This document provides guidance on medical record documentation and selecting codes for evaluation and management (E/M) services billed to Medicare. It discusses the importance of complete and accurate documentation to support the medical necessity and services provided. Five levels of E/M codes are described for new patient office visits, differentiated by the typical time spent, complexity of presenting problems, and components of the history, exam and medical decision making. Proper documentation and code selection ensures quality patient care and accurate reimbursement.
Presentation of proper coding and usage of modifiers (Level I and Level II)
Have trouble knowing what modifier to use and how use will impact your claim? Take a look at the presentation "The In's and Out's of Coding with Modifiers", which explain modifiers for you! Hope you enjoy!
The document provides information and guidelines around evaluation and management documentation, including documentation of the chief complaint, history of present illness, review of systems, past medical history, physical exam, and medical decision making. It discusses the components needed for different levels of evaluation and management services and how to tally the level of service based on the history, exam, and medical decision making complexity.
Here are the key differences between the 1995 and 1997 E/M examination guidelines:
1995 Guidelines:
- Based on extent of exam (problem focused, expanded problem focused, detailed, comprehensive)
- Defines extent by number of body areas/organ systems examined
1997 Guidelines:
- Based on organ systems/body areas examined and elements documented
- Defines extent by minimum number of elements documented across organ systems/body areas
- More flexibility in choice of organ systems/areas examined
So in summary, 1995 based on scope of exam, 1997 based on documentation of exam elements.
Modifiers are two-character suffixes added to procedure codes to provide additional information about the service or procedure performed. The document discusses several common modifiers used in medical billing, including:
- Modifier -22 for increased procedure intensity
- Modifier -23 for unusual anesthesia
- Modifier -24 for unrelated E/M services during the postoperative period
- Modifier -25 for significant, separately identifiable E/M services on the same day
- Modifier -50 for bilateral procedures
- Modifier -76 for repeated procedures
- Modifier -80 for assistant surgeon services
The document provides definitions and examples for how and when to use these common billing modifiers to accurately report medical services and ensure proper
The document discusses evaluation and management (E/M) coding guidelines. It covers the key components of E/M codes which are history, examination, and medical decision making. E/M codes are used to bill for office visits, hospital visits, consultations, and other services. Assignment of the codes depends on factors like new vs. established patient, type of service, place of service, patient age, and time spent. History, examination, and medical decision making are the three main components used to determine the level of E/M service provided.
Basics Of Coding And Medical Record DocumentationAngie Nolan
The document discusses the basics of medical coding and record documentation. It covers the key components of a medical record including that it serves as a medical, legal, and compliance document. It outlines the patient's care and treatment. The document also discusses the key components of evaluation and management (E&M) codes including history, examination and medical decision making. It notes the requirements for documenting new versus established patient visits. The presentation emphasizes that documentation is critical for appropriate coding, reimbursement and defending medical necessity.
Clinical Documentation Guidelines for ICD-10-CMPamela Marasco
1) The document discusses the importance of proper clinical documentation for selecting accurate ICD-10-CM codes beginning October 1, 2015.
2) ICD-10-CM requires more specific documentation than ICD-9-CM to capture details like laterality, severity, and complications.
3) Providers are encouraged to review their documentation practices to ensure specific details are included to support code selection and to avoid issues with reimbursement.
Presentation of proper coding and usage of modifiers (Level I and Level II)
Have trouble knowing what modifier to use and how use will impact your claim? Take a look at the presentation "The In's and Out's of Coding with Modifiers", which explain modifiers for you! Hope you enjoy!
The document provides information and guidelines around evaluation and management documentation, including documentation of the chief complaint, history of present illness, review of systems, past medical history, physical exam, and medical decision making. It discusses the components needed for different levels of evaluation and management services and how to tally the level of service based on the history, exam, and medical decision making complexity.
Here are the key differences between the 1995 and 1997 E/M examination guidelines:
1995 Guidelines:
- Based on extent of exam (problem focused, expanded problem focused, detailed, comprehensive)
- Defines extent by number of body areas/organ systems examined
1997 Guidelines:
- Based on organ systems/body areas examined and elements documented
- Defines extent by minimum number of elements documented across organ systems/body areas
- More flexibility in choice of organ systems/areas examined
So in summary, 1995 based on scope of exam, 1997 based on documentation of exam elements.
Modifiers are two-character suffixes added to procedure codes to provide additional information about the service or procedure performed. The document discusses several common modifiers used in medical billing, including:
- Modifier -22 for increased procedure intensity
- Modifier -23 for unusual anesthesia
- Modifier -24 for unrelated E/M services during the postoperative period
- Modifier -25 for significant, separately identifiable E/M services on the same day
- Modifier -50 for bilateral procedures
- Modifier -76 for repeated procedures
- Modifier -80 for assistant surgeon services
The document provides definitions and examples for how and when to use these common billing modifiers to accurately report medical services and ensure proper
The document discusses evaluation and management (E/M) coding guidelines. It covers the key components of E/M codes which are history, examination, and medical decision making. E/M codes are used to bill for office visits, hospital visits, consultations, and other services. Assignment of the codes depends on factors like new vs. established patient, type of service, place of service, patient age, and time spent. History, examination, and medical decision making are the three main components used to determine the level of E/M service provided.
Basics Of Coding And Medical Record DocumentationAngie Nolan
The document discusses the basics of medical coding and record documentation. It covers the key components of a medical record including that it serves as a medical, legal, and compliance document. It outlines the patient's care and treatment. The document also discusses the key components of evaluation and management (E&M) codes including history, examination and medical decision making. It notes the requirements for documenting new versus established patient visits. The presentation emphasizes that documentation is critical for appropriate coding, reimbursement and defending medical necessity.
Clinical Documentation Guidelines for ICD-10-CMPamela Marasco
1) The document discusses the importance of proper clinical documentation for selecting accurate ICD-10-CM codes beginning October 1, 2015.
2) ICD-10-CM requires more specific documentation than ICD-9-CM to capture details like laterality, severity, and complications.
3) Providers are encouraged to review their documentation practices to ensure specific details are included to support code selection and to avoid issues with reimbursement.
The document provides an overview of the Current Procedural Terminology (CPT) coding system. It describes CPT as a standardized coding system maintained by the American Medical Association to provide uniform descriptions and codes for medical services and procedures. The document outlines the 10 learning objectives of the chapter, including describing the purpose, organization, and use of CPT codes. It also summarizes the different code categories and sections within CPT as well as modifiers used to provide additional information about procedures.
This document lists modifiers that affect payment for medical procedures. It includes CPT and HCPCS modifiers and describes how payment is determined when each modifier is used, such as paying 150% of the fee for bilateral procedures (-50) or 100% of the fee for unrelated E/M services (-24). Local modifiers are also provided, such as -1S for surgical dressings for home use.
The document provides updates to ICD-10-CM coding guidelines for 2023. Some key updates include clarifying that code assignment for complications of care is based on documentation of a relationship between the condition and care/procedure. Chapter-specific updates include guidance on coding HIV infections, sepsis, malignancies, diabetes, dementia, gestational diabetes, and termination of pregnancy. Social determinants of health codes and codes for underimmunization status are also addressed.
ICD-10 Presentation Takes Coding to New HeightsPYA, P.C.
PYA Staff Consultant Kim-Marie Walker updated physicians at Robins Air Force Base on the latest in ICD-10 as part of “Soaring Together: A Collaboration in Continuing Medical Education."
Comprehensive Medical Coding and Billing Training for the AAPC CPC Exam. Online Training with videos and Skype sessions. HIPAA Training included along with Medical Billing. Trainer is Dr Guptha, world record holder.
Join HRG expert, Megan Smith, as she instructs on referrals & authorizations and clarifies the differences between the two. We review insurance benefit hierarchy and dive into coverage levels based on plan benefits. Megan discusses types of authorization denials and how to investigate them and shows tips on sending medical records when appealing a no-authorization denial.
This document provides an overview of the different departments within the revenue cycle management process. It describes the key functions of each department including pre-registration, registration, treatment, medical records, coding, charge entry, claims transmission, payer cash posting, accounts receivables, collections, and quality and compliance. The document explains the purpose and processes involved at each step of the revenue cycle to manage patient information, code procedures, bill for services, obtain payment, and ensure compliance.
The document provides an overview of the Joint Commission International (JCI) accreditation process for hospitals. It describes what accreditation is, its benefits, and timeline. The standards are organized around important hospital functions and patient care. During an on-site survey, surveyors use various methods like document review, interviews, patient tracers, and facility tours to evaluate hospitals' compliance with JCI standards. Scoring guidelines are provided to assess standards as fully met, partially met, not met, or not applicable.
1) Coding is essential for physicians to get paid for the care they provide to patients. CPT and ICD codes are used to describe medical services and diagnoses.
2) RBRVUs and E/M codes determine payment amounts from insurers based on the complexity of care. Higher level E/M codes and procedural codes pay more than lower levels or well visits.
3) It is important for physicians to accurately code at high enough levels to reflect the full work being done, but not overcode and risk audits and penalties. Procedural codes often pay more than E/M visit codes alone.
Revenue cycle management (RCM) is the financial process, utilizing medical billing software, that healthcare facilities use to track patient care episodes from registration and appointment scheduling to the final payment of a balance.
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.
Medical coders analyze medical records to assign numeric or alphanumeric codes to diagnoses, procedures, and medications. Medical billers then use these codes to prepare and submit claims to insurance companies on behalf of healthcare providers. The coding and billing processes help healthcare providers get paid for medical services and generate summaries of patient treatment. Both roles require training to accurately record and track patient data and insurance information.
A comprehensive view of how Medical Billing works. How to prepare medical claims, patient eligibility, example insurance cards, Medicare / Medicade, authorization of services, charge entry, fee schedules, claim submissions, posting ERAs / EOBs, rejected or denied claims (and their correction), secondary claims, cycle of a claim, revenue cycle, provider info needed on a claim, evaluation and management: coding and evaluations and basic components, etc,. By Medwave Medical Billing & Credentialing at http://medwave.io.
Modifiers are two-digit codes appended to procedure codes to provide additional billing information. Ambulance, anesthesia, and surgical procedure modifiers specify origin/destination codes, medical direction, and body sites. Evaluation/management modifiers indicate prolonged services, unrelated visits, or surgery decisions. Correct use of modifiers is important for accurate Medicare billing and payment.
The document discusses evaluation and management (E/M) coding guidelines. It covers the key components of E/M codes which are history, examination, and medical decision making. E/M codes are used to bill for office visits, hospital visits, consultations, and other services. Assignment of the codes depends on factors like new vs. established patient, type of service, place of service, patient age, and time spent. History, examination, and medical decision making are the three main components used to determine the level of E/M service provided.
The document provides an overview of the roles and responsibilities of a health insurance specialist. It discusses how insurance specialists assist physician practices by gathering patient information, obtaining authorizations, filing claims, and tracking reimbursements. It also outlines the qualifications needed for the role, including skills in medical terminology, coding, insurance regulations, and use of billing software. Additional sections cover topics like common health plans, insurance terminology, the claims process, coding, fee schedules, and communicating with patients about financial matters.
The document summarizes a presentation on the transition from ICD-9-CM to ICD-10-CM. It discusses the reasons for replacing ICD-9-CM, including that it is outdated and lacks specificity. It also describes some key differences between ICD-9-CM and ICD-10-CM, such as ICD-10-CM codes having up to 7 characters instead of 3-5. Additionally, it provides an overview of the structure and users of the new ICD-10-CM classification system which will be implemented on October 1, 2013.
Dan Wellisch gave this presentation to the Chicago Technology For Vaue Based Healthcare Meetup at https://www.meetup.com/Chicago-Technology-For-Value-Based-Healthcare-Meetup/
This document provides guidance on using external cause of injury codes, including:
1. External cause codes describe the circumstances surrounding an injury, including how and where it occurred.
2. There are different types of external cause codes that describe how the injury happened, where it happened, what the patient was doing, and whether the intent was intentional or unintentional.
3. External cause codes are used with injury codes in ranges A00-T88 or Z00-Z99. The 7th character must match between the injury and external cause codes.
4. Examples are provided to demonstrate proper use of external cause codes according to the described guidelines.
The document discusses diagnosis counts. It likely contains data on the number of diagnoses made or recorded. The counts may be broken down by category, location, time period, or other factors important for medical reporting and analysis. In summary, the document title "Diagnosis count" indicates it contains numerical data related to medical diagnoses.
The document provides an overview of the Current Procedural Terminology (CPT) coding system. It describes CPT as a standardized coding system maintained by the American Medical Association to provide uniform descriptions and codes for medical services and procedures. The document outlines the 10 learning objectives of the chapter, including describing the purpose, organization, and use of CPT codes. It also summarizes the different code categories and sections within CPT as well as modifiers used to provide additional information about procedures.
This document lists modifiers that affect payment for medical procedures. It includes CPT and HCPCS modifiers and describes how payment is determined when each modifier is used, such as paying 150% of the fee for bilateral procedures (-50) or 100% of the fee for unrelated E/M services (-24). Local modifiers are also provided, such as -1S for surgical dressings for home use.
The document provides updates to ICD-10-CM coding guidelines for 2023. Some key updates include clarifying that code assignment for complications of care is based on documentation of a relationship between the condition and care/procedure. Chapter-specific updates include guidance on coding HIV infections, sepsis, malignancies, diabetes, dementia, gestational diabetes, and termination of pregnancy. Social determinants of health codes and codes for underimmunization status are also addressed.
ICD-10 Presentation Takes Coding to New HeightsPYA, P.C.
PYA Staff Consultant Kim-Marie Walker updated physicians at Robins Air Force Base on the latest in ICD-10 as part of “Soaring Together: A Collaboration in Continuing Medical Education."
Comprehensive Medical Coding and Billing Training for the AAPC CPC Exam. Online Training with videos and Skype sessions. HIPAA Training included along with Medical Billing. Trainer is Dr Guptha, world record holder.
Join HRG expert, Megan Smith, as she instructs on referrals & authorizations and clarifies the differences between the two. We review insurance benefit hierarchy and dive into coverage levels based on plan benefits. Megan discusses types of authorization denials and how to investigate them and shows tips on sending medical records when appealing a no-authorization denial.
This document provides an overview of the different departments within the revenue cycle management process. It describes the key functions of each department including pre-registration, registration, treatment, medical records, coding, charge entry, claims transmission, payer cash posting, accounts receivables, collections, and quality and compliance. The document explains the purpose and processes involved at each step of the revenue cycle to manage patient information, code procedures, bill for services, obtain payment, and ensure compliance.
The document provides an overview of the Joint Commission International (JCI) accreditation process for hospitals. It describes what accreditation is, its benefits, and timeline. The standards are organized around important hospital functions and patient care. During an on-site survey, surveyors use various methods like document review, interviews, patient tracers, and facility tours to evaluate hospitals' compliance with JCI standards. Scoring guidelines are provided to assess standards as fully met, partially met, not met, or not applicable.
1) Coding is essential for physicians to get paid for the care they provide to patients. CPT and ICD codes are used to describe medical services and diagnoses.
2) RBRVUs and E/M codes determine payment amounts from insurers based on the complexity of care. Higher level E/M codes and procedural codes pay more than lower levels or well visits.
3) It is important for physicians to accurately code at high enough levels to reflect the full work being done, but not overcode and risk audits and penalties. Procedural codes often pay more than E/M visit codes alone.
Revenue cycle management (RCM) is the financial process, utilizing medical billing software, that healthcare facilities use to track patient care episodes from registration and appointment scheduling to the final payment of a balance.
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.
Medical coders analyze medical records to assign numeric or alphanumeric codes to diagnoses, procedures, and medications. Medical billers then use these codes to prepare and submit claims to insurance companies on behalf of healthcare providers. The coding and billing processes help healthcare providers get paid for medical services and generate summaries of patient treatment. Both roles require training to accurately record and track patient data and insurance information.
A comprehensive view of how Medical Billing works. How to prepare medical claims, patient eligibility, example insurance cards, Medicare / Medicade, authorization of services, charge entry, fee schedules, claim submissions, posting ERAs / EOBs, rejected or denied claims (and their correction), secondary claims, cycle of a claim, revenue cycle, provider info needed on a claim, evaluation and management: coding and evaluations and basic components, etc,. By Medwave Medical Billing & Credentialing at http://medwave.io.
Modifiers are two-digit codes appended to procedure codes to provide additional billing information. Ambulance, anesthesia, and surgical procedure modifiers specify origin/destination codes, medical direction, and body sites. Evaluation/management modifiers indicate prolonged services, unrelated visits, or surgery decisions. Correct use of modifiers is important for accurate Medicare billing and payment.
The document discusses evaluation and management (E/M) coding guidelines. It covers the key components of E/M codes which are history, examination, and medical decision making. E/M codes are used to bill for office visits, hospital visits, consultations, and other services. Assignment of the codes depends on factors like new vs. established patient, type of service, place of service, patient age, and time spent. History, examination, and medical decision making are the three main components used to determine the level of E/M service provided.
The document provides an overview of the roles and responsibilities of a health insurance specialist. It discusses how insurance specialists assist physician practices by gathering patient information, obtaining authorizations, filing claims, and tracking reimbursements. It also outlines the qualifications needed for the role, including skills in medical terminology, coding, insurance regulations, and use of billing software. Additional sections cover topics like common health plans, insurance terminology, the claims process, coding, fee schedules, and communicating with patients about financial matters.
The document summarizes a presentation on the transition from ICD-9-CM to ICD-10-CM. It discusses the reasons for replacing ICD-9-CM, including that it is outdated and lacks specificity. It also describes some key differences between ICD-9-CM and ICD-10-CM, such as ICD-10-CM codes having up to 7 characters instead of 3-5. Additionally, it provides an overview of the structure and users of the new ICD-10-CM classification system which will be implemented on October 1, 2013.
Dan Wellisch gave this presentation to the Chicago Technology For Vaue Based Healthcare Meetup at https://www.meetup.com/Chicago-Technology-For-Value-Based-Healthcare-Meetup/
This document provides guidance on using external cause of injury codes, including:
1. External cause codes describe the circumstances surrounding an injury, including how and where it occurred.
2. There are different types of external cause codes that describe how the injury happened, where it happened, what the patient was doing, and whether the intent was intentional or unintentional.
3. External cause codes are used with injury codes in ranges A00-T88 or Z00-Z99. The 7th character must match between the injury and external cause codes.
4. Examples are provided to demonstrate proper use of external cause codes according to the described guidelines.
The document discusses diagnosis counts. It likely contains data on the number of diagnoses made or recorded. The counts may be broken down by category, location, time period, or other factors important for medical reporting and analysis. In summary, the document title "Diagnosis count" indicates it contains numerical data related to medical diagnoses.
This document provides an overview of medical coding. It begins with a brief history of medical coding originating in 17th century England and the development of the ICD coding system. It then discusses what a medical coder does, translating clinical documentation into medical codes. The revenue cycle is described, showing how medical coding fits within the process from appointment to payment. Various roles in medical coding are outlined, including coders, auditors, and denial management specialists. The pros and cons of in-house versus outsourced medical coding are presented.
http://cpc.certifiedcodertraining.com/index.php/what-is-medical-coding | Curious about the field of Medical Coding? Certified Coder presents a brief overview of Medical Coding and why it is important.
The document provides guidance on billing Medicare for general surgery services, including:
1) Global surgery packages include pre-, intra-, and postoperative services for major and minor surgeries. Major surgeries have a 90-day global period while minor have 0-10 days.
2) Services included in global packages are preoperative visits, intraoperative services, postoperative visits, and complications following surgery. Services not included are unrelated visits, postoperative complications requiring another surgery, treatment for underlying conditions, and distinct procedures.
3) Modifiers are used to indicate separate evaluation and management services (-24,-25), surgical services only (-58,-78,-79), transfer of care (-54,-55), and other circumstances.
This document provides an overview and guidelines for coding patient medical records for Medicare Advantage risk adjustment. It includes sections on hierarchical condition categories (HCCs), risk scores, acceptable provider types, general documentation guidelines, and coding specific conditions. Key points covered are that accurate diagnosis coding is based on clear documentation of conditions in the medical record per CMS guidelines, HCCs group related diagnoses and map to ICD-9 codes that impact risk adjustment payments, and medications listed can provide evidence of conditions when linked to a patient's medication history.
This document provides examples and explanations of common errors in business email writing related to sentence construction. It addresses comma splices, subject-verb agreement, and pronoun-antecedent agreement. For each error type, it gives an incorrect example and the corrected version. It also provides homework instructions for students to practice identifying and fixing these errors.
This document discusses project risk management. It defines risk as an uncertain event that can positively or negatively impact project objectives. Risk management is the systematic process of identifying, analyzing, and responding to project risks. The six processes of risk management are: 1) plan risk management, 2) identify risks, 3) perform qualitative risk analysis, 4) perform quantitative risk analysis, 5) plan risk responses, and 6) monitor and control risks. Tools used include risk breakdown structures, probability and impact matrices to assess risks, and decision trees to evaluate responses. The goal is to prioritize and respond to risks to help ensure project success.
Sleep Apnea – 2017 Update on Evaluation and ManagementSummit Health
The document provides an overview and update on sleep apnea, including its evaluation and treatment. It discusses the definition and types of sleep apnea, risk factors, diagnostic testing options, and treatment approaches such as CPAP, oral appliances, surgery, and lifestyle changes. The key goals in managing sleep apnea are to obtain accurate diagnostic data, educate patients, closely monitor treatment adherence, address any equipment issues, and ensure long-term follow up to optimize outcomes.
Business emails should have a descriptive subject line and avoid unnecessary attachments. The email format depends on the level of formality, from simply addressing by first name for close contacts to "Dear Dr./Mr./Mrs./Ms. Last Name" for more formal relationships. The body should clearly state the purpose upfront, such as to request or provide information. Sign-offs vary from casual endings like "Best regards" to more formal closings like "Yours faithfully". Overall, business emails should be short, simple, and get straight to the point.
Interventional radiology uses minimally invasive techniques guided by imaging to diagnose and treat medical conditions. Procedures use small incisions or catheters inserted through blood vessels to access internal organs. The Seldinger technique is commonly used, involving insertion of a guidewire and catheter through a needle into the femoral artery. A variety of catheters and guidewires are used depending on the target vessel. Angiography involves injecting contrast dye to visualize vessels. Interventional radiology suites contain specialized equipment like large X-ray tubes and digital image receptors to facilitate complex image-guided procedures.
This document advertises a CD containing 10 minimal presentations on various topics for Rs. 300 each. The CDs are available in packs of 10 and can be delivered anywhere in India. Interested buyers should SMS "10CC" to the provided phone number or email the listed address to purchase the CDs.
Even if you’re not the world’s greatest writer, you should still learn how to write effective emails. It’s absolutely essential if you want people to take you seriously. Here are few guidelines that you should follow for better communication.
This document provides guidance on writing professional emails. It discusses types of emails, parts of an email like the subject line, greeting, body, and closing. It also covers issues like confidentiality, keeping messages brief and focused on one topic, using a professional tone, and creating a signature. Sample emails are included to illustrate proper formatting and structure.
Evaluation and Management EM of the CPT Codes (PDF)Jawwad Imran
The document outlines upcoming changes to Evaluation and Management (E/M) codes in the American Medical Association's (AMA) CPT code set effective January 1, 2023. Key changes include the elimination and modification of various E/M codes for hospital inpatient care, consultations, emergency department visits, nursing facility visits, home visits, and prolonged services. Guidelines for selecting E/M codes are also revised, clarifying definitions of new vs. established patients, rules for different care settings, and components of E/M services and medical decision making.
This document provides information about coding tips for orthopaedic offices. It discusses reimbursement statistics for different orthopaedic procedures, insurance issues to consider, guidelines for evaluation and management visits and other orthopaedic procedures. It also reviews modifiers like 24, 25, and 57 which are important for orthopaedic coding. The presenter has many years of experience in orthopaedic coding and compliance.
Department of Health and Human Services OFFICE OF INSPECsimisterchristen
Department of Health and Human Services
OFFICE OF
INSPECTOR GENERAL
June 2001
OEI-02-00-00290
Medicare Coverage of Non-Physician
Practitioner Services
OFFICE OF INSPECTOR GENERAL
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, is to
protect the integrity of the Department of Health and Human Services programs as well as the
health and welfare of beneficiaries served by them. This statutory mission is carried out through
a nationwide program of audits, investigations, inspections, sanctions, and fraud alerts. The
Inspector General informs the Secretary of program and management problems and recommends
legislative, regulatory, and operational approaches to correct them.
Office of Evaluation and Inspections
The Office of Evaluation and Inspections (OEI) is one of several components of the Office of
Inspector General. It conducts short-term management and program evaluations (called
inspections) that focus on issues of concern to the Department, the Congress, and the public.
The inspection reports provide findings and recommendations on the efficiency, vulnerability,
and effectiveness of departmental programs.
OEI's New York Regional Office prepared this report under the direction of John I. Molnar,
Regional Inspector General and Renee C. Dunn, Deputy Regional Inspector General. Principal
OEI staff included:
REGION HEADQUARTERS
Nancy Harrison, Project Leader Jennifer Antico, Program Specialist
Natasha Besch Tricia Davis, Program Specialist
Vincent Greiber Brian Ritchie, Technical Support Staff
Christi Macrina
To obtain copies of this report, please call the New York Regional Office at 212-264-2000.
Reports are also available on the World Wide Web at our home pate address:
http://www.hhs.gov/oig/oei
Department of Health and Human Services
OFFICE OF
INSPECTOR GENERAL
June 2001
OEI-02-00-00290
Medicare Coverage of Non-Physician
Practitioner Services
E X E C U T I V E S U M M A R Y
PURPOSE
To describe the scope of services nurse practitioners, clinical nurse specialists, and
physician assistants provide to Medicare beneficiaries, and to identify any potential
vulnerabilities that may have emerged since the Balanced Budget Act of 1997.
BACKGROUND
Nurse practitioners, clinical nurse specialists, and physician assistants are health care
providers who practice either in collaboration with or under the supervision of a
physician. We refer to them as non-physician practitioners. States are responsible for
licensing and for setting the scopes of practice for all three specialties. Services provided
by them can be reimbursed by Medicare Part B.
The Balanced Budget Act of 1997 (BBA97) modified the way the Medicare program
pays for their services. Prior to January 1, 1998, their services were reimbursed by
Medicare only in rural areas and certain health care settings. Payments are now allowed
in all geographic areas and health care settings ...
Chronic Care Management: 6 Tips for Documentation SuccessManny Oliverez
Take advantage of the Chronic Care Reimbursement opportunity with these tips!
Healthcare providers can be reimbursed for the hours that they spend on the phone, filling prescriptions, and completing paperwork. Medicare now offers reimbursement for doctors who are assisting patients with chronic medical conditions.
The key to reimbursement from Medicare is all in the required documentation for Chronic Care Management (CCM). Here are some tips for documenting for CCM.
Visit Our Website: http://www.CaptureBilling.com/
In Module One, our first step is to direct our focus on what healtrafbolet0
In Module One, our first step is to direct our focus on what healthcare reimbursement means and how that meaning will be applied throughout the course. In Module One, you will be provided with explanations of the terminology and methodologies surrounding the cost of healthcare services and, subsequently, how providers of those services are compensated.
Reimbursement in a healthcare context refers to the payment that providers and facilities receive for the services that they provide their patients. Providers and facilities include physicians, hospitals, clinics, outpatient rehabilitation centers, home healthcare centers, and other healthcare facilities. Many providers are not-for-profit as opposed to investor-owned.
Questions that will be answered in this module include:
· What are reimbursement methodologies and how do they impact healthcare organizations?
· What are the current trends in healthcare reimbursement?
· How might healthcare administrators differentiate between reimbursement methods?
· How are financial management principles applied to reimbursement methods?
· Who are the key stakeholders surrounding healthcare reimbursement?
The answers to these questions will provide you with a better understanding of the background, context, and trends surrounding healthcare reimbursement systems. Further, you will find it helpful to assume the role of a healthcare administrator as you practice what it would be like to assume a management position. Although you will have your own personal opinions based on experiences from a patient perspective, for this course, you will view the assignments through the lens of the healthcare administrator. The administrator is challenged with providing the best care and services to the communities that they serve, while charging a price that is affordable to both the patient and the organization. The administrator must also take into account the various compliance standards and government regulations.
Why Study Reimbursement?
Healthcare administrators and other health personnel can better meet the needs of their patients, clients, and organization by offering clear guidelines and cost structures concerning healthcare reimbursement. The key stakeholders of healthcare reimbursement systems are patients, healthcare providers, and third-party processors. As such, there are many perspectives to consider when administrators develop strategic plans designed around revenue generation. Many healthcare administrators are involved in contract management decisions and also represent their organizations by negotiating with managed care organizations and third-party payers.
The Affordable Care Act is one of the largest pieces of healthcare legislation in our era. The law itself is over 1,000 pages covering funding, Health Insurance Portability and Accountability Act (HIPAA) requirements, insurance coverage, health information systems, and reimbursement. Not surprisingly, this has contributed to the increase in employm ...
This document discusses downcoding and bundling of claims by health insurers, which can reduce physician reimbursement. It provides background on Current Procedural Terminology (CPT) coding, noting that CPT is updated regularly but does not dictate reimbursement amounts. While health insurers must accept CPT codes, they are not required to follow CPT guidelines and can interpret codes differently. The document advises physicians to code correctly but warns that insurers may still improperly downcode or bundle claims as tactics to reduce payments.
This document provides the copyright information and legal disclaimers for the 2019 HCPCS Level II codebook. It states that HCPCS Level II codes and their descriptors are jointly approved and maintained by CMS, HIAA, and BCBS. It also provides notices that knowledge and best practices change over time, and users should rely on their own experience and knowledge. The document notes that inclusion or exclusion of codes does not imply health insurance coverage. It also provides information on updating HCPCS codes.
This webinar provided an overview on the Medicare Diabetes Prevention Program (MDPP) Expanded Model Billing and Claims process. During this webinar, participants were familiarized with the key terms and entities involved in the billing and claims process, MDPP payment structure and how it applies to billing, and learned how to successfully submit claims to Medicare for MDPP services.
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CMS Innovation Center
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http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
A Physician's Guide to Chronic Care ManagementRenae Rossow
Learn how Chronic Care Management can impact your practice whether you choose to implement it in-house or outsource it. Now you will understand CCM and be able to make the right decision for your practice.
The Heartaches Associated with Billing for Cardiac DevicesPYA, P.C.
PYA Principal Denise Hall-Gaulin and Consulting Manager Joanna Malcolm presented a free webinar for the Georgia chapter of the Healthcare Financial Management Association, on Tuesday, December 6, 2016.
The presentation was geared toward C-suite hospital leaders, compliance officers, in-house counsel, operational leaders, and patient accounting leadership, and covered:
The criteria for implantable cardioverter defibrillators (ICDs), pacemakers, and other devices
The documentation requirements for payment
The prerequisites for a clean audit
What are the most common Family Practice CPT codes?Jessica Parker
The most common CPT codes used by family physicians for medical billing are 99213 and 99214. The CPT system and CMS Evaluation & Management (E&M) rule states that 99213 can be used if a physician treats a patient for one stable chronic condition, such as stable cirrhosis of the liver.
The document discusses 4 dangerous trends facing medical groups: 1) Regulatory and compliance burdens continue to increase with many new regulations and compliance dates in 2015. 2) Operating costs continue to rise significantly each year, especially for staffing which accounts for over half of practice costs. 3) Provider reimbursement is declining from both government and commercial payers, with Medicare payments being cut and penalties increasing. 4) Patient collections have become critical with declining reimbursement. The presentation provides strategies for practices to address these challenges through improving productivity, evaluating costs, and protecting staff.
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.
All product and company names mentioned herein are for identification and educational purposes only and are the property of, and may be trademarks of, their respective owners.
The National Priorities Partnership (NPP) is a group of 50 major national organizations focused on creating a safe, affordable, reliable, and equitable healthcare system in the United States. The NPP aims to achieve this vision through coordinated and collaborative action to ensure patients receive comprehensive and well-coordinated care across all healthcare settings.
Critical Success Factors For Physician Adoption Of Emr & Ehr August 2010Joseph Mack & Associates
The document discusses critical success factors for physician adoption of electronic medical records (EMRs) and electronic health records (EHRs). It argues that EMR/EHR initiatives often focus too much on external compliance demands rather than empowering physicians with meaningful internal information. For physicians to fully embrace EMR/EHRs, the technology needs to provide data that helps improve clinical outcomes, mitigate malpractice risks, and enhance the revenue cycle, rather than just meeting regulatory requirements. Successful adoption depends on using information to continuously improve operations from within the practice.
The document discusses documentation problems found in a 2009 Office of Inspector General report regarding chiropractic claims submitted to Medicare. Some key findings included that 83% of chiropractic claims failed to meet one or more Medicare documentation requirements, treatment plans were often missing important elements like goals and measures, and efforts to stop payments for maintenance therapy have been ineffective. The document urges chiropractors to use the report to improve policies and documentation skills in order to become compliant with Medicare standards.
2012 Small Employer Health Insurance Survey EhealthinsuranceRobert Hutt
This document summarizes the findings of a survey of 236 small business owners regarding their health insurance plans and costs. Key findings include:
- Nearly all employers prioritized affordability over other factors like benefits or access to doctors.
- Most spent over $300/month per employee on premiums, though over half required employees to pay 10% or less of premiums.
- While affordability was important, over 60% offered plans with deductibles of $1,500 or less annually.
The document discusses compliance and accounts receivable risk areas for skilled nursing facilities. It identifies five main risk areas for bad debt and lost revenue: bad debt, compliance issues, inefficiencies and waste, cash flow problems, and theft. It also provides tips for minimizing these risks through best practices in admissions, compliance processes, personnel management, billing and collection standards, and oversight and monitoring.
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This document highlights the expertise, education, and experience of Modupe (Maria) Sarratt for administrative support and healthcare assistant roles. She has over 5 years of healthcare experience and 10 years of administrative experience. Her skills include medical terminology, patient care, data entry, Microsoft Office, and communication. She has a Bachelor's degree in Psychology and a Master's in Healthcare Administration from University of Maryland University College.
This document provides instructions for initiating intravenous (IV) infusion and initiating a saline lock. It describes how IV therapy can help casualties by replacing fluid losses from hemorrhage, dehydration, or burns. Complications like infiltration and air embolism are risks if not done carefully. The document then provides step-by-step instructions for setting up IV equipment, selecting and preparing the infusion site, inserting the IV catheter, and initiating a saline lock when continuous infusion is not needed. Maintaining sterility and avoiding air in the line are emphasized.
The document provides a summary of skills and experience for a job or partnership. It lists communication skills, attention to detail, assertiveness, innovation, negotiation, decision making, leadership, goal setting, time management, customer service and problem solving. It then lists some perceived weaknesses and how they could be strengths, such as using stubbornness for persistence. It provides examples of work experiences including advocating for patient expectations, finding solutions through shared responsibilities, and ensuring quality service through leadership and satisfying patients. It emphasizes the importance of collaboration and good customer service through negotiated agreements.
False accusation of plagiarism by professor discriminationModupe Sarratt
Unforgettable higher education injustice
I considered the accusation of plagiarism is an unforgettable injustice to any foreign origin as well as the lack of career readiness for job placement as an injustice to the college graduates.
In my experience of false accusation of plagiarism is by discrimination due to my national origin as foreign students to share my experience in English class. In all my endeavors I am proud of myself for working hard to earn an “A” for grade is what I cherished to go forward to do better because I was lucky that the plagiarism accusation is discrimination for demotion or reduction of my grade from A to D to end up with an associate degree in medical assisting with GPA 3.15. As a result of the experience, I took the opportunity to prove myself with pursuing a bachelor degree in psychology to take college writing for researching with GPA 3.25 in Psychology. Then progress to earn my master degree in healthcare administration with GPA 3.75
Although I love Anne Arundel College, however, the experiences of false accusation of plagiarisms feel as discrimination to hamper/hinder my progress for higher education. I do wish that the rule or the policy is being evaluated to be fair so that some student will not feel as if they are the target for plagiarism due to their national origin.
Presentation of intravalley health for patient experience & satisfaction surveysModupe Sarratt
Intravalley Health strives to provide quality care for patients but faces challenges in measuring patient experience and satisfaction. Regulations from CMS, HIPAA, and ACA dictate medical procedures and policies that can negatively impact the patient experience by being too rigid. For example, a patient was denied a prescription refill due to missing a follow-up appointment, though she felt no additional care was needed. To improve care, Intravalley Health must understand how regulations influence patient experiences and make policies more flexible to accommodate patient needs.
The document highlights the expertise, education, and experience of an individual with skills in administrative support, healthcare assistance, technical office operations, and customer service. Their experience includes over 5 years working in healthcare settings and over 10 years in administrative roles. They have a Bachelor's degree in Psychology and a Master's degree in Healthcare Administration. Their competencies include multi-tasking, creativity, communication, attention to detail, computer skills, and leadership abilities. They also have several certifications in medical fields such as medical assisting and coding.
Dr. Y misdiagnosed and overprescribed medication to Patient X, which led to their death from a heart attack. This was a case of medical malpractice and unintentional tort. Patient X's family could sue Dr. Y for negligence, having to prove that Dr. Y deviated from the standard of care by misreading the medication instructions and that this caused Patient X's death. Healthcare ethics principles of autonomy, beneficence and non-maleficence were violated. Providers must respect patient autonomy, act in their best interest, and do no harm. Ongoing training in healthcare ethics is important to avoid such violations and ensure principles of justice, respect and fairness are followed.
HCAD 650 group 2 project oral presentation for the role of a compliance offi...Modupe Sarratt
This document summarizes a group project presentation on healthcare compliance laws that was never actually presented. It introduces four speakers who were each assigned topics on compliance officer duties, the Stark Law and Anti-Kickback Statute, corporate integrity agreements and compensation agreements, and how these laws aim to resolve false claims act issues. The document provides details on the assigned topics for each speaker in slide format.
The candidate summarizes their qualifications for the position in 3 sentences or less, including highlighting their strong communication skills, problem-solving abilities, organizational skills, customer service experience, knowledge of office software like MS Office and Google Workspace, and ability to perform clerical duties accurately and efficiently. They list their educational achievements and certifications in various medical fields. Finally, they emphasize their diverse skillset including skills in accounting, customer service, typing, filing, and communication.
This document provides guidance on performing a head-to-toe assessment, including necessary equipment, safety goals, examination technique, and palpation methods. The key equipment needed are a stethoscope, blood pressure cuff, watch, and pen light. Safety goals include patient identification, communication, standard precautions, and medication alerts. Region-based examination minimizes position changes. A combination stethoscope allows auscultation of high and low pitched sounds. Palpation is best with the back of the hand for temperature, balls of hands for vibration, and finger pads for pulsation.
The document proposes adding a Mohs surgery service line to the Layman Hospital System (LHS) located in South Florida. Skin cancer rates are high in the area due to sun exposure. Mohs surgery is more effective for treating common skin cancers and has better cosmetic outcomes than traditional excision. The service would benefit LHS's aging patient population, help capture referrals currently going outside the system, and generate revenue. Implementation would require hiring a Mohs surgeon, expanding pathology services, and developing new policies and procedures while overcoming potential resistance from competitors and insurers.
The Layman Hospital Systems is proposing to add a Mohs surgery service line to provide better outcomes for skin cancer patients in their region of South Florida, which has a high rate of skin cancer due to sun exposure. Mohs surgery removes skin cancers with better cosmetic results than traditional surgery, but it requires hiring a Mohs surgeon and supporting staff. The service would benefit LHS's growing elderly patient population that is susceptible to skin cancer, by allowing them to access this preferred treatment option while also generating greater revenue for LHS compared to other surgical procedures.
This document outlines a team project to design and implement a Mohs surgery service line at Layman Hospital Systems (LHS). Mohs surgery removes skin cancers while preserving healthy tissue, reducing scarring. Adding this service could generate greater income for LHS and improve outcomes for skin cancer patients. The project will involve analyzing needs and stakeholders, designing the service, addressing implementation challenges, and conducting marketing and resource analyses to make a recommendation. Hiring a Mohs surgeon and providing laboratory support are the major costs, while billing is straightforward as Mohs is usually covered by insurance.
This grant proposal seeks $100,000 from the Community Foundation of Anne Arundel County to establish a community center providing health education and screenings to low-income individuals. The proposed Maria for Virtual Medical & Telehealth Assistant organization would recruit retired healthcare workers to teach first aid/CPR training and human anatomy/physiology courses. These programs aim to empower poor communities in Annapolis and Glen Burnie to prevent diseases and improve individual and community health.
Dr. Y misdiagnosed and overprescribed medication to patient X, which led to their death from a heart attack. This was a case of medical malpractice and unintentional tort. As a healthcare ethics consultant, I would provide training to Dr. Y on the four principles of healthcare ethics: autonomy, beneficence, non-maleficence, and justice. Training should cover informed consent, doing what is best for the patient, avoiding harm, and fairness. The goal is to prevent future ethical violations and protect patient safety.
Modupe Sarratt has over 20 years of experience in administrative support, medical assisting, and information technology roles. She holds a Master's degree in Healthcare Administration, Bachelor's degrees in Psychology and Medical Assisting, and an Associate's degree in Medical Assisting. Sarratt has strong organizational, problem-solving, and communication skills and is proficient in various computer systems. She currently works as an Information Technology Assistant for a nonprofit advocating for telemedicine.
- Phantom limb pain refers to pain felt in a limb that has been amputated. It is a phenomenon where amputees feel sensations, including pain, in the part of their body that is no longer there.
- There are two major theories for phantom limb pain - the psychogenic theory and the neurologic theory. The psychogenic theory describes pain occurring due to underlying psychological disorders rather than physical stimuli. The neurologic theory suggests pain occurs due to misfiring of nerve pathways in the brain and spinal cord that were originally connected to the amputated limb.
- Amputees report feeling their absent limb in different ways, such as feeling their arm resting on a table or their fingers touching textures. Some
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
3. 1
EVALUATION & MANAGEMENT SERVICES GUIDE
DISCLAIMER
This guide was current at the time it was published or uploaded onto the web. Medicare policy
changes frequently so links to the source documents have been provided within the document for
your reference.
This guide was prepared as a tool to assist providers and is not intended to grant rights or impose
obligations. Although every reasonable effort has been made to assure the accuracy of the
information within these pages, the ultimate responsibility for the correct submission of claims and
response to any remittance advice lies with the provider of services. The Centers for Medicare
& Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or
guarantee that this compilation of Medicare information is error-free and will bear no responsibility or
liability for the results or consequences of the use of this guide. This guide is a general summary that
explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare
Program provisions are contained in the relevant laws, regulations, and rulings.
MEDICARE LEARNING NETWORK
The Medicare Learning Network (MLN) is the brand name for official CMS educational products
and information for Medicare fee-for-service providers. For additional information visit the Medicare
Learning Network’s web page at http://www.cms.hhs.gov/MLNGenInfo on the CMS website.
ICD-9-CM NOTICE
The International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM) is
published by the United States Government. A CD-ROM, which may be purchased through the
Government Printing Office, is the only official Federal government version of the ICD-9-CM. ICD-9-
CM is an official Health Insurance Portability and Accountability Act standard.
CPT DISCLAIMER AMERICAN MEDICAL ASSOCIATION (AMA) NOTICE AND DISCLAIMER
Current Procedural Terminology (CPT) only copyright 2008 American Medical Association. All rights
reserved. CPT is a registered trademark of the American Medical Association (AMA). Applicable
FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion
factors, and/or related components are not assigned by the AMA, are not part of CPT, and the AMA
is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense
medical services. The AMA assumes no liability for data contained or not contained herein.
4. 2
EVALUATION & MANAGEMENT SERVICES GUIDE
PREFACE
This guide is offered as a reference tool and does not replace content found in the
1995 Documentation Guidelines for Evaluation and Management Services and the 1997
Documentation Guidelines for Evaluation and Management Services. It is recommended
that health care providers refer to the 1995 Documentation Guidelines for Evaluation and
Management Services in order to identify differences between the two sets of guidelines.
It is recommended that providers refer to the following publications, which were used to prepare
this guide:
1995 Documentation Guidelines for Evaluation and Management Services■■ , available at
http://www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf on the Centers for Medicare &
Medicaid Services (CMS) website;
1997 Documentation Guidelines for Evaluation and Management Services■■ , available at
http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf on the CMS website;
Medicare Claims Processing Manual (Pub. 100-4), available at■■
http://www.cms.hhs.gov/Manuals/IOM/list.asp on the CMS website; and
Current Procedural Terminology■■ book, available from the American Medical Association
(800-621-8335) or http://www.amapress.org on the Web).
EVALUATION & MANAGEMENT SERVICES GUIDE
5. 3
EVALUATION & MANAGEMENT SERVICES GUIDE
TABLE OF CONTENTS
Medical Record Documentation.................................................................................. 4
Common Sets of Codes.............................................................................................. 5
Key Elements of Service............................................................................................. 7
Acronyms.................................................................................................................. 22
Reference Materials.................................................................................................. 22
6. 4
EVALUATION & MANAGEMENT SERVICES GUIDE
MEDICAL RECORD DOCUMENTATION
“If it isn’t documented, it hasn’t been done” is an adage that is
frequently heard in the health care setting.
Concise medical record documentation is critical to providing patients with quality care as well as to
receiving accurate and timely reimbursement for furnished services. It chronologically documents
the care of the patient and is required to record pertinent facts, findings, and observations about the
patient’s health history including past and present illnesses, examinations, tests, treatments, and
outcomes. Medical record documentation also assists physicians and other health care professionals
in evaluating and planning the patient’s immediate treatment and monitoring his or her health care
over time.
Payers may require reasonable documentation that services are consistent with the insurance
coverage provided in order to validate:
The site of service;■■
The medical necessity and appropriateness of the diagnostic and/or therapeutic services■■
provided; and/or
That services furnished have been accurately reported.■■
To ensure that medical record documentation is accurate, the following principles should be followed:
The medical record should be complete and legible.■■
The documentation of each patient encounter should include:■■
Reason for the encounter and relevant history, physical examination findings, and prior■■
diagnostic test results.
Assessment, clinical impression, or diagnosis.■■
Medical plan of care.■■
Date and legible identity of the observer.■■
If not documented, the rationale for ordering diagnostic and other ancillary services should be■■
easily inferred.
Past and present diagnoses should be accessible to the treating and/or consulting physician.■■
Appropriate health risk factors should be identified.■■
The patient’s progress, response to and changes in treatment, and revision of diagnosis should■■
be documented.
The Current Procedural Terminology (CPT) and International Classification of Diseases,■■
9th
Edition, Clinical Modification (ICD-9-CM) codes reported on the health insurance claim form
or billing statement should be supported by the documentation in the medical record.
Documentation guidelines for teaching physicians, interns, and residents can be found in the Medicare Learning■■
Network (MLN) publication titled Guidelines for Teaching Physicians, Interns, and Residents. This and other MLN
publications are available at http://www.cms.hhs.gov/MLNGenInfo on the CMS website.
7. 5
EVALUATION & MANAGEMENT SERVICES GUIDE
COMMON SETS OF CODES
When billing for a patient’s visit, codes are selected that best represent the services furnished during
the visit. The two common sets of codes that are currently used are:
Diagnostic or International Classification of Diseases, 9■■ th
Edition, Clinical Modification
(ICD-9-CM) codes; and
Procedural or American Medical Association Current Procedural Terminology (CPT) codes.■■
These codes are organized into various categories and levels. It is the physician’s responsibility to
ensure that documentation reflects the services furnished and that the codes selected reflect those
services. The more work performed by the physician, the higher the level of code he or she may
bill within the appropriate category. The billing specialist or alternate source reviews the physician’s
documented services and assists with selecting codes that best reflect the extent of the physician’s
personal work necessary to furnish the services.
Evaluation and management (E/M) services refer to visits and consultations furnished by physicians.
Billing Medicare for a patient visit requires the selection of a CPT code that best represents the level
of E/M service performed. For example, there are five CPT codes that may be selected to bill for
office or other outpatient visits for a new patient:
99201 – Usually the presenting problem(s) are self limited or minor and the physician typically■■
spends 10 minutes face-to-face with the patient and/or family. E/M requires the following three
key components:
Problem focused history.■■
Problem focused examination.■■
Straightforward medical decision making.■■
99202 – Usually the presenting problem(s) are of low to moderate severity and the physician■■
typically spends 20 minutes face-to-face with the patient and/or family. E/M requires the
following three key components:
Expanded problem focused history.■■
Expanded problem focused examination.■■
Straightforward medical decision making.■■
99203 – Usually the presenting problem(s) are of moderate severity and the physician typically■■
spends 30 minutes face-to-face with the patient and/or family. E/M requires the following three
key components:
Detailed history.■■
Detailed examination.■■
Medical decision making of low complexity.■■
99204 – Usually the presenting problem(s) are of moderate to high severity and the physician■■
typically spends 45 minutes face-to-face with the patient and/or family. E/M requires the
following three key components:
Comprehensive history.■■
Comprehensive examination.■■
Medical decision making of moderate complexity.■■
CPT only copyright 2008 American Medical Association. All rights reserved.
8. 6
EVALUATION & MANAGEMENT SERVICES GUIDE
99205 – Usually the presenting problem(s) are of moderate to high severity and the physician■■
typically spends 60 minutes face-to-face with the patient and/or family. E/M requires the
following three key components:
Comprehensive history.■■
Comprehensive examination.■■
Medical decision making of high complexity.■■
International Classification of Diseases, 10th
Edition, Clinical Modification/Procedure
Coding System
The compliance date for implementation of
the International Classification of Diseases,
10th
Edition, Clinical Modification/Procedure
Coding System (ICD-10-CM/PCS) is October
1, 2013 for all Health Insurance Portability and
Accountability Act covered entities. ICD-10-CM/
PCS will enhance accurate payment for services
rendered and facilitate evaluation of medical
processes and outcomes. The new classification
system provides significant improvements
through greater detailed information and the
ability to expand in order to capture additional
advancements in clinical medicine.
ICD-10-CM/PCS consists of two parts:
ICD-10-CM – The diagnosis classification■■
system developed by the Centers for
Disease Control and Prevention for use
in all U.S. health care treatment settings. Diagnosis coding under this system uses 3 – 7 alpha
and numeric digits and full code titles, but the format is very much the same as ICD-9-CM; and
ICD-10-PCS – The procedure classification system developed by the Centers for Medicare■■
& Medicaid Services (CMS) for use in the U.S. for inpatient hospital settings ONLY. The new
procedure coding system uses 7 alpha or numeric digits while the ICD-9-CM coding system
uses 3 or 4 numeric digits.
ICD-10-CM/PCS will not affect physicians, outpatient facilities, and hospital outpatient departments’
use of CPT codes on Medicare fee-for-service claims, as CPT will continue to be utilized.
To find additional information about ICD-10-CM/PCS, visit http://www.cms.hhs.gov/ICD10 on the
CMS website.
CPT only copyright 2008 American Medical Association. All rights reserved.
9. 7
EVALUATION & MANAGEMENT SERVICES GUIDE
KEY ELEMENTS OF SERVICE
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 or her 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 key elements of service and documentation of an encounter dominated by counseling and/or
coordination of care are discussed below.
I. History
The elements required for each type of history are depicted in the table below. Note that each history
type requires more information as you read down the left hand column. For example, a problem
focused history requires the documentation of the chief complaint (CC) and a brief history of present
illness (HPI) and a detailed history requires the documentation of a CC, extended HPI, extended
review of systems (ROS), and pertinent past, family and/or social history (PFSH).
Elements Required for Each Type of History
TYPE OF HISTORY
CHIEF
COMPLAINT
HISTORY OF
PRESENT
ILLNESS
REVIEW OF
SYSTEMS
PAST, FAMILY,
AND/OR
SOCIAL
HISTORY
Problem Focused Required Brief N/A N/A
Expanded
Problem Focused
Required Brief Problem
Pertinent
N/A
Detailed Required Extended Extended Pertinent
Comprehensive Required Extended Complete Complete
The extent of information gathered for history is dependent upon clinical judgment and the nature
of the presenting problem. Documentation of patient history includes some or all of the following
elements:
A. Chief Complaint
A CC is a concise statement that describes the symptom, problem, condition, diagnosis, or reason
for the patient encounter. The CC is usually stated in the patient’s own words. For example, patient
complains of upset stomach, aching joints, and fatigue.
10. 8
EVALUATION & MANAGEMENT SERVICES GUIDE
B. History of Present Illness
HPI is a chronological description of the development of the patient’s present illness from the first sign
and/or symptom or from the previous encounter to the present. HPI elements are:
Location. For example, pain in left leg;■■
Quality. For example, aching, burning, radiating;■■
Severity. For example, 10 on a scale of 1 to 10;■■
Duration. For example, it started three days ago;■■
Timing. For example, it is constant or it comes and goes;■■
Context. For example, lifted large object at work;■■
Modifying factors. For example, it is better when heat is applied; and■■
Associated signs and symptoms. For example, numbness.■■
There are two types of HPIs:
Brief, which includes documentation of one to three HPI elements. In the following example, three1.
HPI elements – location, severity, and duration – are documented:
CC: A patient seen in the office complains of left ear pain.■■
Brief HPI: Patient complains of dull ache in left ear over the past 24 hours.■■
Extended, which includes documentation of at least four HPI elements or the status of at least2.
three chronic or inactive conditions. In the following example, five HPI elements – location,
severity, duration, context, and modifying factors – are documented:
Extended HPI: Patient complains of dull ache in left ear over the past 24 hours. Patient states■■
he went swimming two days ago. Symptoms somewhat relieved by warm compress and
ibuprofen.
C. Review of Systems
ROS is an inventory of body systems obtained by asking a series of questions in order to identify
signs and/or symptoms that the patient may be experiencing or has experienced. The following
systems are recognized:
Constitutional Symptoms (e.g., fever, weight loss);■■
Eyes;■■
Ears, Nose, Mouth, Throat;■■
Cardiovascular;■■
Respiratory;■■
Gastrointestinal;■■
Genitourinary;■■
Musculoskeletal;■■
Integumentary (skin and/or breast);■■
Neurological;■■
Psychiatric;■■
Endocrine;■■
Hematologic/Lymphatic; and■■
Allergic/Immunologic.■■
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EVALUATION & MANAGEMENT SERVICES GUIDE
There are three types of ROS:
Problem pertinent, which inquires about the system directly related to the problem identified in the1.
HPI. In the following example, one system – the ear – is reviewed:
CC: Earache.■■
ROS: Positive for left ear pain. Denies dizziness, tinnitus, fullness, or headache.■■
Extended, which inquires about the system directly related to the problem(s) identified in the HPI2.
and a limited number (two to nine) of additional systems. In the following example, two systems –
cardiovascular and respiratory – are reviewed:
CC: Follow up visit in office after cardiac catheterization. Patient states “I feel great.”■■
ROS: Patient states he feels great and denies chest pain, syncope, palpitations, and shortness■■
of breath. Relates occasional unilateral, asymptomatic edema of left leg.
Complete, which inquires about the system(s) directly related to the problem(s) identified in the3.
HPI plus all additional (minimum of 10) body systems. In the following example, 10 signs and
symptoms are reviewed:
CC: Patient complains of “fainting spell.”■■
ROS:■■
Constitutional: weight stable, + fatigue.■■
Eyes: + loss of peripheral vision.■■
Ear, Nose, Mouth, Throat: no complaints.■■
Cardiovascular: + palpitations; denies chest pain; denies calf pain, pressure, or edema.■■
Respiratory: + shortness of breath on exertion.■■
Gastrointestinal: appetite good, denies heartburn and indigestion. + episodes of nausea.■■
Bowel movement daily; denies constipation or loose stools.
Urinary: denies incontinence, frequency, urgency, nocturia, pain, or discomfort.■■
Skin: + clammy, moist skin.■■
Neurological: + fainting; denies numbness, tingling, and tremors.■■
Psychiatric: denies memory loss or depression. Mood pleasant.■■
D. Past, Family, and/or Social History
PFSH consists of a review of the patient’s:
Past history including experiences with illnesses, operations, injuries, and treatments;■■
Family history including a review of medical events, diseases, and hereditary conditions that■■
may place him or her at risk; and
Social history including an age appropriate review of past and current activities.■■
The two types of PFSH are:
Pertinent, which is a review of the history areas directly related to the problem(s) identified in1.
the HPI. The pertinent PFSH must document one item from any of the three history areas. In the
following example, the patient’s past surgical history is reviewed as it relates to the current HPI:
Patient returns to office for follow up of coronary artery bypass graft in 1992. Recent cardiac■■
catheterization demonstrates 50 percent occlusion of vein graft to obtuse marginal artery.
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EVALUATION & MANAGEMENT SERVICES GUIDE
Complete, which is a review of two or all three of the areas, depending on the category of2.
evaluation and management (E/M) service. A complete PFSH requires a review of all three history
areas for services that, by their nature, include a comprehensive assessment or reassessment of
the patient. A review of two history areas is sufficient for other services. At least one specific item
from two of the three history areas must be documented for a complete PFSH for the following
categories of E/M services:
Office or other outpatient services, established patient;■■
Emergency department;■■
Domiciliary care, established patient; and■■
Home care, established patient.■■
At least one specific item from each of the history areas must be documented for the following
categories of E/M services:
Office or other outpatient services, new patient;■■
Hospital observation services;■■
Hospital inpatient services, initial care;■■
Consultations;■■
Comprehensive Nursing Facility assessments;■■
Domiciliary care, new patient; and■■
Home care, new patient.■■
In the following example, the patient’s genetic history is reviewed as it relates to the current HPI:
Family history reveals the following:■■
Maternal grandparents: both + for coronary artery disease; grandfather deceased at age■■
69; grandmother still living.
Paternal grandparents: grandmother - + diabetes, hypertension; grandfather - + heart■■
attack at age 55.
Parents: mother - + obesity, diabetes; father - + heart attack age 51, deceased age 57■■
of heart attack.
Siblings: sister - + diabetes, obesity, hypertension, age 39; brother - + heart attack at■■
age 45, living.
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EVALUATION & MANAGEMENT SERVICES GUIDE
II. Examination
An examination may involve several organ systems or a single organ system. The extent of the
examination performed is based upon clinical judgment, the patient’s history, and nature of the
presenting problem.
The chart below depicts the body areas and organ systems that are recognized according to the
Current Procedural Terminology (CPT) book:
Recognized Body Areas and Organ Systems
BODY AREAS ORGAN SYSTEMS
Head, including face■■
Neck■■
Chest, including breasts and■■
axilla
Abdomen■■
Genitalia, groin, buttocks■■
Back■■
Each extremity■■
Eyes■■
Ears, Nose, Mouth, and Throat■■
Cardiovascular■■
Respiratory■■
Gastrointestinal■■
Genitourinary■■
Musculoskeletal■■
Skin■■
Neurologic■■
Hematologic/Lymphatic/Immunologic■■
Psychiatric■■
There are two types of examinations that can be performed during a patient’s visit:
General multi-system examination, which involves the examination of one or more organ systems1.
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.■■
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EVALUATION & MANAGEMENT SERVICES GUIDE
Single organ system examination, which involves2.
a more extensive examination of a specific organ
system.
Both types of examinations may be performed by any
physician, regardless of specialty. The chart below
compares the elements of the cardiovascular system/
body area for both a general multi-system and single
organ system examination.
Cardiovascular System/Body Area
SYSTEM/
BODY AREA
GENERAL MULTI-SYSTEM
EXAMINATION
SINGLE ORGAN SYSTEM EXAMINATION
Cardiovascular Palpation of heart (e.g.,■■
location, size, thrills).
Auscultation of heart with■■
notation of abnormal sounds
and murmurs.
Examination of:■■
Carotid arteries (e.g.,■■
pulse amplitude, bruits)
Abdominal aorta (e.g.,■■
size, bruits);
Femoral arteries (e.g.,■■
pulse amplitude, bruits);
Pedal pulses (e.g., pulse■■
amplitude); and
Extremities for edema■■
and/or varicosities.
Palpation of heart (e.g., location, size,■■
and forcefulness of the point of maximal
impact; thrills; lifts; palpable S3 or S4).
Auscultation of heart including sounds,■■
abnormal sounds, and murmurs.
Measurement of blood pressure in two■■
or more extremities when indicated (e.g.,
aortic dissection, coarctation).
Examination of:■■
Carotid arteries (e.g., waveform,■■
pulse amplitude, bruits, apical-carotid
delay);
Abdominal aorta (e.g., size, bruits);■■
Femoral arteries (e.g., pulse■■
amplitude, bruits);
Pedal pulses (e.g., pulse amplitude);■■
and
Extremities for peripheral edema and/■■
or varicosities.
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The elements required for each type of examination are depicted in the table below.
Elements Required for Each Type of Examination
TYPE OF EXAMINATION DESCRIPTION
Problem Focused A limited examination of the affected body area or
organ system.
Expanded Problem Focused A limited examination of the affected body area or
organ system and any other symptomatic or related
body area(s) or organ system(s).
Detailed An extended examination of the affected body area(s)
or organ system(s) and any other symptomatic or
related body areas(s) or organ system(s).
Comprehensive A general multi-system examination OR complete
examination of a single organ system and other
symptomatic or related body area(s) or organ
system(s).
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EVALUATION & MANAGEMENT SERVICES GUIDE
The elements required for general multi-system examinations are depicted in the following chart.
General Multi-System Examinations
TYPE OF EXAMINATION
DESCRIPTION
Problem Focused Include performance and documentation of 1 - 5
elements identified by a bullet in 1 or more organ
system(s) or body area(s).
Expanded Problem Focused Include performance and documentation of at least
6 elements identified by a bullet in 1 or more organ
system(s) or body area(s).
Detailed Include at least 6 organ systems or body areas.
For each system/area selected, performance and
documentation of at least 2 elements identified
by a bullet is expected. Alternatively, may include
performance and documentation of at least 12
elements identified by a bullet in 2 or more organ
systems or body areas.
Comprehensive 1997 Documentation Guidelines for Evaluation and
Management Services:
Include at least 9 organ systems or body areas.
For each system/area selected, all elements of
the examination identified by a bullet should be
performed, unless specific directions limit the
content of the examination. For each area/system,
documentation of at least 2 elements identified by
bullet is expected.
1995 Documentation Guidelines for Evaluation and
Management Services:
Eight organ systems must be examined. If body
areas are examined and counted, they must be over
and above the 8 organ systems.
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.■■
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EVALUATION & MANAGEMENT SERVICES GUIDE
The elements required for single organ system examinations are depicted in the following chart.
Single Organ System Examinations
TYPE OF EXAMINATION DESCRIPTION
Problem Focused Include performance and documentation of 1 - 5
elements identified by a bullet, whether in a box with a
shaded or unshaded border.
Expanded Problem Focused Include performance and documentation of at least 6
elements identified by a bullet, whether in a box with a
shaded or unshaded border.
Detailed Examinations other than the eye and psychiatric
examinations should include performance and
documentation of at least 12 elements identified by a
bullet, whether in a box with a shaded or unshaded
border.
Eye and psychiatric examinations include the
performance and documentation of at least 9 elements
identified by a bullet, whether in a box with a shaded or
unshaded border.
Comprehensive Include performance of all elements identified by a
bullet, whether in a shaded or unshaded box.
Documentation of every element in each box with a
shaded border and at least 1 element in a box with an
unshaded border is expected.
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EVALUATION & MANAGEMENT SERVICES GUIDE
The chart below compares the elements that are required for both general multi-system and single
organ system examinations.
Multi-System and Single Organ Examinations
TYPE OF
EXAMINATION
MULTI-SYSTEM
EXAMINATIONS
SINGLE ORGAN SYSTEM
EXAMINATIONS
Problem Focused 1 - 5 elements identified by
a bullet in 1 or more organ
system(s) or body area(s).
1 - 5 elements identified by a bullet,
whether in a box with a shaded or
unshaded border.
Expanded Problem
Focused
At least 6 elements identified
by a bullet in 1 or more organ
system(s) or body area(s).
At least 6 elements identified by
a bullet, whether in a box with a
shaded or unshaded border.
Detailed At least 6 organ systems or
body areas. For each system/
area selected, performance
and documentation of at least 2
elements identified by a bullet is
expected.
OR
At least 12 elements identified
by a bullet in 2 or more organ
systems or body areas.
At least 12 elements identified by
a bullet, whether in a box with a
shaded or unshaded border.
Eye and psychiatric: At least 9
elements identified by a bullet,
whether in a box with a shaded or
unshaded border.
Comprehensive Include at least 9 organ systems
or body areas. For each system/
area selected, all elements of
the examination identified by
a bullet should be performed,
unless specific directions limit
the content of the examination.
For each area/system,
documentation of at least 2
elements identified by bullet is
expected.
Perform all elements identified by
a bullet, whether in a shaded or
unshaded box.
Document every element in each
box with a shaded border and at
least 1 element in a box with an
unshaded border.
Some important points that should be kept in mind when documenting general multi-system and
single organ system examinations are:
Specific abnormal and relevant negative findings of the examination of the affected or■■
symptomatic body area(s) or organ system(s) should be documented. A notation of “abnormal”
without elaboration is not sufficient;
Abnormal or unexpected findings of the examination of any asymptomatic body area(s) or■■
organ system(s) should be described; and
A brief statement or notation indicating “negative” or “normal” is sufficient to document normal■■
findings related to unaffected area(s) or asymptomatic organ system(s). (However, an entire
organ system should not be documented with a statement such as “negative.”)
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EVALUATION & MANAGEMENT SERVICES GUIDE
III. 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:
The number of possible diagnoses and/or the number of management options that must be■■
considered;
The amount and/or complexity of medical records, diagnostic tests, and/or other information■■
that must be obtained, reviewed and analyzed; and
The 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.
The chart below depicts the elements for each level of medical decision making. Note that to
qualify for a given type of medical decision making, two of the three elements must either be met or
exceeded.
Elements of Medical Decision Making
TYPE OF
DECISION
MAKING
NUMBER OF
DIAGNOSES OR
MANAGEMENT
OPTIONS
AMOUNT AND/
OR COMPLEXITY
OF DATA TO BE
REVIEWED
RISK OF
SIGNIFICANT
COMPLICATIONS,
MORBIDITY, AND/
OR MORTALITY
Straightforward Minimal Minimal or None Minimal
Low Complexity Limited Limited Low
Moderate
Complexity
Multiple Moderate Moderate
High
Complexity
Extensive Extensive High
Number of Diagnoses or Management Options
The number of possible diagnoses and/or the number of management options that must be
considered is based on:
The number and types of problems addressed during the encounter;■■
The complexity of establishing a diagnosis; and■■
The management decisions that are made by the physician.■■
In general, decision making with respect to a diagnosed problem is easier than that for an identified but
undiagnosed problem. The number and type of diagnosed tests performed may be an indicator of the
number of possible diagnoses. Problems that are improving or resolving are less complex than those
problems that are worsening or failing to change as expected. Another indicator of the complexity of
diagnostic or management problems is the need to seek advice from other health care professionals.
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EVALUATION & MANAGEMENT SERVICES GUIDE
Some important points that should be kept in mind when documenting the number of diagnoses or
management options are:
For each encounter, an assessment, clinical impression, or diagnosis should be documented■■
which may be explicitly stated or implied in documented decisions regarding management
plans and/or further evaluation.
For a presenting problem with an established diagnosis, the record should reflect■■
whether the problem is:
Improved, well controlled, resolving, or resolved.-
Inadequately controlled, worsening, or failing to change as expected.-
For a presenting problem without an established diagnosis, the assessment or clinical■■
impression may be stated in the form of differential diagnoses or as a “possible,”
“probable,” or “rule out” diagnosis
The initiation of, or changes in, treatment should be documented. Treatment includes a wide■■
range of management options including patient instructions, nursing instructions, therapies,
and medications.
If referrals are made, consultations requested, or advice sought, the record should indicate to■■
whom or where the referral or consultation is made or from whom advice is requested.
Amount and/or Complexity of Data to be Reviewed
The amount and/or complexity of data to be reviewed is based on the types of diagnostic testing
ordered or reviewed. Indications of the amount and/or complexity of data being reviewed include:
A decision to obtain and review old medical records and/or obtain history from sources other■■
than the patient (increases the amount and complexity of data to be reviewed);
Discussion of contradictory or unexpected test results with the physician who performed or■■
interpreted the test (indicates the complexity of data to be reviewed); and
The physician who ordered a test personally reviews the image, tracing, or specimen to■■
supplement information from the physician who prepared the test report or interpretation
(indicates the complexity of data to be reviewed).
Some important points that should be kept in mind when documenting amount and/or complexity of
data to be reviewed include:
If a diagnostic service is ordered, planned, scheduled, or performed at the time of the E/M■■
encounter, the type of service should be documented.
The review of laboratory, radiology, and/or other diagnostic tests should be documented.■■
A simple notation such as “White blood count elevated” or “Chest x-ray unremarkable” is
acceptable. Alternatively, the review may be documented by initialing and dating the report that
contains the test results.
A decision to obtain old records or obtain additional history from the family, caretaker, or other■■
source to supplement information obtained from the patient should be documented.
Relevant findings from the review of old records and/or the receipt of additional history from■■
the family, caretaker, or other source to supplement information obtained from the patient
should be documented. If there is no relevant information beyond that already obtained, this
fact should be documented. A notation of “Old records reviewed” or “Additional history obtained
from family” without elaboration is not sufficient.
Discussion about results of laboratory, radiology, or other diagnostic tests with the physician■■
who performed or interpreted the study should be documented.
The direct visualization and independent interpretation of an■■ image, tracing, or specimen
previously or subsequently interpreted by another physician should be documented.
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EVALUATION & MANAGEMENT SERVICES GUIDE
Risk of Significant Complications, Morbidity, and/or Mortality
The risk of significant complications, morbidity, and/or mortality is based on the risks associated with
the following categories:
Presenting problem(s);■■
Diagnostic procedure(s); and■■
Possible management options.■■
The assessment of risk of the presenting problem(s) is based on the risk related to the disease
process anticipated between the present encounter and the next encounter. The assessment of
risk of selecting diagnostic procedures and management options is based on the risk during and
immediately following any procedures or treatment. The highest level of risk in any one category
determines the overall risk.
The level of risk of significant complications, morbidity, and/or mortality can be:
Minimal;■■
Low;■■
Moderate; or■■
High.■■
Some important points that should be kept in mind when documenting level of risk are:
Comorbidities/underlying diseases or other factors that increase the complexity of medical■■
decision making by increasing the risk of complications, morbidity, and/or mortality should be
documented;
If a surgical or invasive diagnostic procedure is ordered, planned, or scheduled at the time of■■
the E/M encounter, the type of procedure should be documented;
If a surgical or invasive diagnostic procedure is performed at the time of the E/M encounter, the■■
specific procedure should be documented; and
The referral for or decision to perform a surgical or invasive diagnostic procedure on an urgent■■
basis should be documented or implied.
The table on the following page may be used to assist in determining whether the level of risk of
significant complications, morbidity, and/or mortality is minimal, low, moderate, or high. Because
determination of risk is complex and not readily quantifiable, the table includes common clinical
examples rather than absolute measures of risk.
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EVALUATION & MANAGEMENT SERVICES GUIDE
TABLE OF RISK
Level of
Risk
Presenting Problem(s)
Diagnostic Procedure(s)
Ordered
Management Options
Selected
Minimal
One self-limited or minor problem,ƒƒ
eg, cold, insect bite, tinea corporis
Laboratory tests requiringƒƒ
venipuncture
Chest x-raysƒƒ
EKG/EEGƒƒ
Urinalysisƒƒ
Ultrasound, eg,ƒƒ
echocardiography
KOH prepƒƒ
Restƒƒ
Garglesƒƒ
Elastic bandagesƒƒ
Superficial dressingsƒƒ
Low
Two or more self-limited or minorƒƒ
problems
One stable chronic illness, eg,ƒƒ
well controlled hypertension,
non-insulin dependent diabetes,
cataract, BPH
Acute uncomplicated illness orƒƒ
injury, eg, cystitis, allergic rhinitis,
simple sprain
Physiologic tests not underƒƒ
stress, eg, pulmonary
function tests
Non-cardiovascular imagingƒƒ
studies with contrast, eg,
barium enema
Superficial needle biopsiesƒƒ
Clinical laboratory testsƒƒ
requiring arterial puncture
Skin biopsiesƒƒ
Over-the-counter drugsƒƒ
Minor surgery with no identifiedƒƒ
risk factors
Physical therapyƒƒ
Occupational therapyƒƒ
IV fluids without additivesƒƒ
Moderate
One or more chronic illnesses withƒƒ
mild exacerbation, progression, or
side effects of treatment
Two or more stable chronicƒƒ
illnesses
Undiagnosed new problem withƒƒ
uncertain prognosis, eg, lump in
breast
Acute illness with systemicƒƒ
symptoms, eg, pyelonephritis,
pneumonitis, colitis
Acute complicated injury, eg,ƒƒ
head injury with brief loss of
consciousness
Physiologic tests underƒƒ
stress, eg, cardiac stress
test, fetal contraction stress
test
Diagnostic endoscopies withƒƒ
no identified risk factors
Deep needle or incisionalƒƒ
biopsy
Cardiovascular imagingƒƒ
studies with contrast and
no identified risk factors,
eg, arteriogram, cardiac
catheterization
Obtain fluid from bodyƒƒ
cavity, eg, lumbar puncture,
thoracentesis, culdocentesis
Minor surgery with identifiedƒƒ
risk factors
Elective major surgery (open,ƒƒ
percutaneous or endoscopic)
with no identified risk factors
Prescription drug managementƒƒ
Therapeutic nuclear medicineƒƒ
IV fluids with additivesƒƒ
Closed treatment of fracture orƒƒ
dislocation without manipulation
High
One or more chronic illnesses withƒƒ
severe exacerbation, progression,
or side effects of treatment
Acute or chronic illnesses orƒƒ
injuries that pose a threat to life
or bodily function, eg, multiple
trauma, acute MI, pulmonary
embolus, severe respiratory
distress, progressive severe
rheumatoid arthritis, psychiatric
illness with potential threat to self
or others, peritonitis, acute renal
failure
An abrupt change in neurologicƒƒ
status, eg, seizure, TIA,
weakness, sensory loss
Cardiovascular imagingƒƒ
studies with contrast with
identified risk factors
Cardiac electrophysiologicalƒƒ
tests
Diagnostic Endoscopies withƒƒ
identified risk factors
Discographyƒƒ
Elective major surgery (open,ƒƒ
percutaneous or endoscopic)
with identified risk factors
Emergency major surgeryƒƒ
(open, percutaneous or
endoscopic)
Parenteral controlledƒƒ
substances
Drug therapy requiring intensiveƒƒ
monitoring for toxicity
Decision not to resuscitate orƒƒ
to de-escalate care because of
poor prognosis
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EVALUATION & MANAGEMENT SERVICES GUIDE
IV. Documentation of an Encounter Dominated by Counseling and/or Coordination
of Care
When counseling and/or coordination of care dominates (more than 50 percent of) the physician/
patient and/or family encounter (face-to-face time in the office or other outpatient setting, floor/unit
time in the hospital, or Nursing Facility), time is considered the key or controlling factor to qualify
for a particular level of E/M services. If the level of service is reported based on counseling and/or
coordination of care, the total length of time of the encounter should be documented and the record
should describe the counseling and/or activities to coordinate care. For example, if 25 minutes was
spent face-to-face with an established patient in the office and more than half of that time was spent
counseling the patient or coordinating his or her care, CPT code 99214 should be selected.
The Level I and Level II CPT books available from the American Medical Association list average
time guidelines for a variety of E/M services. These times include work done before, during, and after
the encounter. The specific times expressed in the code descriptors are averages and, therefore,
represent a range of times that may be higher or lower depending on actual clinical circumstances.
CPT only copyright 2008 American Medical Association. All rights reserved.
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EVALUATION & MANAGEMENT SERVICES GUIDE
ACRONYMS
AMA American Medical Association
CC Chief Complaint
CMS Centers for Medicare & Medicaid Services
CPT Current Procedural Terminology
E/M Evaluation and Management
HPI History of Present Illness
ICD-9-CM International Classification of Diseases, 9th
Edition, Clinical Modification
ICD-10-CM/PCS International Classification of Diseases, 10th
Edition, Clinical Modification/
Procedure Coding System
PFSH Past, Family, and/or Social History
ROS Review of Systems
REFERENCE MATERIALS
Centers for Medicare & Medicaid Services
Documentation Guidelines for E&M Services
http://www.cms.hhs.gov/MLNEdWebGuide/25_
EMDOC.asp
Internet-Only Manuals
http://www.cms.hhs.gov/Manuals/IOM/list.asp
ICD-10-CM/PCS Resources and Information
http://www.cms.hhs.gov/icd10
Medicare Learning Network
http://www.cms.hhs.gov/MLNGenInfo
Other Organizations
Level I and Level II CPT Books
American Medical Association
(800) 621-8335
http://www.amapress.org
ICD-9-CM CD-ROM
Government Printing Office
U.S. Government Bookstore
(866) 512-1800
http://bookstore.gpo.gov