Evaluation and Management Strategies For Success

1. Evaluation and ManagementStrategies For Success American Academy of Professional Coders Woodland Hills California Chapter Meeting June 2010 (Revised May 2018)

2. Part OneFundamentals of Coding Evaluation and Management Services Presented by: Elizabeth McAllister, CPC, CPC-H, CPC-I, CEMC

3. Identify traditional physician (or physician extender) encounter Account for approximately 30% of charges received by third party payers In some practices, these services generate between 80-90% of total revenue E/M Services have been included in every work plan issued by OIG Chart auditing is a component of an effective compliance plan Evaluation and Management …

4. Documentation Principles • The medical record should be complete and legible. • The documentation for the encounter should include the following: • reason for the encounter and a relevant history, physical examination findings and prior diagnostic test results; • plan for care and • date and legible identity of the observer

5. Documentation Principles • 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.

6. S Subjective O Objective A Assessment P Plan Subjective includes all of the information that the patient tells the provider. Objective: includes the physical exam, diagnostic testing and observations. Physician’s documentation of the diagnosis or problem. Further work up that is planned. S O A P Note

7. Evaluation and ManagementDefinitions and Guidelines • A new patient is defined as one who has notreceived face-to-face services rendered by a physician or a physician of the same specialty who belongs to the same medical group within the last three years. • On Call Service Exception If a patient is seen by a physician who is “on call” or “covering” for a colleague – the patient encounter is considered an established patient.

8. A new patient is one who is new to the physician or an established patient with a new industrial injury or condition. New Patient California Workers’ Compensation Cases

9. Transfer of care is the process whereby a physician who is providing management for some or all of the patient’s problems relinquishesthe responsibility to another physician whoexplicitly agrees to accept responsibility, and who, from the initial encounter is not providing consultative services. The physician transferring the care is then no longer providing care for these problems though he or she many continue providing care for other conditions as appropriate. Evaluation and ManagementDefinitions and Guidelines (New for 2010)

10. Evaluation and ManagementDefinitions and Guidelines (New for 2010) A consultation is a type of evaluation and management service provided by a physician at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to acceptresponsibility for ongoing management of the patient’s entire care of for the care of a specific condition or problem.

11. CMS Consultation Code Update • Effective January 1, 2010 CMS will eliminate the use of all consultation CPT/HCPC codes. This includes inpatient codes (99251-99255) and office/outpatient codes (99241-99245) for various places of service, instead of consultation codes, providers are instructed to bill initial hospital care (99221-99223), initial nursing facility care (99304-99306) or initial office visits (99201-99205), as applicable.

12. Evaluation and ManagementDefinitions and Guidelines • Physician assistant, NP, OT, psychologist, social worker, attorney are all considered appropriate source for requesting a consultation. • “Consultation” requested by the patient and/or family is reported by using the office visit, home visit or other evaluation and management codes.

13. Evaluation and ManagementDefinitions and Guidelines • Concurrent care is the provision of similar services to the same patient by more than one physician on the same day.

14. KEY COMPONENTS History Examination Medical Decision Making Counseling Coordination of Care Nature of Present Problem Time* ( if longer than 30 min. it can then become the key component, therefore it overrides the history, examination and medical decision making) Evaluation & ManagementComponents

15. History • The history is one of the three key components of E/M documentation. • Acts as a narrative which provides information about the clinical problems or symptoms being addressed during the encounter.

16. History Four Elements The selection of the level of history obtained will depend on the following factors: • Chief Complaint • History of Present Illness • Review of Systems- questions to patient regarding issues with patient might have had in the past. • Past, Family & Social History We are billing the code on the basis of how much history weighs on the code

17. The chief complaint should be the first notation in the medical record. It is required for all levels of service. The physician uses the chief complaint to : derive a diagnosis discover if any additional body systems or anatomical areas are affected. Chief Complaint

18. History of Present Illness Chronological description of the development if the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present.

19. History of Present Illness • Every type of encounter requires some form of HPI. • When documenting a follow-up encounter, it is acceptable to label the HPI an Interval History. The physician must personally complete and record the HPI.  The HPI is the only part of the history which cannot be recorded by ancillary staff.

20. Eight Elements Location ex: what area of body Quality ex: quality of the sensation Severity Duration ex: how long Timing ex: how often, is it in the morning or evening only? Context ex: ”if I don’t eat fatty foods I’m okay, when I sit it bothers me more.” Modifying Factors ex: Aspirin helps, bright light makes it worse. Associated Signs & Symptoms ex: does ur blood pressure go up and down, are you dizzy or feverish? Brief and Extended HPIs are distinguished by the amount of detail needed to accurately characterize the clinical problem(s). Everything qualifies to characterize the problems. History of Present IllnessHPI

22. Brief 1 – 3 Elements Extended 4 – 8 Elements or (using the 1997 documentation guidelines) the status of at least three inactive chronic conditions.

23. HPI: Patient complains of chest pain which began three hours ago duration.  Pain has been off and on since that time with each episode lasting two to three minutes.  The pain is described as “crushing” and at times is rated as an eight on a scale of one to ten.  The pain occurs with minimal exertion and is associated with nausea and shortness of breath.  The pain was relieved with sublingual NTG in the ambulance. Location Duration Timing Quality Severity Context Associated signs and symptoms Modifying factors Extended HPI

24. Review of Systems ROS • An inventory of body systems obtained through a series of questions seeking to identify signs and or symptoms which the patient may be experiencing or may have experienced. • Helps define the problem, clarify the differential diagnosis, identify needed testing or serves as baseline data for other systems that might be affected by any possible management options.

25. ROSCMS/AMA Systems (question and answer process) • Constitutional Symptoms • Eyes • Ears, Nose, Mouth & Throat • Cardiovascular • Respiratory • Gastrointestinal • Genitourinary • Musculoskeletal • Integumentatry System • Neurological • Psychiatric • Endocrine • Hematologic/Lymphatic • Allergic/Immunologic

26. General/Constitutional Average weight, weight loss or gain, general state of health, sense of well-being, strength, ability to conduct usual activities, exercise tolerance Ex: im so tired and my body hurts Eyes/Ears/Nose/Mouth/Throat Headaches (location, time of onset, duration, precipitating factors), vertigo, lightheadedness, injury Vision, double vision, tearing, blind spots, pain Nose bleeding, colds, obstruction, discharge Dental difficulties, gingival bleeding, dentures Neck stiffness, pain, tenderness, masses in thyroid or other areas Review of Systems

27. Cardiovascular Precordial pain, substernal distress, palpitations, syncope, dyspnea on exertion, orthopnea, nocturnal paroxysmal dyspnea, edema, cyanosis, hypertension, heart murmurs, varicosities, phlebitis, claudication Respiratory Pain (location, quality, relation to respiration), shortness of breath, wheezing, stridor, cough (time of day, of productive, amount in tablespoons or cups per day and color of sputum), hemoptysis, respiratory infections, tuberculosis (or exposure to tuberculosis), fever or night sweats Review of Systems

28. Review of Systems Gastrointestinal Appetite, dysphagia, indigestion, food idiosyncrasy, abdominal pain, heartburn, eructation, nausea, vomiting, hematemesis, jaundice, constipation, or diarrhea, abnormal stools (clay-colored, tarry, bloody, greasy, foul smelling), flatulence, hemorrhoids, recent changes in bowel habits Genitourinary Urgency, frequency, dysuria, nocturia, hematuria, polyuria, oliguria, unusual (or change in) color of urine, stones, infections, nephritis, hesitancy, change in size of stream, dribbling, acute retention or incontinence, libido, potency, genital stores, discharge, venereal disease (Female) Age of onset of menses, regularity, last period, dysmenorrhea, menorrhagia, or metrorrhagia, vaginal discharge, post-menopausal bleeding, dyspareunia, number and results of pregnancies (gravida, para)

29. Review of Systems Musculoskeletal Pain, swelling, redness or heat of muscles or joints, limitation, of motion, muscular weakness, atrophy, cramps Neurologic/Psychiatric Convulsions, paralyses, tremor, coordination, parathesias, difficulties with memory of speech, sensory or motor disturbances, or muscular coordination (ataxia, tremor) Predominant mood "nervousness" (define), emotional problems, anxiety, depression, previous psychiatric care, unusual perceptions, hallucinations

30. Allergic/Immunologic/ Lymphatic/Endocrine Reactions to drugs, food, insects, skin rashes, trouble breathing Anemia, bleeding tendency, previous transfusions and reactions, Rh incompatibility Local or general lymph node enlargement or tenderness. -Polydipsia, polyuria, asthenia, hormone therapy, growth, secondary sexual development, intolerance to heat or cold Skin/Breast Rash, itching, pigmentation, moisture or dryness, texture, changes in hair growth or loss, nail changes Breast lumps, tenderness, swelling, nipple discharge Review of Systems

31. Review of Systems • Problem Pertinent ROS - positive or negative responses for at least 1 system related to the presenting problem example is a patient comes in that cuts there finger. • Extended ROS – Inquires about the system directly related to the problem(s) identified in the HPI and a limited number of additional systems. Positive or negative responses for 2 – 9 systems.ex: same finger but now patient has a rash • Complete ROS – positive or negative responses for all additional body systems. At least 10 identified. • Example doctor is on a huge scavenger hunt due to not knowing what a patient has.

32. Past (Medical) Family and/or Social History (PFSH) • Past History - Review of patient’s previous illness, injuries, hospitalization, current medications, allergies, immunization status. • Family History – Review of patient’s family health status or cause of death of parents, siblings, children. Also includes a review of any diseases that may be hereditary, that may put patient at risk. • Social – Review of current activities, may include alcohol, tobacco use, marital status, occupation, sexual history.

33. Pertinent PFSH Describes 1 – 3 components Complete PFSH Describes 1 from each of the 3 components Past Medical Family & Social History

34. The Problem Focused History is the lowest and least descriptive level of history.   This historyrequires only a chief complaintand a Brief HPI (which requires one to three HPI elements).  No ROS or PFSHare required. Example is if a patient has a cut finger there is no need to go into a persons past history to treat or document. Chief complaint: Follow-up nephrolithiasis      Interval History: The patient’s left flank pain has resolved. chief complaint is clearly stated and only one HPI element (location) is utilized. The Problem Focused History

35. The Expanded Problem Focused History The Expanded Problem Focused History is the second lowest level of history.  This history requires a chief complaint, a brief HPI(containing one to three HPIelements), plus one ROS.  No PFSHis required. ROS- review of systemsCC : Follow-up for allergic rhinitis .Interval History: The patient’s nasal congestion has significantly improved with steroid nasal spray and is now described as “mild” in severity. ROS is negative for cough, hoarseness, or shortness of breath.Expanded Problem Focused History does not require a lot of information.   In this case, 2 HPI elements were used - location and severity.   The ROS required review of only one system.  In this case the respiratory system was reviewed.

36. CC : Follow-up hypertension and diabetesInterval History : The patient’s hypertension is stable on current medications.  Diabetes, however, remains sub-optimally controlled with hgbA1c greater than 7.  There is also a history of osteoarthritis, which requires only intermittent Tylenol for symptomatic relief .ROSGeneral--Negative for fatigue, weight loss, anorexia constitutional symptomsCardiovascular--Negative for CP, orthopnea, PNDEndocrine--Negative for polyuria, polydipsia, cold intolerancePertinent PMH is positive for CAD, which has been quiescent Extended HPI was constructed by commenting on the status of three chronic or inactive problems (hypertension, diabetes, OA).  The ROS described three systems, although technically only two systems are required.  This example utilized an element of PMH (CAD) to satisfy the requirement of one pertinent PFSH. The Detailed History

37. The Comprehensive History • The Comprehensive History is the highest level of history and requires a chief complaint, an extended HPI (fourHPI elements OR the status of three chronic or inactive problems - if using the 1997 E/M guidelines), plus a 10 system ROS, plus a Complete PFSH .

38. The Comprehensive History • CC : Chest pain HPI : The patient is a 65 year old male who developed sudden onset of chest pain, which began early this morning.  The pain is described as “crushing” and is rated nine out of 10 in terms of intensity . PMH is remarkable for GERD and hypertensionFH : Mother died at 78 of breast cancer; Father at 75 of CVA.  No history of premature cardiovascular disease in first degree relatives.SH : Negative for tobacco abuse; consumes moderate alcohol; married for 39 years ROSConstitutional--Negative for fevers, chills, fatigueCardiovascular--Negative for orthopnea, PND, positive for intermittent lower extremity edema Gastrointestinal--Positive for nausea without vomiting; negative for diarrhea, abdominal painPulmonary--Positive for intermittent dyspnea on exertion, negative for cough or hemoptysis All other systems reviewed and are negative

39. Putting it togetherDetermining the Level of History (this briefs all the information)

40. Examination Key Component

41. Factors to consider: Documentation Clinical judgment Nature of the presenting problem(s). Ranges from limited examinations of single body areas to general multi-system or complete single organ system examinations. Examination Determining the Extent

42. 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 other symptomatic or related organ system(s). Detailed -- an extended examination of the affected body area(s) and other symptomatic or related organ system(s). ONE SYSTEM Comprehensive -- a general multi-system examination or complete examination of a single organ system. MANY SYSTEMS Evaluation and ManagementExamination - Four Levels

43. Examination For purposes of examination, the following body areasare recognized: • Head, including the face • Neck • Chest, including breasts and axillae • Abdomen • Genitalia, groin, buttocks • Back, including spine • Each extremity

44. Examination The following organ systems are recognized: • Constitutional (e.g., vital signs, general appearance) • Eyes • Ears, nose, mouth and throat • Cardiovascular • Respiratory • Gastrointestinal • Genitourinary • Musculoskeletal • Skin • Neurologic • Psychiatric • Hematologic/lymphatic/immunologic * KEEP BODY ORGAN SYSTEMS AND BODY AREAS SEPARATE, IT SHOULD NOT BE REDUDANT.

45. One to five bulletsfrom one or more organ systemsExampleVitals: 120/80, 88, 98.6 General appearance: NAD, conversant Lungs: CTA CV: RRR, no MRGs Three vital signs general appearance auscultation of lungs auscultation of the heart 1997 Problem Focused Examination

46. At least six bulletsfrom anyorgan systemsExampleVitals: 120/80, 88, 98.6 General appearance: NAD, conversantLungs: Clear to auscultation CV: RRR, no MRGs Abdomen: Soft, nontender Extremities: No peripheral edema Three vital signs general appearance auscultation of lungs auscultation of the heart examination of the abdomen examination of extremities for edema 1997 Expanded Problem Focused Exam

47. The Detailed Physical Exam • The Detailed Physical Exam is the second highest level of physical exam. • 1997 Detailed Exam requires at least 12 bullets from any organ systems (1997 SYSTEM IS A SCORING SYSTEM)

48. 1997 Detailed ExamAt least two bulletsfrom six organ systems OR 12 bullets from two or more organ systems Vitals: 120/80, 88, 98.6 General appearance: NAD, conversant Neck: FROM, supple Lungs: Clear to auscultation CV: RRR, no MRGs; normal carotid upstroke and amplitude without bruits Abdomen: Soft, non-tender; no masses or HSM Extremities: No peripheral edema or digital cyanosisSkin: no rash, lesions or ulcers Psych: Alert and oriented to person, place and time

49. 1997 Detailed Exam • three vital signs • general appearance • examination of neck • auscultation of lungs • auscultation of the heart • assessment of carotid arteries • examination of the abdomen • examination of liver and spleen • examination of extremities for edema • examination and/or palpation of digits and nails • inspection of skin and subcutaneous tissue • brief assessment of mental status—orientation • * USE PAGE 53 IN LECTURE GUIDE FOR REFERENCE

50. 1997 Comprehensive Examination Vitals: 120/80, 88, 98.6 General appearance: NAD, conversant Eyes: anicteric sclerae, moist conjunctivae; no lid-lag; PERRLA HENT: Atraumatic; oropharynx clear with moist mucous membranes and no mucosal ulcerations;normal hard and soft palate Neck: Trachea midline; FROM, supple, no thyromegaly or lymphadenopathy Lungs: CTA, with normal respiratory effort and no intercostal retractions CV: RRR, no MRGs Abdomen: Soft, non-tender; no masses or HSM Extremities: No peripheral edema or extremity lymphadenopathySkin: Normal temperature, turgor and texture; no rash, ulcers or subcutaneous nodules Psych: Appropriate affect, alert and oriented to person, place and time