10/20/10 1 Coding Education

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  • This is the objective findings, i.e. examination.
  • 10/20/10 1 Coding Education

    1. 1. Coding Education & Training Program, HIM Department Documentation Requirements for Evaluation & Management Services
    2. 2. Coding Education & Training Program, HIM Department Presentation Goals Introduce the 3 Key Components to an E/M Service  History  Examination  Medical Decision Making Introduce the UC Davis Health System Audit Tool, version 2.4 Review time and how it may effect a level of service Review critical care documentation guidelines Review Teaching Physician Guidelines
    3. 3. Coding Education & Training Program, HIM Department Overview of E/M Services Classification of Common E/M Services Office or Other Outpatient Services  New Patient 99201-99205  Established Patient 99211-99215 Consultations  Office or Other Outpatient Consultations 99241-99245  Initial Inpatient Consultations 99251-99255 Hospital Inpatient Services  Initial Hospital Care 99221-99223  Subsequent Hospital Care 99231-99233  Hospital Discharge Services 99238-99239 Emergency Department Services  New or Established 99281-99285 Critical Care  Over 24 months of age 99291-99296 Preventive Medicine  Initial Preventive Medicine 99381-99387  Established Patient 99391-99397
    4. 4. Coding Education & Training Program, HIM Department Overview of E/M Services Classification of Other E/M Services Nursing Facility/SNF/Rest Homes, etc 99304-99350 Prolonged Services 99354-99359 Care Plan Oversight 99374-99380
    5. 5. Coding Education & Training Program, HIM Department Overview of E/M Section Code assignment in the CPT E/M Section vary according to three factors: Place of Service  office, hospital, emergency room, nursing home Type of Service  consultation, admission, office visit Patient Status  new patient, established patient, inpatient, outpatient Each E/M category includes three to five levels of service The levels indicate the wide variations in skill, time, effort, responsibility and knowledge required to diagnose, treat or prevent an illness or injury
    6. 6. Coding Education & Training Program, HIM Department Overview of E/M Section In a Teaching Setting, a fourth factor needs to be considered: Reimbursement Factor(s)  Performing Provider vs Billing Provider (NP/PA vs MD)?  Are there additional Payor Specific Guidelines (Medi-cal/Medicare)? 1. Have the documentation guidelines been met?  Is the clinician (NP/PA) on the Hospital Cost Report?
    7. 7. Coding Education & Training Program, HIM Department Overview of E/M Section All providers who are licensed to provide medical services may use the same E/M codes for reporting their services regardless of specialty The specific level is referring to the last digit in each E/M service code for example, a 99201 is referred to as a “New Patient, level 1” This level requires meeting or exceeding the following Three Key Components: a problem focused History a problem focused Exam straightforward Medical Decision Making
    8. 8. Coding Education & Training Program, HIM Department Overview of E/M Section The E/M levels are selected based on the clinicians documentation Therefore, it is important that the clinician documents each patient encounter as accurate and complete as possible What should be considered when analyzing the patient’s medical record? Does the documentation justify the medical necessity of the service and/or procedure performed? Does the documentation support the level of service reported? Is the documentation legible? Are there specific payer documentation guidelines and have they been met?
    9. 9. Coding Education & Training Program, HIM Department Overview of E/M Section Medical Necessity Medicare defines "medical necessity" as services or items reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member Clinician vs Coder  Questions regarding an extensive write up for a minor problem should be referred back to the clinician for clarification
    10. 10. Coding Education & Training Program, HIM Department Overview of E/M Section Medicare-Selection of Level of E/M Service The CMS Manual, Publication 100-4, Chapter 12, §30.6.1 - Selection of Level of Evaluation and Management Service states the following: “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted.
    11. 11. Coding Education & Training Program, HIM Department Overview of E/M Section Medicare-Selection of Level of E/M Service, con’t The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record. Instruct physicians to select the code for the service based upon the content of the service. The duration of the visit is an ancillary factor and does not control the level of the service to be billed unless more than 50 percent of the face-to-face time (for non-inpatient services) is spent providing counseling or coordination of care.”
    12. 12. Coding Education & Training Program, HIM Department Overview of E/M Section E/M Guidelines There are two guidelines that may be utilized, 1995 or 1997 Providers/Coders may use either guideline Whichever is most advantageous to the provider Must follow one guideline per patient encounter Cannot mix and match
    13. 13. Coding Education & Training Program, HIM Department Overview of E/M Section 1995 Based on the number and/or extent of body areas or organ systems examined 1997 Based on the examination of specific bulleted items identified within a body area or organ system
    14. 14. Coding Education & Training Program, HIM Department E/M Terms New Patient According to the American Medical Association, a new patient is one who has not received any professional services from a given physician or another physician of the same specialty who belongs to the same group practice within the past three (3) years Established Patient According to the American Medical Association, an established patient is one who has received professional services from that physician or another physician of the same specialty within the same group within the past three (3) years Consultations A type of service provided by a licensed provider whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another licensed provider or appropriate source. For example, a Physician, NP, PA
    15. 15. Coding Education & Training Program, HIM Department E/M Terms Consultations vs Referral Consultation  Services rendered to give advice or an opinion to a requesting provider about a patient’s diagnosis and/or management of a condition 1. The 3 R’s  Request  Render opinion  Report Referral  Transfer of care  Referring provider transfers the responsibility for managing the patient’s complete care for a condition to the receiving physician and the receiving physician documents approval of care
    16. 16. Coding Education & Training Program, HIM Department E/M Services Remember, documentation must support the medical necessity and the level of service Billed. The Level of Service is based on the documentation of the 3 Key Components and the Contributing Factors: 3 Key Components  History  Examination  Medical Decision Making Contributing Factors  Nature of Presenting Problem  Time 1. Outpatient Setting (Counseling by Provider face-to-face) 2. Inpatient Setting (Counseling by Provider face-to-face and/or Coordination of Care)
    17. 17. Coding Education & Training Program, HIM Department E/M – History Component Now let’s take a look at the History Component on the Audit Tool The History is divided into four levels: Problem Focused Expanded Problem Focused Detailed Comprehensive These levels are determined by……
    18. 18. Coding Education & Training Program, HIM Department E/M – History Component Four Elements History levels are determined by the following 4 elements 1. Chief Complaint (CC) 2. History of Present Illness (HPI) 3. Review of Systems (ROS) 4. Past, Family, and/or Social History (PFSH) The extent of the history is dependent upon clinical judgment and on the nature of the presenting problem(s) Not all histories will have or need all elements
    19. 19. Coding Education & Training Program, HIM Department E/M – History Component The Four Elements of History 1. Chief Complaint (CC)  A concise statement describing the symptom, problem, condition, diagnosis, or other factor as the reason for the encounter. Example:a return visit recommended by the physician 2. History of Present Illness (HPI)  Describes the patient’s developing condition/problem from the first sign and/or symptom or from the previous encounter to the present or the status of three chronic or inactive conditions 3. Review of Systems (ROS)  An inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms the patient may be experiencing or has experienced 3. Past, Family, and Social History (PFSH)  Review of the patient’s past history, family history, and social history
    20. 20. Coding Education & Training Program, HIM Department E/M – History Component Chief Complaint  The reason for seeking medical care should be recorded in the patient’s own words “Patient complains of left foot pain due to fall last month.” 
    21. 21. Coding Education & Training Program, HIM Department E/M – History Component The History of Present Illness (HPI)  Two types 1. Brief HPI  1 to 3 HPI Elements 2. Extended HPI  4 or more HPI Elements or the status of at least 3 chronic or inactive conditions
    22. 22. Coding Education & Training Program, HIM Department E/M – History Component The HPI Elements Location – Where the symptom or problem is occurring  Abdomen, chest, leg, arm, head Severity - A rating or description of severity of the symptom or pain  Bad, intolerable, minimal, slight Timing – When symptom or pain occurs  Before bed, upon waking, two hours after taking medicine, continuous Quality – The character of the sign or symptom  Burning, dull, puffy, puss-filled, red, itchy Duration – How long a pain or symptom lasts, has been present, or persisted  For two months, since prescription began Associated signs/symptoms – Any organ system or body area complaints associated with the chief complaint  Rash with blistering, nausea and vomiting, abdominal pain Context – Instances or items that can be associated with the chief complaint  When walking, in company of smokers, at work Modifying factors – Actions taken or things done to effect the symptom or pain, making it better or worse  Improves when lying down, worse after eating
    23. 23. Coding Education & Training Program, HIM Department E/M – History Component The HPI Example of an extended HPI with 4 or more elements HPI: For the past two days she has had chills, fever and muscle aches. She feels worse in the evening. Her illness is so severe she has not been able to work.  Duration  Associated Signs  Timing  Severity
    24. 24. Coding Education & Training Program, HIM Department E/M – History Component The HPI Extended HPI with status of at least three chronic or inactive conditions. Example: The patient is currently under my care for the management of hypertension controlled with diet and exercise, diabetes controlled with insulin, and asthma requiring inhaler twice daily.
    25. 25. Coding Education & Training Program, HIM Department E/M – History Component The Review of Systems (ROS) ROS includes 14 systems 1. Constitutional symptoms (fever, weight loss, etc) 2. Eyes 3. Ears, nose, mouth, throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary 8. Musculoskeletal 9. Integumentary (skin and/or breast) 10. Neurological 11. Psychiatric 12. Endocrine 13. Hematologic/Lymphatic 14. Allergic/Immunologic
    26. 26. Coding Education & Training Program, HIM Department E/M – History Component The ROS ROS has 3 types 1. Problem Pertinent  1 system 2. Extended  2-9 systems 3. Complete  10 or more systems
    27. 27. Coding Education & Training Program, HIM Department E/M – History Component The ROS Medicare Documentation Guidelines Problem Pertinent ROS  The patient's positive responses and pertinent negatives for the system related to the problem should be documented. Extended ROS  The patient's positive responses and pertinent negatives for two to nine system should be documented. Complete ROS  At least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented.
    28. 28. Coding Education & Training Program, HIM Department E/M – History Component The ROS Example of a complete ROS: The provider can list pertinent findings in 2 or more systems and note all other systems are negative A patient is seen in the physician’s office with flu-like symptoms. For the past two days she has had chills, fever, and muscle aches. She feels worse in the evening. Her illness is so severe she has not been able to work. (Provider queries patient on at least ten systems, notes pertinent findings) She has lost 7 pounds in the last month. She denies abdominal pain, diarrhea, and vomiting. All other systems are negative.  Constitutional  Gastrointestinal  “All other systems are negative” gives provider credit for a complete ROS
    29. 29. Coding Education & Training Program, HIM Department E/M – History Component The Past, Family, and Social History (PFSH) Past History  The patient’s past experience with illnesses, operations, injuries and treatments Family History  A review of medical events in the patient’s family, including diseases that may be hereditary or place the patient at risk Social History  Age appropriate review of past and current activities
    30. 30. Coding Education & Training Program, HIM Department E/M – History Component The PFSH There are two types of PFSH, pertinent and complete The required elements for each differs based on the patient status  New patient status 1. Pertinent  1 specific item from any of the 3 history areas 1. Complete  1 specific item from each of the 3 history areas  Established patient status 1. Pertinent  1 specific item from any of the 3 history areas 1. Complete  1 specific item from any 2 of the 3 history areas
    31. 31. Coding Education & Training Program, HIM Department E/M – History Component The PFSH If the PFSH is non-contributory a statement is required in the documentation to qualify it for a complete PFSH  Example: 1. “Reviewed PFSH, non-contributory to current condition.” For those categories of E/M services that require only an interval history, it is not necessary to record information about PFSH  Example: 1. Subsequent hospital care 2. Subsequent nursing facility care
    32. 32. Coding Education & Training Program, HIM Department Overall History Component Each history element must be met or exceeded to determine an overall history level Let’s look at an example CC  Must be present in patient’s medical record HPI  Extended ROS  Complete PSFH  Pertinent Overall History level = Detailed
    33. 33. Coding Education & Training Program, HIM Department E/M – History Component Example Outpatient Grid Detailed Pertinent Extended 2-9 Extended 4 or more Comprehensive Complete Complete Expanded Problem Focused Problem Focused OVERALL HISTORY LEVEL None PFSH Past Medical History Family History Social History Established Patient: only need 2 to be considered “Complete” New Patient: Requires all 3 to be considered “Complete” Pertinent to Problem 1 None ROS Constitutional Ears, Nose Throat, Mouth Skin/breast Endo Hem/Lymph Eyes Card/Vasc GI Neuro Allergy/Immune Resp Musculo GU Psych All Others Neg Brief 1-3 HPI Location Severity Timing Modifying Factors Quality Duration Context Associated Signs & Symptoms
    34. 34. Coding Education & Training Program, HIM Department E/M History Caveat Patient is unable to speak Physician must document this  “Patient intubated, unable to obtain History” Provider gets credit for a complete History!
    35. 35. Coding Education & Training Program, HIM Department E/M – Examination Component Now let’s look at the Examination Portion of the Audit Tool Four Levels  Problem Focused  Expanded Problem Focused  Detailed  Comprehensive Exam Elements  Body Areas  Organ Systems (Cannot combine Body Areas and Organ Systems for Comprehensive Exam) 2 Types  Multi-system  Single Organ System
    36. 36. Coding Education & Training Program, HIM Department E/M Examination Elements Organ Systems: Constitutional ears, nose, mouth, throat Eyes resp GI GU Cardio skin neuro psych Hem, lymph, immune musculo ComprehensiveDetailedExpanded Problem Focused Problem FocusedOVERALL EXAMINATION LEVEL >=85-72-40-1 Body Areas: Head/face chest, including breasts & axillae Neck back, spine each extremity genitalia, groin, buttocks abdomen
    37. 37. Coding Education & Training Program, HIM Department Examination Problem Focused Expanded Problem Focused Detailed Comprehensive 1995 1 Body Area or Organ System Limited Exam 2-4 Body Areas or Organ Systems Extended Exam 5-7 Body Areas or Organ Systems 8 Organ Systems or a Comprehensive Single Organ System Exam 1997 Any 1-5 Bullets Any 6+ Bullets General: 2 bullets from 6 or more organ systems/body areas or 12 bullets from 2 or more organ systems/body areas Eye/Psych: 9+ bullets All Others: 12+ bullets General: Perform all, document 2 bullets from 9 Organ Systems/body areas All Others: Perform all, document all elements in each bolded box and 1 element in each un-bolded box
    38. 38. Coding Education & Training Program, HIM Department E/M – Medical Decision Making Component Now let’s look at the Medical Decision Making Portion of the Audit Tool Four Levels 1. Straightforward 2. Low Complexity 3. Moderate Complexity 4. High Complexity To determine the level of Medical Decision Making, two of the three following Elements must meet or exceed Elements  Number of Diagnoses or Treatment Options  Amount and/or Complexity of Data to be Reviewed  Risk of Complication and/or Morbidity/Mortality
    39. 39. Coding Education & Training Program, HIM Department E/M – Medical Decision Making Component Number of Diagnoses or Treatment Options 3 Categories 1. Self-limited or minor stable, improved or worse 2. Established problem stable, improved, worsening 3. New problem to examiner no additional work up planned additional work-up planned
    40. 40. Coding Education & Training Program, HIM Department E/M – Medical Decision Making Component 1. Self-limited or minor (stable, improved or worse) Sore throat Earache (simple) Simple laceration  This category does not indicate that the problem is new or established  American Medical Association (AMA) 1. “A problem that runs a definitive and prescribed course, is transient in nature, and is not likely to permanently alter health status or has a good prognosis with management/compliance.”
    41. 41. Coding Education & Training Program, HIM Department E/M – Medical Decision Making Component 2. Established problem; stable, improved For this provider/specialty group – usually diagnosis and treatment has already been started Established problem; worsening For this provider/specialty group; must be documented or CLEARLY implied, (pain has increased, etc.)
    42. 42. Coding Education & Training Program, HIM Department E/M – Medical Decision Making Component 3. New problem to examiner; no additional work- up planned New problem to examiner; additional work-up Planned  Starting treatment does not constitute “additional work-up”.  Any diagnostic study or plan to help find a definitive diagnosis. Example:  Radiology  Laboratory  Consultation with another physician
    43. 43. Coding Education & Training Program, HIM Department NUMBER OF DIAGNOSES AND/OR TREATMENT OPTIONS A B  C = D Problem(s) status Number Points Result Self–limited or minor (stable, improved or worse) max=2 1 Est. problem; stable, improved 1 Est. problem; worsening 2 New problem; no additional workup planned max=1 3 New Problem; additional workup planned 4 Total
    44. 44. Coding Education & Training Program, HIM Department E/M – Medical Decision Making Component Amount and/or Complexity of Data to be Reviewed Review &/or order of clinical lab tests Review &/or order in the radiology section of the CPT Review &/or order of tests in the medicine section Discussion of test results with performing physician Decision to obtain old records &/or history from someone other than patient Review and summarization of old records &/or obtaining history from someone other than patient &/or discussion of case with another health care provider Independent visualization of image, tracing or specimen itself (not simple review of report)
    45. 45. Coding Education & Training Program, HIM Department E/M – Medical Decision Making Component Review &/or order of clinical lab tests Any documentation of the review of tests previously ordered Example(s):  Test results documented in notes  Documentation that Provider reviewed results Documentation that indicates tests are ordered
    46. 46. Coding Education & Training Program, HIM Department E/M – Medical Decision Making Component Review &/or order in the radiology section of the CPT Review of Report not actual film Example(s):  Documentation of review of x-ray report  Documentation that a x-ray was ordered Not viewed in Stentor (review of actual film)
    47. 47. Coding Education & Training Program, HIM Department E/M – Medical Decision Making Component Review &/or order of tests in the medicine Section Report(s) is reviewed or ordered Example(s):  EKG Report  Stress Test  Documentation that a medicine test was ordered
    48. 48. Coding Education & Training Program, HIM Department E/M – Medical Decision Making Component Discussion of test results with performing physician Discussion = verbal communication and NOT a report or letter Example:  Pathologist viewing specimen then pages ordering MD to discuss results  PCP MD pages MD Specialist to discuss test results
    49. 49. Coding Education & Training Program, HIM Department E/M – Medical Decision Making Component Decision to obtain old records &/or history from someone other than patient Documentation should support the reason/need to get old records or obtain the history from someone other than the patient Does not include:  Parent’s of pediatric patient  Interpreter
    50. 50. Coding Education & Training Program, HIM Department E/M – Medical Decision Making Component Review and summarization of old records &/or obtaining history from someone other than patient &/or discussion of case with another health care provider Summarize the review of old record or history and document how it pertains to the patients current problem It must be Additional/Relevant information
    51. 51. Coding Education & Training Program, HIM Department E/M – Medical Decision Making Component Independent visualization of image, tracing or specimen itself (not simple review of written report) Does not include:  Rapid Strep Test  Urine Pregnancy Test Does include:  Reviewing image in Stentor, etc.  EKG Strip
    52. 52. Coding Education & Training Program, HIM Department AMOUNT AND/OR COMPLEXITY OF DATA REVIEWED Points Review &/or order of clinical lab tests 1 Review &/or order in the radiology section of CPT 1 Review &/or order of tests in the medicine section of CPT 1 Discussion of test results with performing physician 1 Decision to obtain old records &/or obtain history from someone other than patient 1 Review and summarization of old records &/or obtaining history from someone other than patient &/or discussion of case with another health care provider 2 Independent visualization of image, tracing or specimen itself (not simply review of report) 2 Total
    53. 53. Coding Education & Training Program, HIM Department E/M – Medical Decision Making Component Risk of Complication and/or Morbidity/Mortality Four Levels  Minimal  Low  Moderate  High
    54. 54. Coding Education & Training Program, HIM Department Table of Risk Level of Risk Presenting Problem(s) Diagnostic Procedure(s) Ordered Management Option Selected Minimal * One self–limited or minor problem, e.g. cold, insect bite * Lab tests requiring venipuncture * CXRs * ECG/EEG, U/A, echo * Rest * Gargles * Elastic bandages * Superficial dressings Low * 2 or more self–limited or minor problems * 1 stable chronic illness •* Acute uncomplicated illness or injury, e.g. cystitis, sprain * Physiologic tests not under stress, e.g. PFTs * Non–CV imaging with contrast, e.g. barium enema * Superficial needle biopsy * Clinical lab test requiring arterial puncture * Skin biopsies * OTC drugs * Minor surgery w/ no identified risk factors * PT, OT •IV fluids w/out additives Moderate * 1 or more chronic illnesses with mild exacerbation, progression, or side effects of treatment * 2 or more stable chronic illnesses * Undiagnosed new problem with uncertain prognosis, e.g., lump in breast * Acute illness with systemic symptoms, e.g. pyelonephritis, pneumonia, colitis * Acute complicated injury, e.g. head injury with brief LOC * Physiologic test under stress, e.g. cardiac stress test, fetal contraction stress test * Diagnostic endoscopies with no identified risk factors * Deep needle or incisional biopsy * CV imaging studies with contrast and no identified risk factors, e.g. arteriogram and cardiac cath * Obtain fluid from body cavity * Minor surgery with identified risk factors * Elective major surgery (open, percutaneous, or endoscopic) with no identified risk factors * Prescription drugs * Therapeutic nuclear medicine * IV fluids w/ additives * Closed tx of fracture or dislocation without manipulation High * 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment * Acute or chronic illnesses or injuries that may pose a threat to life or bodily functions, e.g. peritonitis, acute failure, multiple injuries, acute MI * An abrupt change in neurological status, e.g. seizure * CV imaging studies with contrast with identified risk factors * Cardiac EP test * Diagnostic endoscopies with identified risk factors * Discography * Elective major surgery w/ identified risk factors * Emergency major surgery * Parenteral controlled substances * Drug therapy requiring intensive monitoring for toxicity * Decision not to resuscitate or to de–escalate care because of poor prognosis
    55. 55. Coding Education & Training Program, HIM Department Final Medical Decision-Making Level 2 of the 3 Elements must be met or exceeded Number of Diagnosis or Treatment Options Amount and/or Complexity of Data Reviewed Risk of Complication and/or Morbidity/Mortality
    56. 56. Coding Education & Training Program, HIM Department Final Result for Medical Decision Making (must meet or exceed two out of three elements) Number diagnoses/treatment options <=1 Minimal 2 Limited 3 Multiple >=4 Extensive Amount & complexity of data <=1 Minimal 2 Limited 3 Multiple >=4 Extensive Highest risk Minimal Low Moderate High Type of decision making Straight­ forward Low Complex Moderate Complex High Complex
    57. 57. Coding Education & Training Program, HIM Department Example of Medical Decision Making Number of Diagnoses or Treatment Options Assessment: The diabetes is controlled with diet and exercise, blood glucose levels are within acceptable limits. The high blood pressure that we have been monitoring and trying to control with diet and exercise is now far above an acceptable range. The first problem is considered an established stable problem while the blood pressure is an established problem worsening.  Established Problem – Stable Improved  Established Problem – Worsening
    58. 58. Coding Education & Training Program, HIM Department Example of Medical Decision Making Amount &/or Complexity of Data Reviewed The patient comes in for a recheck of diabetes that is controlled with diet and exercise, blood glucose levels are within acceptable limits, and high blood pressure that you have been monitoring and trying to control with diet and exercise is through the roof. A CBC, Chemical profile, urinalysis,electrocardiogram, and chest x-ray are ordered.  Review &/or order of clinical lab tests  Review &/or order of tests in the medicine section of CPT  Review &/or order in the radiology section of CPT
    59. 59. Coding Education & Training Program, HIM Department Example of Medical Decision Making Risk of Complications &/or Morbidity of Mortality The patient comes in for a recheck of diabetes that is controlled with diet and exercise, blood glucose levels are within acceptable limits, and high blood pressure that you have been monitoring and trying to control with diet and exercise is through the roof. A CBC, Chemical profile, urinalysis,electrocardiogram, and chest x-ray are ordered. Impression: 1. Diabetes-controlled. 2. Hypertension- uncontrolled. Atenolol 50 mg prescribed. The patient is to return in one week for recheck.  1 or more chronic illnesses with mild exacerbation, progression or side effects of treatment  Lab test requiring venipuncture/CXRs/ECG  Prescription Drugs
    60. 60. Coding Education & Training Program, HIM Department Contributing Factors Time The American Medical Association guidelines state that when counseling and/or coordination of care dominates (MORE THAN 50%) the physician/patient and/or family encounter (face-to-face time) then time may be considered the key or controlling factor to qualify for a particular level of E/M services Documentation of time is key if time is the determining factor The total amount of time spent with the patient must be clearly documented The record should describe the counseling and/or activity to coordinate care  “A total of 30 minutes was spent with the patient, more than half of this time was spent discussing treatment options and subsequent effects of chemotherapy.”
    61. 61. Coding Education & Training Program, HIM Department Time Typical Times New Office Visit 99201-10 99202-20 99203-30 99204-45 99205-60 Office Consult 99241-15 99242-30 99243-40 99244-60 99245-80 Inpatient Consult 99251-20 99252-40 99253-55 99254-80 99255-110 Established Office Visit 99211- 5 99212-10 99213-15 99214-25 99215-40 Initial Hospital Observation 99218-30 99219-50 99220-70 Initial Hospital Visit 99221-30 99222-50 99223-70 Subsequent Hospital Visit 99231-15 99232-25 99233-35
    62. 62. Coding Education & Training Program, HIM Department E/M – Critical Care Critical Care Definition Critical care is the care of critically ill or critically injured patients who require the full, exclusive attention by a physician(s). A critical illness or injury “acutely impairs one or more vital organ systems such that there is high probability of imminent or life threatening deterioration in the patient’s condition”.
    63. 63. Coding Education & Training Program, HIM Department E/M – Critical Care Critical Care, con’t Documentation Requirements Since critical care is a time-based code, the physician progress note must contain documentation of the total time involved providing critical care services. In a teaching environment, the time recorded as critical care time is the actual time spent by the physician, not a resident, fellow, or allied health provider. The time must be personally documented by the teaching physician. Teaching time does not count toward critical care time. Critical care of less than 30 minutes duration on any given day is reported with an evaluation and management code.
    64. 64. Coding Education & Training Program, HIM Department E/M – Critical Care Critical Care, con’t Example Documentation Patient seen and examined with Dr. Resident. Reviewed and agree with his note and the plan of care we developed together. One hour of critical care time personally performed due to patient’s hemodynamic instability. Patient was resuscitated with 2 units of packed red blood cells. Obtained additional studies to determine possible causes for patient’s instabilities.
    65. 65. Coding Education & Training Program, HIM Department E/M – Teaching Facility Teaching Facility Documentation requirements for State and Federal Payers  The teaching physician saw the patient  The teaching physician reviewed the resident’s note, and agreed or revised the findings  The teaching physician actively participated in the care by either documenting involvement in the development of the plan or by changing the plan
    66. 66. Coding Education & Training Program, HIM Department E/M – Teaching Facility Teaching Physician Examples of minimally acceptable documentation  “I saw the patient with the resident and agree with the resident’s findings and plan we developed.”  “I saw and evaluated the patient. Discussed with the resident and agree with the resident’s findings and plan we developed as documented in the resident’s note.”  “See the resident’s note for details. I saw and evaluated the patient and agree with the resident’s findings and plans we developed as written.”
    67. 67. Coding Education & Training Program, HIM Department E/M – Teaching Facility Teaching Physician Examples of unacceptable documentation for State and Federal Payers  “Agree with above.”  “Rounded, Reviewed, Agree.”  “Discussed with resident.” “Agree.”  “Seen and Agree.”  “Patient seen and evaluated.”  A legible countersignature and/or identity alone does not meet State and Federal payer requirements
    68. 68. Coding Education & Training Program, HIM Department E/M – Teaching Facility Teaching Physician Non-State and Non-Federal Documentation Requirements (Commercial Payers): Minimum evidence of review by the attending shall be demonstrated by countersignature in the patient medical record Other requirements: The teaching physician shall be promptly available If the service includes direct patient contact, the teaching physician’s availability must include the ability to be physically present to review the resident’s note and ensure the services were furnished appropriately
    69. 69. Coding Education & Training Program, HIM Department E/M – Teaching Facility Medical Students The teaching physician and/or resident must reference the medical student’s dated documentation The medical student’s documentation may only contribute in two elements of the History component  The Review of Systems and the Past Medical, Family, Social History (ROS and PFSH)
    70. 70. Coding Education & Training Program, HIM Department E/M – Differences, Inpatient vs Outpatient Inpatient Encounters vs Outpatient Encounters Inpatient Encounters  Key Components are the same 1. History 2. Examination 3. Medical Decision Making  Elements within each component are the same  Difference 1. Levels  Example: Initial H&P has 3 levels, not 5 1. Number of Elements Required  Example: Initial H&P requires a Complete ROS (10 or more systems) for levels 2 and 3
    71. 71. Coding Education & Training Program, HIM Department E/M – Differences, Inpatient vs Outpatient Inpatient Encounters vs Outpatient Encounters Inpatient Encounters  Initial Hospital Visit/Hospital Observation Levels 1. Detailed 2. Comprehensive  Subsequent Hospital Visit/Follow-up Consult Levels 1. Problem Focused 2. Expanded Problem Focused 3. Detailed  Initial Hospital Consultation Levels 1. Problem Focused 2. Expanded Problem Focused 3. Detailed 4. Comprehensive
    72. 72. Coding Education & Training Program, HIM Department Pulling it All Together Overall E/M Code Selection Place of Service  Hospital vs Physician’s Office Type of Service  Consultation vs Office Visit vs Admission Patient Status  New Patient vs Established Patient  Outpatient vs Inpatient Documentation Requirements  State/Federal Payer vs Non-State/Non-Federal Payer Any Contributing Factors?  Time
    73. 73. Coding Education & Training Program, HIM Department Pulling It All Together Overall E/M Code Selection Key Components must be met or exceeded  New Patient/ER/Consultation 1. Requires all three key components  Established Patient 1. Requires two of three key components
    74. 74. Coding Education & Training Program, HIM Department Resources UCDHS Coding Education & Training Program http://www.ucdmc.ucdavis.edu/cet  (916) 734-8856 Coding Advisory Board (CAB) http://intranet.ucdmc.ucdavis.edu/cab/ Medicare Medlearn Matters http://www.cms.hhs.gov/MedlearnMattersArticles/ Compliance Office http://www.ucdmc.ucdavis.edu/compliance/  (916) 734-8808

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