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Medical Documentation for E&M Coding

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Learn about the medical documentation rules in the 1997 E&M Guidelines that are used by Medicare, Medicaid, and virtually all insurers to determine the value of many healthcare services like office visits and hospital admissions.

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Medical Documentation for E&M Coding

  1. 1.  Define E&M Services  Know the E&M Documentation Components  Review E&M documentation criteria
  2. 2.  Common patient/physician encounters  Clinic visit  H&P  Does not include tests or procedures
  3. 3.  Issued by Centers for Medicare & Medicaid Services  1995  1997
  4. 4. E&M Encounter History Exam MDM
  5. 5. E&M Encounter History Exam MDM Medical Decision Making
  6. 6.  Chief Complaint (CC)  History of Present Illness (HPI)  Review of Systems (ROS)  Past, Family, and Social History (PFSH)
  7. 7.  Comprehensive  Detailed  Expanded Problem Focused  Problem Focused
  8. 8. Problem Focused Expanded Problem Focused Detailed Comprehensive CC Yes Yes Yes Yes HPI 1Element Or 1 Chronic Condition 4 Elements Or 3 Chronic Conditions ROS 1 System 2 Systems 10 Systems PFSH 3 Areas 3 Areas 3 Areas 3 Areas
  9. 9. Problem Focused Expanded Problem Focused Detailed Comprehensive CC Yes Yes Yes Yes HPI 1Element Or 1 Chronic Condition 4 Elements Or 3 Chronic Conditions ROS 1 System 2 Systems 10 Systems PFSH 3 Areas 3 Areas 3 Areas 3 Areas HPI elements – Location, Quality, Severity, Duration, Timing, Context, Modifying Factors, Associated Signs and Symptoms
  10. 10. Problem Focused Expanded Problem Focused Detailed Comprehensive CC Yes Yes Yes Yes HPI 1Element Or 1 Chronic Condition 4 Elements Or 3 Chronic Conditions ROS 1 System 2 Systems 10 Systems PFSH 3 Areas 3 Areas 3 Areas 3 Areas ROS Systems – Constitutional, Eyes, ENT, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Integumentary, Neurological, Psychiatric, Endocrine,
  11. 11. Problem Focused Expanded Problem Focused Detailed Comprehensive CC Yes Yes Yes Yes HPI 1Element Or 1 Chronic Condition 4 Elements Or 3 Chronic Conditions ROS 1 System 2 Systems 10 Systems PFSH 3 Areas 3 Areas 3 Areas 3 Areas PFSH Areas – Past (medical and surgical), Social, and Family History Noncontributory is not acceptable to some insurers
  12. 12. Problem Focused Expanded Problem Focused Detailed Comprehensive CC Yes Yes Yes Yes HPI 1Element Or 1 Chronic Condition 4 Elements Or 3 Chronic Conditions ROS 1 System 2 Systems 10 Systems PFSH 1 Area 3 Areas
  13. 13.  General Multisystem  Cardiovascular  Ear, Nose and Throat  Eye  Genitourinary  Hematologic/Lymphatic/Immunologic  Musculoskeletal  Neurologic  Psychiatric  Respiratory  Skin
  14. 14.  Comprehensive  Detailed  Expanded Problem Focused  Problem Focused
  15. 15. Rules Problem Focused Expanded Problem Focused Detailed Comprehensive 1995 1 Area 2 Areas 7 Areas 8 Areas 1997 (GMS) 1 Bullet Item 6 Bullet Items 2 Bullet Items from 6 Systems OR 12 Bullet Items from 2+ Systems 2 Bullet Items from 9 Systems 1997 (Specialty) See 1997 Guidelines for details
  16. 16.  Number of diagnosis or management options  Amount or complexity of data  Risk of complications, morbidity, or mortality
  17. 17. Complexity Dx Options Data Reviewed Risk High Extensive Extensive High Moderate Multiple Moderate Moderate Low Limited Low Low Straightforward Minimal Minimal or None Minimal Complexity of MDM Set by the highest two of three areas
  18. 18. Complexity Dx Options Data Reviewed Risk High Extensive Extensive High Moderate Multiple Moderate Moderate Low Limited Low Low Straightforward Minimal Minimal or None Minimal Criteria for these levels are not defined In the E&M Documentation Guidelines Medicare Carriers can decide how to interpret these areas
  19. 19.  Maximum of 4 points (Extensive) Problem Status Points New Problem with Workup 4 New Problem w/o Workup 3 Established problem, Worse 2 for each problem Established problem, Stable 1 for each problem Minor problem 1 (up to 2 points) This method is used by most Medicare Carriers Check with your Medicare Carrier to confirm what method they use
  20. 20.  Maximum of 4 points (Extensive) Data Item Points Summary of old records 2 Interpret image/tracing 2 Request old records 1 Discuss pt with another MD 1 Review/Order Imaging Study 1 Review/Order Lab Test 1 Review/Order Other Test 1This method is used by most Medicare Carriers. Check with your Medicare Carrier to confirm what method they use No Double Credit
  21. 21. Risk Presenting Problem Dx Procedures Management Options High Severe exacerbation of chronic illnesses Acute or chronic illness or injury that threatens life or limb Abrupt change in neurologic status Cardiovascular imaging studies + Risk factors Cardiac electro-physiologic tests Diagnostic endoscopies + Risk factors Discography Elective surgery + Risk factors Emergency Major surgery Parenteral controlled substances Drug therapy requiring intensive monitoring DNR or de-escalate care decision Moderat e Mild exacerbation a chronic illness 2 or more stable, chronic illnesses New problem with uncertain prognosis Acute illness with systemic symptoms Acute complicated injury Physiologic tests under stress Diagnostic endoscopies with NO risk factors Deep needle or incisional biopsy Cardiovascular imaging studies with contrast Obtaining body cavity fluid Minor surgery WITH identified risk factors Elective major surgery with NO risk factors Prescription drug management Therapeutic nuclear medicine IV fluids with additives Closed treatment of fracture Low 2 self-limited or minor problems Stable, well- controlled chronic illness Acute uncomplicated illness or injury Physiologic tests NOT under stress Noncardiovascular imaging studies + contrast Superficial needle biopsies Clinical lab tests requiring arterial puncture Skin biopsies OTC drugs Minor surgery without identified risk factors Physical therapy Occupational therapy IV fluids without additives Minimal A self limited or minor problem Venipuncture X-rays EKG EEG Rest Gargles Elastic bandages
  22. 22. Risk Presenting Problem Dx Procedures Management Options High Acute or chronic illness or injury that threatens life or limb Abrupt change in neurologic status Parenteral controlled substances Drug therapy requiring intensive monitoring Moderat e New problem with uncertain prognosis Prescription drug management Low OTC drugs Minimal
  23. 23. Complexity Dx Options Data Reviewed Risk High Extensive Extensive High Moderate Multiple Moderate Moderate Low Limited Low Low Straightforward Minimal Minimal or None Minimal Complexity of MDM Set by the highest two of three areas
  24. 24. Level 5 CPT 99205 Level 4 CPT 99204 Level 3 CPT 99203 Level 2 CPT 99202 Level 1 CPT 99201 History Comprehensi ve Comprehensiv e Detailed Expanded Problem Focused Problem Focused Exam Comprehensi ve Comprehensiv e Detailed Expanded Problem Focused Problem Focused MDM High Moderate Low Low Straightforwar d
  25. 25. Level 5 CPT 99215 Level 4 CPT 99214 Level 3 CPT 99213 Level 2 CPT 99212 Level 1 CPT 99211 History Comprehensi ve Detailed Expanded Problem Focused Problem Focused Minimal problem that may not require presence of a physician Exam Comprehensi ve Detailed Expanded Problem Focused Problem Focused MDM High Moderate Low Straightforwar d2 out of three components must be at this level
  26. 26.  Emergency department visits  Inpatient (New and Follow up)  Observation (New and Follow up)  Nursing Facility (New and Follow up)  …and others.
  27. 27. Model used by 75% of practices in 2012/2013 Merritt Hawkins Survey
  28. 28.  Complex Rules  Mastery of the rules relevant to your practice is essential for financial success

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