E&M

Evaluation & Management, Teaching Physician Guidelines & Pain Management Documentation

Disclaimer The Revenue Management Solutions business unit is one of several business units within McKesson Technology Solutions. We refer to ourselves as “ RMS ” or “ Revenue Management Solutions ” for internal communications and certain external communications, such as media releases. PST Services, Inc. is the legal entity RMS uses with contracts with its clients or third party vendors. 06/11/11

Objectives for Today….. E/M Documentation Guidelines E/M Components Consultations Teaching Physician Guidelines Q&A 06/11/11

E&M DOCUMENTATION GUIDELINES 06/11/11

New vs. Established Patients If the physician , or any physician of the same specialty billing under a common group number , has never seen a patient before, you can categorize that patient as “new”. And if the same physician (or, again, any physician of the same specialty billing under a common group number ) hasn ’t seen the patient within the past 36 months, you may likewise consider the patient “new” from a billing and coding standpoint. Note : If a physician has seen a patient within 3 years as part of another group and has since joined a new practice, this patient is considered an established patient to this group. 06/11/11

Handwritten vs. Dictated Notes Food for Thought……. Notes are only notes if they can be read. If a note is illegible, an insurance company could view this as inadequate documentation and ask for a refund. When faced with a review or audit of such documentation, the payer will usually allow the handwritten note to be transcribed, under the physician ’s direction, into a legible format as long as both notes are submitted for review. The transcribed note cannot substitute for the original, but can be used to help the payer understand the handwritten one. 06/11/11

CHIEF COMPLAINT The chief complaint is most important because it answers the question, “Why is the patient here?” and it will help you select an appropriate ICD-9-CM code. In addition, you’ll use the chief complaint to determine the history of present illness (HPI), the review of systems (ROS) and the nature of the physical exam. Physicians often indicate that an established patient is being seen in follow-up . Without giving specific details, this would not be viewed as a valid chief complaint. The physician should describe what is being followed. 06/11/11

E/M - Components The descriptors for the levels of E/M services recognize seven components, six of which are used in defining the levels of E/M services. These components are : H istory, Examination, Medical decision making (MDM), Counseling, Coordination of care, Nature of presenting problem; Time 06/11/11

E/M - Key Components Of these seven components, three are considered as “Key Components” : History, Examination, Medical decision making (MDM) The remaining four components are contributory factors and help determine the intensity of the service provided 06/11/11

E & M Documentation Requirements HISTORY History is the most difficult of all 3 areas within the E&M Documentation on an Initial Inpatient visit and/or Consultation service. “History” is broken into 3 parts and all 3 parts must be complete because the score is based on the all 3 parts. If one part is not very well documented, it automatically lowers the score for the entire E/M Service. 1. History of Present Illness (HPI) 2. Review of Systems (ROS) 3. Past Medical, Family, Social History (PFSH) 06/11/11

E/M – History - HPI The HPI describes the patient ’ s h istory of p resent i llness/injury from the first sign and/or symptom to the present condition. The two types of HPIs are brief and extended. They are distinguished by the amount of detail needed and/or documentation provided. Brief HPI- A brief HPI consists of one to three elements of the HPI. Extended HPI- An extended HPI consists of at least four elements of the HPI Brief = 1-3 ( Impact: for a New Patient and/or Consultation Service, this would score immediately as a 99201/99241/99251 Extended = 4 or more elements ( Impact: for a New Patient and/or Consultation Service, this would place your score as either Level III, Level IV or Level V 06/11/11

E/M – History The ROS and/or PFSH may be recorded by ancillary staff or the patient on a form. The provider must document that he/she reviewed the information and either confirm or add an additional supplement to the medical record. If this information is not incorporated within the office dictation, the form must be made available as part of the chart. If the provider is unable to obtain a history from the patient or another source, he/she must describe in the medical record the patient ’s condition or other circumstance that prevents obtaining the history. 06/11/11

E/M – History - ROS At least ten organ systems must be reviewed to be considered a Complete Review of Systems. 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. (Not all carriers allow the use of this statement, check your carrier guidelines.) 06/11/11

Physical Exam Organ Systems Body Areas Constitutional Genitourinary Head Abdomen Eyes Musculoskeletal Neck Genital, groin, buttocks ENT Skin Chest Back Respiratory Neurological Each extremity Cardiovascular Psychiatric Gastrointestinal Hematological/Lymphatic Problem Focused – 1 body area or organ system ( Impacts your score immediately to reflect 99201/99241/99252) Expanded Problem Focused – 2-4 body areas or organ systems ( Impact: this could impact your score to reflect 99202/99242/99252) Detailed – 5-7 body areas or organ systems ( Impact: this could impact your score to reflect 99203/99243/99253) Comprehensive – 8+ organ systems ( Impact: this places a potential score to reflect either Level IV or Level V (Based on 95 guidelines) 06/11/11

MEDICAL DECISION MAKING 06/11/11

MEDICAL DECISION MAKING Medical Decision Making (MDM) is broken into 3 parts but we only need to match 2 out of 3 in the same column. 1. Diagnosis/Management Options 2. Amount/Complexity of Data Reviewed by Physician 3. Risk of Complications and/or Morbidity/Mortality 06/11/11

Medical Decision Making 06/11/11 Number of Diagnoses and Treatment Options Pts Total Self limiting or minor problems (stable, improved, or worsening) Maximum of 2 points 1 Established Problem – Stable Improved 1 Established Problem - Worsening 2 New Problem – No Additional Work-up Planned Maximum of 1 problem given credit 3 New Problem – Additional Work-up Planned 4 Total Points

Medical Decision Making cont. 06/11/11 Amount and Complexity of Data Pts Total Ordered and/or reviewed clinical lab 1 Ordered and/or reviewed radiology 1 Ordered/reviewed test in Medicine Section, CPT 1 Discussed tests with performing/interpreting Doc 1 Independent visualization and direct view of image, tracing, specimen 2 Decision to obtain old records/additional HX from someone other than patient (family, caretaker, previous physician) 1 Reviewed and summarized old records and/or obtained history from someone other than patient 2 Total Points

Medical Decision Making cont. Table of Risk 06/11/11 Level Presenting Problem Diagnostic Procedure Management Options Straight-forward One self limited or minor problem, ie: cold, insect bite, tinea coporis Lab test requiring venipuncture, chest x-ray, EKG/Eeg, Urinalysis, Ultrasound, KOH prep Rest Gargles Elastic Bandages Superficial Dressing Low Two or more self limited or minor problems One stable chronic illness Acute uncomplicated illness Non-cardiovascular imaging study w/contrast Superficial needle biopsy Clinical laboratory test requiring arterial puncture Skin biopsy Over the counter drugs Minor surgery w/no identified risk factors Physical therapy Occupational therapy IV fluids without addititives Moderate One or more chronic illnesses with mild exacerbation, progression or side effect of treatment Two or more stable chronic illnesses Undiagnosed new problem with uncertain prognosis Acute illness with systemic symptoms Physiological tests under stress Diagnostic endoscopies w/no identified risk factors Deep needle or incisional biopsy Cardiovascular imaging study w/contrast & no identified risk factor Obtain fluid from body cavity Minor surgery w/identified risk factor Elective major surgery w/no identified risk factor Prescription drug management Therapeutic nuclear medicine IV fluids w/additives Closed treatment of fracture or dislocation w/o manipulation High One or more chronic illnesses w/severe exacerbation, progression or side effect of treatment Acute or chronic illness or injuries that pose a threat to life or bodily function An abrupt change in neurological status Cardiovascular imaging studies w/contrast w/identified risk factor Cardiac electrophysiological tests Diagnostic endoscopies w/identified risk factors Discography Elective major surgery w/identified risk factor Emergency major surgery Parenteral control substances Drug therapy requiring intensive monitoring for toxicity Decision not to resuscitate or to de-escalate care because of poor prognosis

Tallying Level of Service New Patient/Consultations 06/11/11 HISTORY EPF Detailed C C EXAM EPF Detailed C C COMPLEXITY OF MEDICAL DECISION Straight Forward Low Moderate High Initial 99202 99242 99252 99203 99243 99253 99204 99244 99254 99205 99245 99255

Tallying Level of Service Established Out Pt/Subsequent Consult 06/11/11 If a column has 2 or 3 circles, draw a line down the column and circle the code OR draw a line down the column with the center circle and circle the code HISTORY PF interval EPF D C EXAMINATION PF EPF D C COMPLEXITY OF MEDICAL DECISION SF L M H Subsequent 99212 99213 99214 99215

Consultations Carriers pay for a reasonable and medically necessary consultation service when all of the following criteria are met: A request for a consultation and the need for consultation is documented by the consultant in the patient ’s medical record and included in the requesting physician's plan of care. The service is provided by a physician or qualified NPP whose opinion or advise regarding evaluation & management of a specific problem is requested by another physician or other appropriate source. After the consultation is provided, the consultants must prepare a written report of his/her findings and recommendations, which must be provided to the referring physician. 06/11/11

Consults Followed by Treatment A physician consultant may initiate diagnostic services and treatment at the initial consultation service or subsequent visit. Ongoing management, following the initial consultation service by the consultant physician must not be reported with consultation service codes. These services should be reported as subsequent visits for the appropriate place of service and level of service. Payment for a consultation service should be made regardless of treatment initiation unless a transfer of care occurs. 06/11/11

Transfer of Care vs. Consult A transfer of care occurs when a physician requests that another physician takes over the responsibility for managing the patient ’s complete care for the condition and does not expect to continue treating or caring for the patient for that condition. When this transfer is arranged, the requesting physician is not asking for an opinion or advise to personally treat this patient. In a transfer of care the receiving physician would report the appropriate new or established patient visit code and not a consult code. 06/11/11

Consultations Requested by Members of Same Group If one physician or qualified NPP in a group practice requests a consultation from another physician in the same group practice when the consultation physician or NPP has expertise in a specific medical area beyond the requesting professional ’s knowledge, a consult code may be billed. However, a consultation service should not be reported on every patient as a routine practice between physicians and qualified NPPs within a group practice setting. 06/11/11

Consultation Documentation Requirements Consultation Report – A written report must be furnished to the requesting physician. In the ED, Inpatient or Outpatient Setting – In a shared record, the request may be documented as part of a plan written in the requesting physician ’s progress note, an order in the medical record, or a specific written request for the consultation. In these settings, the report may consist of an appropriate entry in the common medical record. In an office Setting – The consultation report is a separate document communicated to the requesting physician or qualified NPP. In a large group practice, Academic Dept., or Multi-Specialty group – If the record is a shared record, it is acceptable to include the consultant ’s report in the medical record documentation and not require a separate letter from the consulting physician. 06/11/11

CONSULTATION SERVICES ON MEDICARE PATIENTS ONLY 06/11/11

Consultation Codes for Medicare Patients CMS (not CPT) – Deletion of all Consultation Codes Effective January 1, 2010, the consultation codes are no longer recognized for Medicare part B payment. The elimination use of all consultation codes (inpatient and office/outpatient codes) on a budget neutral basis by increasing the work RVUs for new and established office visits by 6%, increasing the work RVUs for initial hospital visits by 0.3%, and incorporating the increased use of these visits into their PE and malpractice RVU calculations. 06/11/11

Consultations on Medicare Patients 2010 Physicians shall code patient Consultation visits with E/M codes that represent where the visit occurs and that identify the complexity of the visit performed. In the inpatient hospital setting an initial evaluation may bill the initial hospital care codes (99221 – 99223). The principal physician of record (admitting physician) is identified in Medicare as the physician who oversees the patient ’ s care from other physicians who may be furnishing specialty care. The principal physician of record shall append modifier “ -AI ” , Principal Physician of Record, in addition to the E/M code. Follow-up Inpatient Consultation visits shall be billed as subsequent hospital care visits. In the office or other outpatient setting where an evaluation is performed, physicians and qualified nonphysician practitioners shall use the CPT codes (99201 – 99215) depending on the complexity of the visit and whether the patient is a new or established patient to that physician. All physicians and qualified nonphysician practitioners shall follow the E/M documentation guidelines for all E/M services. These rules are applicable for Medicare secondary payer claims as well as for claims in which Medicare is the primary payer. 06/11/11

Consultation on Medicare Patients 2010 To report consultations performed in the emergency department, consultants may report the appropriate ED codes 99281-99285. Medicare will allow payment to both the ED physician and the consultant even if both report an ED code. 06/11/11 3 of 3 key components Required New PT 99201 99202 99203 99204 99205 OP Cons 99241 99242 99243 99245 99245 IP Cons 99251 99252 99253 99254 99255 Initial IP 99221 99222 99223 ED 99281 99282 99283 99284 99285

E/M Visits during Post Op Period 30.6.6 - Payment for Evaluation and Management Services Provided During Global Period of Surgery (Rev. 954, Issued: 05-19-06, Effective: 06-01-06, Implementation: 08-20-06) A. CPT Modifier “ -24 ” - Unrelated Evaluation and Management Service by Same Physician During Postoperative Period Carriers pay for an evaluation and management service other than inpatient hospital care before discharge from the hospital following surgery (CPT codes 99221-99238) if it was provided during the postoperative period of a surgical procedure, furnished by the same physician who performed the procedure, billed with CPT modifier “ -24, ” and accompanied by documentation that supports that the service is not related to the postoperative care of the procedure. They do not pay for inpatient hospital care that is furnished during the hospital stay in which the surgery occurred unless the doctor is also treating another medical condition that is unrelated to the surgery. All care provided during the inpatient stay in which the surgery occurred is compensated through the global surgical payment 06/11/11

Medicare Consultation in ER then admitted 30.6.11 - Emergency Department Visits (Codes 99281 - 99288) (Rev. 1875, Issued: 12-14-09, Effective: 01-01-10, Implementation: 01-04-10) F. Emergency Department Physician Requests Another Physician to See the Patient in Emergency Department or Office/Outpatient Setting If the emergency department physician requests that another physician evaluate a given patient, the other physician should bill an emergency department visit code. If the patient is admitted to the hospital by the second physician performing the evaluation, he or she should bill an initial hospital care code and not an emergency department visit code. 06/11/11

Teaching Physician Guidelines 06/11/11

Residents and Teaching Physicians Both residents and physicians may document their services in the patient ’s chart. The record must be dated and contain a legible signature or identity for both providers. The record may be: Typed Handwritten Dictated and transcribed Computer generated 06/11/11

Residents and Teaching Physicians “ When an attending physician bills Medicare for an E/M service in the teaching setting, he/she must personally document their participation in the management of the patient and document that he/she performed the service or was physically present during the critical or key portions of the service performed by the resident. NOTE: The resident’s certification that the attending physician was present is NOT sufficient.”* 06/11/11

Residents and Teaching Physicians Medical students may make notes in the patient ’s medical record. The teaching physician is allowed to refer only to the notes related to the ROS (review of systems) and/or PFSH. Even if the medical student may have performed and documented a physical examination. The teaching physician must verify and repeat the documentation of the physical exam as well as his/her medical decision making. 06/11/11

Procedure Documentation The Operative Note & Modifier 25 06/11/11

The Operative Note The Pre- and Postoperative diagnosis should agree, or when appropriate differ. The language should be similar to the ICD-9 language. The diagnosis portion of the procedure justifies the medical necessity of the services provided. The Title of the Operation/Procedure must reflect what is dictated in the body of the note. The Body of the Report : For a good medical record, you must clearly and completely state each and every thing that was done during the procedure, even if you know it cannot be billed separately. 06/11/11

The Operative Note Examples of important documentation needed in Operative Note: Local Infiltration/Block Entry Level Identify each level treated Medication and dosage instilled Disposition of the patient at the completion of the Procedure. 06/11/11

Modifier 25 The AMA CPT Manual  defines modifier –25 as a “significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or service”. Modifier –25 may be appended to an E&M CPT  code to indicate that the E&M service is significant and separately identifiable from other services reported on the same date of service. The E&M service may be related to the same or different diagnosis as the other procedure(s). 06/11/11

Modifier 25 Cont. However, according the Centers for Medicare & Medicaid (CMS) guidelines, (Policy Narrative (NCCI 14.3): Chapter 1 General Correct Coding Policies, Excerpt – Section E), all procedures and services, no matter how minor, include an inherent E&M component. Since minor surgical procedures and XXX procedures include pre-procedure, intra-procedure, and post-procedure work inherent in the procedure, the provider should not report an E&M service for this work. Furthermore, Medicare Global Surgery rules prevent the reporting of a separate E&M service for the work associated with the decision to perform a minor surgical procedure whether the patient is a new or an established patient. Any E&M service you report separately must exceed the minimal evaluation that normally accompanies any other same day service(s) or procedures(s). CMS Transmittal 954, dated May 19, 2006, states specifically you should apply modifier 25 only for “ a significant, separately identifiable E&M service that is above and beyond the usual pre- and post-operative work for the service ” . 06/11/11

Questions and Answers 06/11/11

Sites & References The Home Health Alphabetical Site Index: http://www.cms.gov/providers/hhindex.asp (1995 & 1997 documentation guidelines) and many other references at this site Carriers Manual Part 3 - Claims Processing: http://www.cms.gov/manuals/14_car/3btoc.asp ? Medicare Claims Processing Manual 100-04 – Chapter 12 http://www.cms.hhs.gov/Manuals/IOM/itemdetail.asp?filterType=none&filterByDID=0&sortByDID=1& sortOrder=ascending&itemID=CMS018912&intNumPerPage=10 Medicare MLN Matters:MM5993 Released date July 9, 2008 Physician ’s Information Resource for Medicare: http://www.cms.gov/default.asp Centers for Medicare and Medicaid Services AMA ’s Current Procedural Terminology - CPT 2010 06/11/11

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