This document provides an overview of evaluation and management (E/M) coding for physician and hospital services. It discusses the key components used to determine E/M levels, including history, examination and medical decision making. For physicians, these components involve documenting elements like the chief complaint, review of systems, and number of diagnoses. For hospitals, E/M levels are typically determined by clinical care time for outpatient and emergency department visits. The document compares new vs established patient definitions and level determination between physicians and hospitals.
Compliatric continuous compliance series chapter 9Compliatric
As Operational Site Visits (OSVs) resume virtually, it is important for Community Health Centers to maintain continuous compliance. Compliatric is excited to continue their “Compliance Webinar Series” where each month, program requirements are reviewed to assist health centers in understanding various elements. Participants will be able to utilize these webinars to increase their knowledge of the requirements, and also take compliance to the next level.
This month’s webinar will focus on the following chapter:
Chapter 9: Sliding Fee Discount Program
Webinar attendee takeaways will include:
· Understanding the requirements and why they are important
· Methods to maintain continuous compliance (without addressing it last minute or only during an OSV)
· How to use the requirement in everyday practice to improve your Community Health Center
Compliatric continuous compliance series chapter 5Compliatric
As Operational Site Visits (OSVs) resume virtually, it is important for Community Health Centers to maintain continuous compliance. Compliatric is excited to continue their “Compliance Webinar Series” where each month, program requirements are reviewed to assist health centers in understanding various elements. Participants will be able to utilize these webinars to increase their knowledge of the requirements, and also take compliance to the next level.
This month’s webinar will focus on the following chapter:
Chapter 5: Clinical Staffing
Webinar attendee takeaways will include:
· Understanding the requirements and why they are important
· Methods to maintain continuous compliance (without addressing it last minute or only during an OSV)
· How to use the requirement in everyday practice to improve your Community Health Center
Overcoming the challenges of credentialing and privilegingCompliatric
While COVID-19 has consumed our lives both personally and professionally, health centers are still required to maintain compliance with Section 330 and FTCA requirements. How do we do that? By implementing an effective and cohesive credentialing and privileging process. The purpose of this webinar is to provide a better understanding of the requirements for credentialing and privileging, as well as provide tips and strategies for overcoming the challenges associated with the process during this time of crisis. Areas of focus include the following:
1. Basic Concepts
2. Understanding the difference between credentialing and privileging
3. How credentialing and privileging relates to Scope of Project
4. Where Peer Review fits in
5. Credentialing and privileging during COVID-19
The patients hand over their future and lives to them and hence medical credentialing is a must at the hospitals, clinics, laboratories and other healthcare centers.
Provider Credentialing - Overview and ChecklistJessica Parker
Provider credentialing is a process in which a provider's qualifications and competency-based on demonstrated competence are formally assessed by a health insurance carrier.
Bookends of the Patient Experience: Improvement Strategies from Admission to ...TraceByTWSG
In this webinar, Yvonne Chase of Mayo Clinic shares strategies to improve patient experience across the continuum of care - from pre-service to post-servcie activities. This presentation shares tools and processes used to streamline patient access, coordinate patient care and conduct patient follow-up post discharge - all while monitoring patient interactions to ensure clear and accurate communication from the first point of contact to the last.
Compliatric continuous compliance series chapter 9Compliatric
As Operational Site Visits (OSVs) resume virtually, it is important for Community Health Centers to maintain continuous compliance. Compliatric is excited to continue their “Compliance Webinar Series” where each month, program requirements are reviewed to assist health centers in understanding various elements. Participants will be able to utilize these webinars to increase their knowledge of the requirements, and also take compliance to the next level.
This month’s webinar will focus on the following chapter:
Chapter 9: Sliding Fee Discount Program
Webinar attendee takeaways will include:
· Understanding the requirements and why they are important
· Methods to maintain continuous compliance (without addressing it last minute or only during an OSV)
· How to use the requirement in everyday practice to improve your Community Health Center
Compliatric continuous compliance series chapter 5Compliatric
As Operational Site Visits (OSVs) resume virtually, it is important for Community Health Centers to maintain continuous compliance. Compliatric is excited to continue their “Compliance Webinar Series” where each month, program requirements are reviewed to assist health centers in understanding various elements. Participants will be able to utilize these webinars to increase their knowledge of the requirements, and also take compliance to the next level.
This month’s webinar will focus on the following chapter:
Chapter 5: Clinical Staffing
Webinar attendee takeaways will include:
· Understanding the requirements and why they are important
· Methods to maintain continuous compliance (without addressing it last minute or only during an OSV)
· How to use the requirement in everyday practice to improve your Community Health Center
Overcoming the challenges of credentialing and privilegingCompliatric
While COVID-19 has consumed our lives both personally and professionally, health centers are still required to maintain compliance with Section 330 and FTCA requirements. How do we do that? By implementing an effective and cohesive credentialing and privileging process. The purpose of this webinar is to provide a better understanding of the requirements for credentialing and privileging, as well as provide tips and strategies for overcoming the challenges associated with the process during this time of crisis. Areas of focus include the following:
1. Basic Concepts
2. Understanding the difference between credentialing and privileging
3. How credentialing and privileging relates to Scope of Project
4. Where Peer Review fits in
5. Credentialing and privileging during COVID-19
The patients hand over their future and lives to them and hence medical credentialing is a must at the hospitals, clinics, laboratories and other healthcare centers.
Provider Credentialing - Overview and ChecklistJessica Parker
Provider credentialing is a process in which a provider's qualifications and competency-based on demonstrated competence are formally assessed by a health insurance carrier.
Bookends of the Patient Experience: Improvement Strategies from Admission to ...TraceByTWSG
In this webinar, Yvonne Chase of Mayo Clinic shares strategies to improve patient experience across the continuum of care - from pre-service to post-servcie activities. This presentation shares tools and processes used to streamline patient access, coordinate patient care and conduct patient follow-up post discharge - all while monitoring patient interactions to ensure clear and accurate communication from the first point of contact to the last.
Streamlining Your Medical Practice for Profitability and SuccessConventus
Conventus webinar video providing key success strategies and tactics for improving productivity, profitability, and patient care. The one-hour video features host Susan Lieberman of Conventus and Stevie Davidson of Health Informatics Consulting.
There is no doubt patient experience is one of the most crucial factors in the Healthcare industry. Check out factors that influence patient satisfaction scores and how to use patient experience data more actionable.
Key Findings from MD Ranger's 2018 Total Facility Benchmarks ReportMD Ranger, Inc.
Review key findings from our recently published 2018 Total Facility Benchmark Reports, as well as compare them to past years' reports to uncover trends in physician payments.
This presentation covers:
-How much hospitals spend on call coverage and medical directorships
-Facility-wide physician contracting trends
-How healthcare organizations use facility-wide benchmarks to drive better performance
-And more!
The Joint Commission is a Chicago-based organization which accredits 15,000 hospitals in the United States. The Joint Commission International (JCI) is its subsidiary which accredits hospitals outside the U.S. As the medical travel trend grows, JCI accreditation is becoming an important benchmark for quality standards.
The State of Consumer Healthcare: A Study of Patient ExperienceProphet
There is a vital change happening in healthcare: People are demanding to be treated as savvy consumers, who deserve choices, convenience and fair prices. The same revolution of consumerism that’s shaking up the way the world buys financial services, airline tickets and groceries is finally underway in healthcare. And as healthcare options multiply, this trend will only accelerate. Providers who are ready to respond by creating a strong patient experience are going to win, and those who aren’t will be left behind.
This presentation explains findings from the patient experience study which was conducted to understand the consumer healthcare experience by assessing the gap between patient and providers’ expectations and perceptions, and arm institutions with the ability to assess their own organization, define a successful strategy, and deliver on it.
View the webinar here: http://bit.ly/1RLgTFX
Physician Contracting at Small and Rural HospitalsMD Ranger, Inc.
In this webinar we discuss discuss the unique physician contracting and compliance considerations facing small and rural hospitals.
We will cover:
- Key considerations for physician contracting at small and rural hospitals
- Spending trends in compensation at these facilities
- Strategies for managing your contracting and compliance program
- And more!
Bookends of the Patient Experience: Improvement Strategies from Admission to ...TraceByTWSG
Yvonne Chase has a strategy. She shows how hospitals can prepare for the paradigm shift of value-based purchasing. She has the exact revenue cycle tools and processes used to streamline patient access, coordinate patient care and conduct patient follow-up post discharge – all while monitoring patient interactions to ensure clear and accurate communication from the first point of contact to the last.
Streamlining Your Medical Practice for Profitability and SuccessConventus
Conventus webinar video providing key success strategies and tactics for improving productivity, profitability, and patient care. The one-hour video features host Susan Lieberman of Conventus and Stevie Davidson of Health Informatics Consulting.
There is no doubt patient experience is one of the most crucial factors in the Healthcare industry. Check out factors that influence patient satisfaction scores and how to use patient experience data more actionable.
Key Findings from MD Ranger's 2018 Total Facility Benchmarks ReportMD Ranger, Inc.
Review key findings from our recently published 2018 Total Facility Benchmark Reports, as well as compare them to past years' reports to uncover trends in physician payments.
This presentation covers:
-How much hospitals spend on call coverage and medical directorships
-Facility-wide physician contracting trends
-How healthcare organizations use facility-wide benchmarks to drive better performance
-And more!
The Joint Commission is a Chicago-based organization which accredits 15,000 hospitals in the United States. The Joint Commission International (JCI) is its subsidiary which accredits hospitals outside the U.S. As the medical travel trend grows, JCI accreditation is becoming an important benchmark for quality standards.
The State of Consumer Healthcare: A Study of Patient ExperienceProphet
There is a vital change happening in healthcare: People are demanding to be treated as savvy consumers, who deserve choices, convenience and fair prices. The same revolution of consumerism that’s shaking up the way the world buys financial services, airline tickets and groceries is finally underway in healthcare. And as healthcare options multiply, this trend will only accelerate. Providers who are ready to respond by creating a strong patient experience are going to win, and those who aren’t will be left behind.
This presentation explains findings from the patient experience study which was conducted to understand the consumer healthcare experience by assessing the gap between patient and providers’ expectations and perceptions, and arm institutions with the ability to assess their own organization, define a successful strategy, and deliver on it.
View the webinar here: http://bit.ly/1RLgTFX
Physician Contracting at Small and Rural HospitalsMD Ranger, Inc.
In this webinar we discuss discuss the unique physician contracting and compliance considerations facing small and rural hospitals.
We will cover:
- Key considerations for physician contracting at small and rural hospitals
- Spending trends in compensation at these facilities
- Strategies for managing your contracting and compliance program
- And more!
Bookends of the Patient Experience: Improvement Strategies from Admission to ...TraceByTWSG
Yvonne Chase has a strategy. She shows how hospitals can prepare for the paradigm shift of value-based purchasing. She has the exact revenue cycle tools and processes used to streamline patient access, coordinate patient care and conduct patient follow-up post discharge – all while monitoring patient interactions to ensure clear and accurate communication from the first point of contact to the last.
The !CHAOS project is aiming at the development of a new concept of control system and data acquisition framework providing, with a high level of abstraction, all the services needed for controlling and managing a large scientific, or non-scientific, infrastructure.
Accurate data mining is the best thing in medical billing services, MGSI providing and helping physicians and medical practices with Tops ideas to improve medical billing services.
https://www.mgsionline.com/medical-billing-and-collections.html
#MedicalBillingCollections
Presentation by Rich Pollack, VP and Chief Information Officer, VCU Health, at the marcus evans National Healthcare CIO Summit held in Pasadena, CA March 13-14 2017
Read and discuss the following three articles 1. ACAs Perform.pdfSALES97
Read and discuss the following three articles:
1. ACAs Performance Based Healthcare
Standards ACAsPerformanceBasedHealthCareStandards.pdf
2. Road to Accreditation RoadToAccreditation.pdf
3. JCAHO Accreditation and Quality of Care for Acute Myocardial Infarction JCAHO
accreditation and quality of care for acute myocardial infarction.pdf
Have an open discussion about these articles. Share your thoughts
For example, here are some questions to answer and discuss:
Does accreditation impact quality? Are there less errors in hospitals that are accredited? What is
the value of accreditation? Do quality concerns initiate changes in staff behavior? Should
accreditation be based on results?
Read and discuss the following three articles:
1. ACAs Performance Based Healthcare
Standards ACAsPerformanceBasedHealthCareStandards.pdf
2. Road to Accreditation RoadToAccreditation.pdf
3. JCAHO Accreditation and Quality of Care for Acute Myocardial Infarction JCAHO
accreditation and quality of care for acute myocardial infarction.pdf
Have an open discussion about these articles. Share your thoughts
For example, here are some questions to answer and discuss:
Does accreditation impact quality? Are there less errors in hospitals that are accredited? What is
the value of accreditation? Do quality concerns initiate changes in staff behavior? Should
accreditation be based on results?
Solution
ACAs Performance Based Healthcare Standards-
This booklet is intended to assist anyone dealing with or affected by Health and Employment
issues. It is one of a series of booklets and handbooks designed to give impartial advice on
employment matters to employers, employees and their representatives. Legal information is
provided for guidance only and should not be regarded as an authoritative statement of the law,
which can only be made by reference to the particular circumstances which apply. It may,
therefore, be wise to seek legal advice.
Acas is committed to building better relationships in the workplace and offers training to suit
you. From a two-hour session on the key points of new legislation or employing people to
courses specially designed for people in your organisation. Click here to find out about training
sessions in your area. We also offer hands-on practical help and support to tackleissues in your
business with you. This might be through one of our wellknown problem-solving services or a
programme we have worked out together to put your business firmly on track for effective
employment
relations.
road to accrediation -
Accreditation is usually a voluntary program, sponsored by a non-governmental organization
(NGO), in which trained external peer reviewers evaluate a healthcare organization\'s
compliance and compare it with pre-established performance standard
Accreditation is a quality assurance process designed to ensure an educational program meets a
national standard. It serves to support and encourage program responsiveness to the ra pidly
changing environmental .
Patient’s experience, improve the quality health3zsaddique
Putting patients first requires more than world-class clinical care – it requires care that addresses every aspect of a patient’s encounter with Hospital, including the patient’s physical comfort, as well as their educational, emotional, and spiritual needs. A team of professionals should serves as an advisory resource for critical initiatives across the Hospital health system. In addition, it should provide resources and data analytics; identify, support, and publish sustainable best practices; and collaborate with a variety of departments to ensure the consistent delivery of patient-centered care.
Three Keys to a Successful Margin: Charges, Costs, and LaborHealth Catalyst
How can cost management and complete charge capture protect and enhance the margin?
In this webinar, we will look at 2024 margin pressures likely to impact your organization’s financial resiliency. This presentation will also share how organizations can move from Fee-for-Service to Value; bringing Cost to the forefront.
How can you be successful at healthcare revenue cycle management.pdfCosentus
The best way to be successful at healthcare revenue cycle process is to outsource RCM services. Cosentus is one of the best companies that can help you get the desired result in your healthcare RCM. Visit their website today and get the best RCM service!
Physician contract compliance can be less of a headache if your organization takes a planned, methodical approach to obtaining and recording payments rates.
If your facility could use best practices for determining and documenting FMV for physician contracts, join us for our 30-minute webinar covering:
--The meaning of FMV
--Various methods to determine FMV
--Strategies for efficient documentation
In the world of healthcare, there are many aspects that come together and make healthcare organizations work. While the main focus is on providing quality healthcare services, other aspects, like employee satisfaction, equipment quality, healthcare revenue cycle management, and much more are also equally important to get the services going smoothly and ensure that the healthcare provider receives the payment for their services on time.
The Impact of Patient Eligibility Verification on the Revenue Cycle.pdftevixMD
Patient eligibility verification is critical for a provider to maintain a healthy revenue cycle management (RCM) process. This step ensures that patients are eligible for the services provide, that the correct insurance information is used for billing for these services and the patient owed amount is defined.
This presentation by the Bureau of Health Information to the Royal Australasian College of Physicians looks at using clinical outcome data to improve patient care.
It examines:
Why measure and report on performance?
- Accountability and quality improvement
What is performance really?
- It is not a measure of what the system is, it is a measure of how well the system does
Whose performance is it anyway?
- Attributing results to providers, units or sectors requires a careful assessment
Medical coding best-practices_for_emergency_departments (1)Manish Jain
In this paper, you will learn about the unique medical coding and billing challenges posed by emergency departments and the coding best practices to ensure optimal reimbursements.
Principles of Surgical Audit presented by Meeran Earfan, Kurdistan Board Trainee/General Surgery in Sulaimaniyah Teaching Hospital, As Sulaimaniyah, Iraq
5. Page 5
What are Evaluation and Management Services?
» A category of billing for physician and facility services that focuses on
understanding the patient's problems and arranging a care plan to help.
» Evaluation and Management Services most often include
› Emergency Room Visits
› Inpatient Consultations
› Outpatient Clinic Visits
» Most often referred to as E/M services.
7. Page 7
Physician E/M Component Overview
» To determine the appropriate level of service for a patient’s visit, it is
necessary to first determine whether the patient is new or already
established.
» The physician then uses the presenting illness as a guiding factor and his
clinical judgment about the patient’s condition to determine the extent of
key elements of service to be performed.
» The key elements of service are:
› History;
› Examination; and
› Medical Decision Making.
» The three key components appear in the AMA descriptors for office and
other outpatient services, hospital observation services, hospital inpatient
services, consultations, emergency department services, nursing facility
services, domiciliary care services, and home services.
» EXCEPTION: in visits which consist predominately of counseling or
coordination of care, the time spent is key in determining the level of E/M.
CMS Evaluation and Management Services Guide – March 2006
8. Page 8
Physician Key Component - History
» Documentation of patient history includes some or all of the following
elements:
› Chief Complaint (CC)
› History of Present Illness (HPI)
› Review of Systems (ROS)
› Past, Family, And/Or Social History (PFSH)
» The elements documented will determine the level of history for the E/M
level.
9. Page 9
Physician Key Component - Examination
» There are two types of examinations that can be performed during a
patient’s visit:
› General multi-system examination
› Single organ system examination
» Below are the body areas and organ systems that are recognized according
to the Current Procedural Terminology (CPT) book:
10. Page 10
Physician Key Component - Examination
» The elements documented will determine the level of examination for the
E/M level.
11. Page 11
Physician Key Component – Medical Decision Making
» Medical decision making refers to the complexity of establishing a
diagnosis and/or selecting a management option, which is determined by
considering the following factors:
› Number of possible diagnoses and/or management options;
› Amount and/or complexity of medical records, diagnostic tests, and/or other
information that must be obtained, reviewed and analyzed; and
› Risk of significant complications, morbidity, and/or mortality as well as
comorbidities associated with the patient's presenting problem(s), the diagnostic
procedure(s), and/or the possible management options.
12. Page 12
Physician Key Component – Medical Decision Making
» To qualify for a given type of medical decision making, two of the three
elements must either be met or exceeded.
14. Page 14
Hospital E/M Overview
» Separate CPT/HCPCS codes have yet to be established to describe E/M
services provided within a facility.
» Hospitals are permitted to utilize “physician” E/M to capture charges for
services provided.
› Physicians – expertise
› Hospitals – overhead
» To determine the appropriate level of service for a patient’s visit, it is
necessary to first determine whether the patient is new or already
established.
» Hospitals are to create their own system for determining visit level.
› In Maryland this has been established by the HSCRC.
› Outside of Maryland, various methods are utilized
‒ Point systems
‒ Time-Based
‒ Severity-Based
» It is not an expectation of payers that levels reported by the physician and
facility for the same patient, same encounter will be at the same level.
15. Page 15
Hospital E/M – Maryland HSCRC
» Emergency Department Visits
› Clinical Care Time (CCT)
‒ Level I 0-<15 minutes
‒ Level II 15-<30 minutes
‒ Level III 30<60 minutes
‒ Level IV 60<120 minutes
‒ Level V 120+ minutes
› Includes all procedures and services performed by ED staff
» Outpatient Clinic Visits
› Clinical Care Time (CCT)
‒ Level I 0-10 minutes
‒ Level II 11-25 minutes
‒ Level III 26-45 minutes
‒ Level IV 46-90 minutes
‒ Level V 91+ minutes
› Procedures can be reported separately
17. Page 17
New vs. Established Patient
» E/M codes will often differ between new and established patients.
» Criteria differs between physician and hospital reporting of E/M services.
› Physician
‒ New vs. Established
◦ Pertains to whether a patient has been seen by a provider or a fellow provider from
the same specialty of the same group practice within the past 3 years
› Hospital
‒ New vs. Established
◦ Pertains to whether or not the patient already has a medical record number
◦ If patient had use of that medical record number within the past 3 years, the patient
is considered an established patient to the hospital
◦ The same patient could be “new” to a physician or department, but “established” to
the hospital
18. Page 18
Level Determination
» Physician
› Level determination for physicians can be complex.
› Subject to great scrutiny.
» Hospital
› Level determination for hospitals remains to be unstructured.
› Not easily scrutinized.
19. Page 19
Reportable CPT/HCPCS
» E/M Services do not always share the same CPT/HCPCS when reporting
services performed by a physician or on behalf of a facility.
24. Page 24
Our Values
Responsive – we anticipate and respond quickly to client needs. We are experts in
highly regulated environments, and our deep industry knowledge enables us to
develop innovative and practical solutions to our clients’ business challenges.
Resourceful – as an integrated company, we are able to leverage the diverse skills and
industry expertise of our professionals to help clients overcome the challenges of
uncertainty, risk, distress and significant change. We work seamlessly, drawing from
an array of resources, to help clients transform ideas in actions.
Trustworthy – clients count on us for effective solutions, accurate answers and honest
responses. We approach every task in a straightforward manner, providing
independent and objective advice in which clients can have confidence.
Innovative – we have a history of helping clients identify and implement innovative
solutions to complex and challenging business issues. Our entrepreneurial culture
encourages all professionals to be innovative exploring new ideas and methods to help
clients address their business challenges.
25. Page 25
Our Unique Approach
» Integration – We believe it is imperative to integrate a strategic and
operational focus. Linkages to financial and clinical performance are
critical.
» Experience – Our consultants have on average 10+ years of operational
and/or consulting experience. Our senior resources work on the project –
not just lead the project.
» Flexibility – We are a consulting group consisting of highly experienced
consultants. We bring methodology but tailor efforts to meet the clients
needs and success factors.
» Size – We are not too big…not too small. With over 300 employees serving
the healthcare industry, we can leverage our operational, clinical, financial,
regulatory and technical capabilities depending on the client’s needs.
We believe there are key differentiators that drive Navigant Consulting’s
unique approach to assisting our clients.
Editor's Notes
The extent of information gathered for history is dependent upon clinical judgment and the nature of the presenting problem.
The extent of information gathered for history is dependent upon clinical judgment and the nature of the presenting problem.
The extent of information gathered for history is dependent upon clinical judgment and the nature of the presenting problem.
The extent of information gathered for history is dependent upon clinical judgment and the nature of the presenting problem.
According to the 1997 Documentation Guidelines for Evaluation and
Management Services, the 10 single organ system examinations are:
• Cardiovascular;
• Ear, Nose, and Throat;
• Eye;
• Genitourinary;
• Hematologic/Lymphatic/Immunologic;
• Musculoskeletal;
• Neurological;
• Psychiatric;
• Respiratory; and
• Skin.
General multi-system examination, which involves the examination of one or
more organ systems or body areas. According to the 1997 Documentation
Guidelines for Evaluation and Management Services each body area or organ
system contains two or more of the following examination elements:
• Constitutional Symptoms (e.g., fever, weight loss);
• Eyes;
• Ears, Nose, Mouth, Throat;
• Neck;
• Respiratory;
• Cardiovascular;
• Chest (breasts);
• Gastrointestinal;
• Genitourinary;
• Lymphatic;
• Musculoskeletal;
• Integumentary;
• Neurological; and
• Psychiatric.
The extent of information gathered for history is dependent upon clinical judgment and the nature of the presenting problem.
According to the 1997 Documentation Guidelines for Evaluation and
Management Services, the 10 single organ system examinations are:
• Cardiovascular;
• Ear, Nose, and Throat;
• Eye;
• Genitourinary;
• Hematologic/Lymphatic/Immunologic;
• Musculoskeletal;
• Neurological;
• Psychiatric;
• Respiratory; and
• Skin.
General multi-system examination, which involves the examination of one or
more organ systems or body areas. According to the 1997 Documentation
Guidelines for Evaluation and Management Services each body area or organ
system contains two or more of the following examination elements:
• Constitutional Symptoms (e.g., fever, weight loss);
• Eyes;
• Ears, Nose, Mouth, Throat;
• Neck;
• Respiratory;
• Cardiovascular;
• Chest (breasts);
• Gastrointestinal;
• Genitourinary;
• Lymphatic;
• Musculoskeletal;
• Integumentary;
• Neurological; and
• Psychiatric.