52. 52. Number of Dx or Mgmt Options  Generally, decision-making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem.  The number and type of diagnostic tests employed may be an indicator of the number of possible diagnoses.  Problems which are improving or resolving are less complex than those which are worsening or failing to change as expected.  The need to seek advice from others is another indicator of the complexity.
  53. 53. Amt and/or complexity of data  The amount and complexity of data to be reviewed is based on the types of diagnostic testing ordered or reviewed. A decision to obtain and review old medical records and/or obtain history from sources other than the patient increases the amount and complexity.
  54. 54. Amt and/or complexity of data  Discussion of contradictory or unexpected test results with the physician who performed or interpreted the test is an indication of the complexity of data being reviewed. On occasion, the physician who ordered a test may personally review the image, tracing or specimen to supplement information from the physician who prepared the test report or interpretation.
  55. 55. Risk of Significant Complications, Morbidity and/or Mortality  These are based on the risks associated with the presenting problem(s), the diagnostic procedure(s), and the possible management options.  The table of risk breaks down different categories. Levels of risk are determined by the risk of the:  Presenting problem(s)  Diagnostic procedure(s) ordered  Management options selected
  56. 56. How do I build an E/M level?  There are so many complexities and facets I have to address when extracting data from a chart. Where do I even begin!?
  57. 57. Calculating an E/M Level  When calculating the history portion, all three elements in a row must be met (HPI, ROS and PFSH). You must have 3/3 for a given category in the table, or you must drop to the lowest level. Level 1-3 HPI 0 ROS 0 PFSH PF 1-3 HPI 1 ROS 0 PFSH SPF 4+ HPI 2-9 ROS 1 PFSH D 4+ HPI 10+ ROS 2/3 PFSH C
  58. 58. Calculating an E/M Level  When calculating the exam portion, choose the exam that matches how many levels were met. LEVEL 1 Area/System PF 2-7 Systems EPF 2-7 Systems or 3+ each system D 8+ Systems C
  59. 59. Calculating an E/M Level Number of diagnoses or management options Amount and/or complexity of data to be reviewed Risk of complications and/or morbidity or mortality Type of decision making Minimal Minimal or none Minimal Straightforward Limited Limited Low Low Multiple Moderate Moderate Moderate Extensive Extensive High High
  60. 60. Number of Dx or Mgmt Options Self-limited or minor (stable, improved, or worsened) Max 2 points 1 point Established problem (to examining MD); stable or improved 1 point Established problem (to examining MD); worsening 2 points New problem (to examining MD); no additional workup planned Max 3 points 3 points New problem (to examining MD); additional workup (eg, admit/transfer) 4 points
  61. 61. Amt and/or Complexity of Data Reviewed Lab ordered and/or reviewed 1 point X-ray ordered and/or reviewed 1 point Medicine section (90701-99199) ordered and/or reviewed 1 point Discussion of test results w/ performing physician 1 point Decision to obtain old records and/or obtain hx from someone other than the pt 1 point Review and summary of old records and/or obtaining history from someone other than patient and/or discussion with another health provider 2 points Independent visualization of image, tracing or specimen (not simply review of report) 2 points
  62. 62. Table of Risk  See attached table of risk (separate)  Choose the highest risk out of each of the categories.  Because your MDM needs 2/3 elements to be satisfied, you can choose the highest risk and be sure to tally the points so that your level can be justified. However, due to the other two grids, the level may be lowered.
  63. 63. E & M Clinical Examples
  64. 64. E/M Coding Example HISTORY -- DETAILED HPI: Location (bronchial asthma) Timing (one day per week) Context (exercize induced) Modifying factors (treated with Albuterol Inhaler) ROS: Respiratory (snoring & sleep apnea) Psych (depression) GI (GERD symptoms) PFSH: Past (history of aspirin intolerance) Social (no environmental changes) EXAM – EXP. PROB. FOCUSED Constitutional (general condition/VS) Eyes (conjunctivae) ENT (TM/nasal mucosa) Respiratory (lungs) Cardio (CVS) MDM -- MODERATE 4 Diagnoses Prescription Drug Mgmt BILLED AS: 99213 SUPPORTS: 99214 REQUIRED FOR NEXT LEVEL: “All other systems reviewed & negative” 3 other body systems in Exam
  65. 65. HISTORY – EXP. PROB. FOCUSED HPI: Location (arms, legs & neck) Associated signs & symptoms (not puritic nor painful) ROS: Constitutional (no fevers) All/Immuno (allergies reviewed and updated) PFSH: Past (immunization history, unremarkable) EXAM – EXP. PROB. FOCUSED Constitutional (VS) Eyes (conjunctivae) ENT (TM/no erythema) Respiratory (without rhonchi, wheezes) Cardio (RRR, no murmurs) GI (soft, NT/ND) Skin (large vesicular-bullous lesions) MDM -- LOW 1 new problem – no additional work-up Obtaining history from someone other than pt OTC drugs BILLED AS: 99213 SUPPORTS: 99213 REQUIRED FOR NEXT LEVEL: 2 elements HPI 8 ROS or “all others reviewed…” 1 additional body system in exam
  66. 66. Clinical example: 1. An established patient is seen in the clinic for allergic rhinitis. A problem focused history, EPF exam and a low level of MDM were performed. What E/M code would be reported for the visit? a. 99212 b. 99213 c. 99214 d. 99215
  67. 67. Clinical example answer: 1. b. 99213 Established patient requires 2/3 key components.
  68. 68. Clinical example: 2. A patient is admitted to the hospital for a lung transplant. The admitting physician performs a comprehensive history, a comprehensive exam, and a high level of MDM. What CPT code should be reported? a. 99221 b. 99222 c. 99223 d. 99234
  69. 69. Clinical example answer: 2. c. 99223 Initial hospital care codes require 3/3 key components to be met.
  70. 70. Clinical example: 3. A new patient is seen in the pediatric office for ear pain. The patient has had pain for four days and it keeps her awake at night. She has had a slight fever (99 degrees). She has not been swimming or actively in water for the past couple of months. She denies any cough, nasal congestion, or stuffiness, or loss of weight. The provider does a limited exam on the ears, nose, throat and neck. The patient is determined to have otitis media. Amoxicillin is prescribed. What E/M code would be reported for this visit? a. 99201 b. 99202 c. 99203 d. 99204
  71. 71. Clinical example answer: 3. b. 99202 For a new patient visit, all three key components must be met. This visit has an EPF HPI, EPF exam and moderate MDM for prescription drug management.
  72. 72. Clinical example: 4. A 45-year old patient is seeing the neurologist, Dr. Williams, at the request of his family physician to evaluate complaints of weakness, numbness, and pain in his left hand and arm. The pain started last year after rocks fell on him while mining. He still has significant, sharp, burning wrist pain and reports the problems are continuing to get worse. He is limited in his job as a machinist for a mining company due to the pain and numbness. He has no swelling in his hand, no neck pain, or radiating pain. His past medical history is negative for significant diseases. He has had carpal tunnel surgery. He has a family history of hypertension, heart disease, and stroke. He is married with children and smokes one pack of cigarettes/day.
  73. 73. Clinical example (cont.) A detailed exam is performed of the mental status, cranial nerves, motor nerves, DTRs, sensory nerves, and head and neck. After performing an EMG and NCS, Dr. Williams determined the patient has left ulnar neuropathy, at the cubital tunnel region, as well as ongoing carpal tunnel syndrome. Repeat carpal tunnel surgery is recommended, along with a possible cubital tunnel surgical procedure. If the patient does not have surgery, he risks permanent nerve damage. A report is sent back to the physician requesting the consult. What E/M consultation code would be reported for this visit? a. 99242 b. 99243 c. 99244 d. 99245
  74. 74. Clinical example answer: 4. b. 99243 A consultation requires all three key components be met to support the level of visit. There is a detailed history, detailed exam and a moderate MDM for the elective major surgery.
  75. 75. Contributory Components  Counseling  Coordination of Care  Nature of Presenting Problems, and  Time
  76. 76. Contributory Component: Counseling  May be included during the visit of a patient and reflect conversations with the patient and/or family regarding risk reduction, treatment options, benefits and risks associated with differing treatment options and other education given to the patient/family.  Often occurs when there is a complicated illness/injury or when there is a newly diagnosed patient with an acute or chronic illness posing a threat to life.
  77. 77. Counseling example:  “I had an extremely extensive 60+ minute examination and series of discussions with the patient and her family members. Over half of the time was spent on counseling them. At great length, with the patient and her daughter, and later with her son- in-law who arrived secondarily, and later again with her husband, who arrived at the end of my visit, I discussed how diabetic injury, especially with neuropathy, she would be at risk, over time, of valvular dysfunction in the leg veins. I discussed the anatomy and physiology of orthostatic hypotension, and how this can be very pronounced, especially in long-term diabetics…”
  78. 78. Contributory component: Coordination of care  Usually with other providers or agencies  Without a patient encounter on that day  Reported with case management codes  Example: Physician spends 20 minutes assessing a patient with recurrent ear infections. Spends additional 20 minutes counseling parents with strategies to decrease the incidence of ear infections, treatment options and allaying parent anxiety. 99213 E/M selected on the basis of time criteria (more than 50% of face-to-face encounter dominated by counseling).
  79. 79. Contributory component: Nature of presenting problem(s)  Reason for visit: sign, symptom, illness, or disease being treated  Minimal- may not require presence of physician, services are provided under physician’s supervision. Examples: removal of sutures, supervised drug screen, patient needs release for school/work.
  80. 80. Contributory component: Nature (cont.)  Self-limited or minor- Does not permanently alter health status and with management and compliance has an outcome of “good”. Typically heal well on their own without physician supervision. Examples: poison ivy, poison oak exposure, sore throat, resolved tonsillitis
  81. 81. Contributory Component: Nature (cont.)  Low- Risk of morbidity/mortality without treatment is low and full recovery with no functional impairment is expected. Examples: management of a hypertensive patient on medication, established patient for follow up of osteoporosis, painful bunion.
  82. 82. Contributory Component: Nature (cont.)  Moderate- Risk of morbidity/mortality without treatment is moderate, uncertain prognosis or increased probability of prolonged functional impairment. Examples: diabetic w/ complications, s/p MI patient who is not doing well on medication, patient with new onset of RLQ abdominal pain
  83. 83. Contributory Component: Nature (cont.)  High- Risk of morbidity/mortality without treatment is highly probable; uncertain prognosis or high probability of severe prolonged functional impairment. Examples: s/p transplant patient developing new symptoms or cancer patient with signs of paralysis
  84. 84. Contributory Component: Time  “When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter…” (CPT guidelines)  May include face-to-face time in the office or other outpatient setting, or floor/unit time in the hospital or nursing facility, and includes time spent with parties who have assumed responsibility for the care of the patient or decision making whether or not they are family members.
  85. 85. Contributory Component: Time (cont.)  Time the physician spends taking the patient’s history or performing an examination does not count as counseling time.  He/She must look at the entire patient encounter and determine if they spent the majority of time in counseling and/or coordination of care or if they should bill using an E/M.
  86. 86. Contributory Component: Time (cont.)  Counseling and coordination of care could include discussion with the patient (or his or her family) about one or more of the following, according to CPT guidelines:  Diagnostic results  Impressions and/or recommended diagnostic studies  Prognosis  Risks and benefits of treatment options  Instructions for treatment and/or follow-up  Importance of compliance with chosen treatment options  Risk-factor reduction  Patient/family education
  87. 87. References:  E/M University, http://emuniversity.com  Current Procedural Terminology (2011). (2011). Chicago : American Medical Association  Buck, C. (2010) Step-by-Step Medical Coding. Retrieved May 28, 2011. www.educode.com/vaees (private access)  2011 Medical Coding Training (2011). Salt Lake City: American Medical Association  Department of Health and Human Services. Evaluation and Management Services Guide. , 2010. Web. 28 Jun 2011. <https://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide- ICN006764.pdf>.  Pierce, B. (2008) Advanced Coding Education Guide for Evaluation and Management Auditing. Rockville: DecisionHealth.
  88. 88. THANK YOU!  I appreciate your time in joining us today to refresh your understanding of the E/M process.  So many of you have been doing this for years and I understand and appreciate the talent you have in determining levels.  Let’s continue to stay on task and use the proper rules for coding these visits, so that we can maintain accuracy and compliance within the health care system. -Grace Bower, CPC Outpatient Coding/Billing Liaison
  89. 89. NOTES:  _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________
  90. 90. NOTES:  _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________

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