Evaluation & Management Services

1. Evaluation & Management Services

2. E/M Coding • Key components • History • Physical examination • Medical Decision making • Contributory factors • Nature of the presenting problem • Medical Necessity drives code selection • Extent of counseling • Coordination of care • Time

3. E/M Guidelines • Medicare and Commercial Insurance • CMS 1995 and 1997E/M guidelines • Use either set • 1997 approved by AMA • Medicaid • Does not use ‘95 or ‘97 guidelines • Uses AMA guidelines found in the CPT book • E/M Service Guidelines section in “Instructions for selecting a Level of E/M Service”

4. Medical Necessity • A service that is reasonable and necessary for the diagnosis and treatment of illness or injury, or to improve the functioning of a malformed body member Government definition

5. History • Definitions • Chief complaint (CC) • Reason for the visit • History of present illness (HPI) • Chronological review of condition/complaint • Review of systems (ROS) • Inventory of systems through questions • Past, Family, Social, History (PFSH)

6. History • Problem FocusedDetailed • Chief Complaint  Chief Complaint • Brief HPI (1-3)  Extended HPI (4 or status of • No ROS 3 chronic/inactive) • No PFSH  Extended ROS (2-9) • Expanded Problem Pertinent PFSH (1) FocusedComprehensive • Chief Complaint Chief Complaint • Brief HPI (1-3)  Extended HPI (4 or status of • Problem pertinent ROS (1) 3 chronic/inactive) • No PFSH  Complete ROS (10) ALL 3 elements must be Complete PFSH (2 or 3 met: HPI,ROS,PFSH based on category of E/M)

7. CPT History Guidelines(Medicaid) • Problem focused: CC; brief HPI • Expanded problem focused: CC; brief HPI, problem pertinent ROS • Detailed: CC; extended HPI, problem pertinent ROS extended to include a review of limited number of additional systems; pertinent PFSH directly related to the patient’s problems • Comprehensive: CC; extended HPI, ROS which is directly related to the problem(s) identified in the HPI plus a review of all additional body systems; complete PFSH

8. History Example • CC - Vaginal discharge • HPI - New patient is complaining of a white vaginal (location) discharge for the past 2 days (duration) with a heavier flow in the morning (timing). There is no change with Monistat (modifying factor). • ROS - Patient denies itching (integumentary), burning with urination (genitourinary) or fever (constitutional). • PFSH - Patient has had 2 sexual partners in the past 60 days (social)

9. History Example • History Level = Detailed (3 of 3) • CC • HPI = Extended (4+ elements) • ROS = Extended (3 elements) • PFSH = Pertinent (1 element)

10. Physical Exam • Detailed • (95) 5-7 body areas/organ systems • (97) 12 elements in 2+areas/systems • Comprehensive • (95) 8 organ systems • (97) General exam: Perform all elements document at least 2 elements in each of 9 areas/systems • Problem Focused • (95)<1 body area/ organ system • (97) 1-5 elements • Expanded Problem Focused • (95) 2-4 body areas/ organ systems • (97) 6 - 11 elements

11. CPT Physical Exam Guidelines(Medicaid) • Problem focused: limited exam of the affected body area or organ system • Expanded problem focused: limited exam of the affected body area or organ system and other symptomatic or related organ system(s) • Detailed: extended exam of the affected body area(s) and other symptomatic or related organ system(s) • Comprehensive: general multi-system exam or a complete exam of a single organ system

12. Physical Exam Example • Vaginal Discharge Exam • Constitutional • BP, temp, pulse • Genitourinary • Examination of external genitalia • Examination of cervix • Physical Exam level = Expanded Problem Focused • At least two body areas/organ systems

13. Straightforward #Diagnostic/treatment options (0 -1) Amt./complexity of data (0 -1) Risk (minimal) Low Complexity #Diagnostic/treatment options (2) Amt./complexity of data (2) Risk (low) Moderate Complexity #Diagnostic/treatment options (3) Amt./complexity of data (3) Risk (moderate) High Complexity #Diagnoses/mgmt options (4) Amt./complexity of data (4) Risk (high) Decision Making

14. CPT MDM Guidelines(Medicaid) • Complexity measured by: • # of possible diagnoses and/or the number of management options that must be considered. • Amount/complexity of records, tests, other information that must be obtained, reviewed, and analyzed. • Risk of significant complications, morbidity, mortality, as well as co-morbidities, associated with the patient’s presenting problem(s),the diagnostic procedure(s) and/or the possible management options.

15. Decision Making Example • Vaginal Discharge Exam • New problem, additional workup planned • Lab is ordered (4) • Review/order tests in 8xxxx series (1) • Moderate decision making • Undiagnosed new problem with uncertain prognosis • Prescription drug management • Prescription written • Decision Making level = Moderate (2 0f 3) • Extensive # Diagnosis/treatment options • Minimal amount of data to be reviewed • Table of risk - Moderate

16. Level Assignment Example • History = Detailed • Physical exam = Expanded Problem Focused • Decision Making = Moderate • Level = 99202, new patient • If established patient = 99214

17. Contributing Factors • Presenting Problem • Minimal • Self-Limited/Minor • Low Severity • Moderate Severity • High Severity • Time • FACE-TO-FACE • Time is a key factor ONLY when: • Counseling or coordination of care takes up OVER 50% of the total visit time

18. Counseling/Coordination of Care • Main factor determining code when takes up MORE than 50% of the total visit time • Documentation: • Total visit time • Time spent in Counseling/Coordination of Care • Face to face • Subject/ content • Code level is based on the total visit time • not just the time spent in counseling

19. Counseling Examples • Established patient, 20 minute visit to follow-up on oral contraceptive use • NP 99213 • RN 99211 (MA 99213) • 15 minutes of a 20 minute visit spent counseling the patient on alcohol and cigarette use during pregnancy • NP 99213 • RN 99211 (MA 99213)

20. Definitions • New patient • Has not received face-to-face services from • ANY provider in the agency • Within past 3 years (AMA) • Established patient • Has received face-to-face services from • ANY provider in the agency • Within past 3 years (AMA)

21. Selecting a Level of E/M • Identify • Place of service (POS) = where (office) • Type of service (TOS) = what (Problem/Preventive) • Status of Patient = who (New/Established) • Determine the extent of history - physical exam - decision making - counseling • Must consider all factors, and make sure adequate DOCUMENTATION in chart to justify code.

22. Office99201-99215 • Report Problem visit (vs. Preventive visit) • 99201-99205, 99212-99215 performed by MD,DO,NP,PA,CNS • 99211 - Ancillary staff i.e. RN, LPN, CNA • MD/NP must be in the clinic • Report only 1 E/M per day • Report diagnostic tests, studies, procedures separately

23. Office99201-99215(Medicaid) • 99201-99205, 99212-99215 may be performed by any staff of a “certified family planning clinic”. Staff may be MD, NP, PA, RN, CMA or unlicensed personnel acting in a coordinated manner to provide the service(s). • Other reporting requirements are the same as other providers

24. Preventive Medicine Services

25. Preventive Medicine 99381-99397 • Routine management of patients without presenting problems, i.e. annual, routine, well child exams • Performed by MD, DO,NP,PA,CNS • Includes other clinic staff if Medicaid • Codes • New/established patients • Age • Not used for scheduled follow-up visits for specified problems