Uploaded byRobert Robinson
Medical Documentation for E&M Coding
The document outlines the definitions and components of evaluation and management (E&M) services, detailing criteria for documentation and common patient-physician encounters. It provides guidance on the history of present illness, review of systems, and past family and social history, alongside complexities in medical decision making. Additionally, it emphasizes adherence to Medicare guidelines while engaging in documentation practices for various levels of service.
In this document
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Defines Evaluation & Management (E&M) services, components of documentation, and common patient-physician encounters including clinic visits.
Introduces E&M documentation criteria issued by Medicare in 1995 and 1997, focusing on encounter history, examination, and medical decision-making.
Details components of medical history including Chief Complaint, History of Present Illness, Review of Systems, and Past, Family, and Social History. Outlines types of visits (Comprehensive, Detailed, Expanded Problem Focused, Problem Focused) with criteria for each including specific counts for CC, HPI, ROS, and PFSH.
Lists systems involved in Review of Systems and compares 1995 vs 1997 guidelines for E&M documentation related to problem focus.
Explains complexity of Medical Decision Making (MDM) based on diagnosis options, data reviewed, and associated risks with different levels outlined.
Describes how to score MDM points based on problem status and complexity, including examples of presenting problems and associated management options.
Presents levels of CPT codes (99201-99205 for new patients and 99211-99215 for established patients), outlining history and exam requirements plus MDM levels.
Applicable settings for E&M services including emergency visits and the importance of mastering complex rules for financial success in practice.
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Similar to Medical Documentation for E&M Coding
Medical Documentation for E&M Coding
- 2. Define E&MServices Know the E&M Documentation Components Review E&M documentation criteria
- 3. Common patient/physicianencounters Clinic visit H&P Does not include tests or procedures
- 4. Issued byCenters for Medicare & Medicaid Services 1995 1997
- 5.
- 6. E&M Encounter History ExamMDM Medical Decision Making
- 8. Chief Complaint(CC) History of Present Illness (HPI) Review of Systems (ROS) Past, Family, and Social History (PFSH)
- 9. Comprehensive Detailed Expanded Problem Focused Problem Focused
- 10. Problem Focused Expanded Problem Focused Detailed Comprehensive CCYes Yes Yes Yes HPI 1Element Or 1 Chronic Condition 4 Elements Or 3 Chronic Conditions ROS 1 System 2 Systems 10 Systems PFSH 3 Areas 3 Areas 3 Areas 3 Areas
- 11. Problem Focused Expanded Problem Focused Detailed Comprehensive CCYes Yes Yes Yes HPI 1Element Or 1 Chronic Condition 4 Elements Or 3 Chronic Conditions ROS 1 System 2 Systems 10 Systems PFSH 3 Areas 3 Areas 3 Areas 3 Areas HPI elements – Location, Quality, Severity, Duration, Timing, Context, Modifying Factors, Associated Signs and Symptoms
- 12. Problem Focused Expanded Problem Focused Detailed Comprehensive CCYes Yes Yes Yes HPI 1Element Or 1 Chronic Condition 4 Elements Or 3 Chronic Conditions ROS 1 System 2 Systems 10 Systems PFSH 3 Areas 3 Areas 3 Areas 3 Areas ROS Systems – Constitutional, Eyes, ENT, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Integumentary, Neurological, Psychiatric, Endocrine,
- 13. Problem Focused Expanded Problem Focused Detailed Comprehensive CCYes Yes Yes Yes HPI 1Element Or 1 Chronic Condition 4 Elements Or 3 Chronic Conditions ROS 1 System 2 Systems 10 Systems PFSH 3 Areas 3 Areas 3 Areas 3 Areas PFSH Areas – Past (medical and surgical), Social, and Family History Noncontributory is not acceptable to some insurers
- 14. Problem Focused Expanded Problem Focused Detailed Comprehensive CCYes Yes Yes Yes HPI 1Element Or 1 Chronic Condition 4 Elements Or 3 Chronic Conditions ROS 1 System 2 Systems 10 Systems PFSH 1 Area 3 Areas
- 16. General Multisystem Cardiovascular Ear, Nose and Throat Eye Genitourinary Hematologic/Lymphatic/Immunologic Musculoskeletal Neurologic Psychiatric Respiratory Skin
- 17. Comprehensive Detailed Expanded Problem Focused Problem Focused
- 18. Rules Problem Focused Expanded Problem Focused Detailed Comprehensive 19951 Area 2 Areas 7 Areas 8 Areas 1997 (GMS) 1 Bullet Item 6 Bullet Items 2 Bullet Items from 6 Systems OR 12 Bullet Items from 2+ Systems 2 Bullet Items from 9 Systems 1997 (Specialty) See 1997 Guidelines for details
- 20. Number ofdiagnosis or management options Amount or complexity of data Risk of complications, morbidity, or mortality
- 21. Complexity Dx OptionsData Reviewed Risk High Extensive Extensive High Moderate Multiple Moderate Moderate Low Limited Low Low Straightforward Minimal Minimal or None Minimal Complexity of MDM Set by the highest two of three areas
- 22. Complexity Dx OptionsData Reviewed Risk High Extensive Extensive High Moderate Multiple Moderate Moderate Low Limited Low Low Straightforward Minimal Minimal or None Minimal Criteria for these levels are not defined In the E&M Documentation Guidelines Medicare Carriers can decide how to interpret these areas
- 23. Maximum of4 points (Extensive) Problem Status Points New Problem with Workup 4 New Problem w/o Workup 3 Established problem, Worse 2 for each problem Established problem, Stable 1 for each problem Minor problem 1 (up to 2 points) This method is used by most Medicare Carriers Check with your Medicare Carrier to confirm what method they use
- 24. Maximum of4 points (Extensive) Data Item Points Summary of old records 2 Interpret image/tracing 2 Request old records 1 Discuss pt with another MD 1 Review/Order Imaging Study 1 Review/Order Lab Test 1 Review/Order Other Test 1This method is used by most Medicare Carriers. Check with your Medicare Carrier to confirm what method they use No Double Credit
- 25. Risk Presenting ProblemDx Procedures Management Options High Severe exacerbation of chronic illnesses Acute or chronic illness or injury that threatens life or limb Abrupt change in neurologic status Cardiovascular imaging studies + Risk factors Cardiac electro-physiologic tests Diagnostic endoscopies + Risk factors Discography Elective surgery + Risk factors Emergency Major surgery Parenteral controlled substances Drug therapy requiring intensive monitoring DNR or de-escalate care decision Moderat e Mild exacerbation a chronic illness 2 or more stable, chronic illnesses New problem with uncertain prognosis Acute illness with systemic symptoms Acute complicated injury Physiologic tests under stress Diagnostic endoscopies with NO risk factors Deep needle or incisional biopsy Cardiovascular imaging studies with contrast Obtaining body cavity fluid Minor surgery WITH identified risk factors Elective major surgery with NO risk factors Prescription drug management Therapeutic nuclear medicine IV fluids with additives Closed treatment of fracture Low 2 self-limited or minor problems Stable, well- controlled chronic illness Acute uncomplicated illness or injury Physiologic tests NOT under stress Noncardiovascular imaging studies + contrast Superficial needle biopsies Clinical lab tests requiring arterial puncture Skin biopsies OTC drugs Minor surgery without identified risk factors Physical therapy Occupational therapy IV fluids without additives Minimal A self limited or minor problem Venipuncture X-rays EKG EEG Rest Gargles Elastic bandages
- 26. Risk Presenting ProblemDx Procedures Management Options High Acute or chronic illness or injury that threatens life or limb Abrupt change in neurologic status Parenteral controlled substances Drug therapy requiring intensive monitoring Moderat e New problem with uncertain prognosis Prescription drug management Low OTC drugs Minimal
- 27. Complexity Dx OptionsData Reviewed Risk High Extensive Extensive High Moderate Multiple Moderate Moderate Low Limited Low Low Straightforward Minimal Minimal or None Minimal Complexity of MDM Set by the highest two of three areas
- 29. Level 5 CPT 99205 Level4 CPT 99204 Level 3 CPT 99203 Level 2 CPT 99202 Level 1 CPT 99201 History Comprehensi ve Comprehensiv e Detailed Expanded Problem Focused Problem Focused Exam Comprehensi ve Comprehensiv e Detailed Expanded Problem Focused Problem Focused MDM High Moderate Low Low Straightforwar d
- 30. Level 5 CPT 99215 Level4 CPT 99214 Level 3 CPT 99213 Level 2 CPT 99212 Level 1 CPT 99211 History Comprehensi ve Detailed Expanded Problem Focused Problem Focused Minimal problem that may not require presence of a physician Exam Comprehensi ve Detailed Expanded Problem Focused Problem Focused MDM High Moderate Low Straightforwar d2 out of three components must be at this level
- 31. Emergency departmentvisits Inpatient (New and Follow up) Observation (New and Follow up) Nursing Facility (New and Follow up) …and others.
- 33. Model used by75% of practices in 2012/2013 Merritt Hawkins Survey
- 34. Complex Rules Mastery of the rules relevant to your practice is essential for financial success