Understanding Evaluation and Management Documentation for Outpatient Services

1. DOCUMENTATIONREQUIREMENTS E/M Codes

2. Targeted Codes 99214 : established patient, outpt. visit – presenting problems are usually moderate to high severity 99212: established patient, outpt. Visit – presenting problems usually self limited or minor 99233: subsequent hospital care – usually patient is unstable, developed a significant complication or a significant new problem 99231: subsequent hospital care – usually a stable, recovering, or improving patient Codes accounting for the errors What codes should have been used

3. Principles of Documentation: • MR should be complete & legible • Documentation for each patient encounter should include: • Reason for encounter & relevant history • Physical exam & findings • Prior diagnostic test results • Assessment • Clinical impression or diagnosis • Plan for care • Date • Legible identity of the observer

4. Principles of Documentation Cont. • If not documented, the rationale for ordering diagnostic & ancillary services should be easily inferred • Past & present diagnosis should be accessible to the treating/consulting physician • Appropriate risk factors should be identified • Pt’s progress, response to & changes in treatment & diagnosis revision should be documented • CPT & ICD-9 codes on claim must be supported by MR documentation

5. Evaluation and Management Codes-Developed jointly by HCFA & the AMA How to stay on the good side of HCFA

6. MEDICAL NECESSITY • Inpatient : Does the diagnosis code support the medical need for the service performed? If not, does the documentation in the record support the necessity? • Outpatient : Level of Visit Codes

7. The 7 Components: 1) History 2) Examination 3) Medical Decision Making 4) Counseling 5) Coordination of Care 6) Nature of Presenting Problem 7) Time KEY

8. E & M Determination

9. The 7 Components: 1) History 2) Examination 3) Medical Decision Making 4) Counseling 5) Coordination of Care 6) Nature of Presenting Problem 7) Time KEY

10. Documentation of History: Level of service is based on 4 types: 1) problem focused 2) expanded problem focused 3) detailed 4) comprehensive History elements (some or all): chief complaint, CC  history of present illness, HPI  review of systems, ROS  past, family and/or social history, PFSH

11. ROS & PFSH obtained Earlier w/o any change: • Do not have to re-record if there is evidence that a physician had reviewed & updated the previous one • How to documented the review: • Describe any new information, • not that there has been no change, or • note the date & location of the earlier entry DG 1

12. ROS & PFSH may be recorded by ancillary staff or by the patient - physician must supplement or confirm the information received for documentation • If not able to obtain information - note in chart the patient’s condition & the circumstances that preclude obtaining a history DG 2 & 3

13. HPI Elements Brief: 1-3 1) location 2) quality 3) severity 4) duration 5) timing 6) context 7) modifying factors 8) associated signs & symptoms • Extended: • at least 4or the status of at least 3 chronic or inactive conditions DG 4 & 5

14. constitutional symptoms eyes ears, nose, mouth, throat cardiovascular respiratory gastrointestinal genitourinary ROS Elements • musculoskeletal • integumentary • neurological • psychiatric • endocrine • hematologic/lymphatic • allergic/immunologic

15. PROBLEM PERTINENT - inquires about the system directly related to the problem in HPI EXTENDED - directly related system + 2 - 9 systems documented COMPLETE - directly related system + all additional body systems ROS Definitions DG 6, 7 & 8

16. PFSH - • Pertinent - review of history areas directly related to problem in HPI • Complete- review of 2 or all 3, depending on the category on E&M code (required for comprehensive assessments) DG 9

17. Initial Patients requires 1 item from the 3 areas applies to outpt/office, consults, observation pts, nursing home assessments, domiciliary care, home care Est. Patients requires 1 item from the 2 areas applies to outpt/office, ER services, domiciliary care, home care PFSH requirements for: DG 10 & 11

18. Level of Service Determination * Must have all 3 in column or choose lowest

19. The 7 Components: 1) History 2) Examination 3) Medical Decision Making 4) Counseling 5) Coordination of Care 6) Nature of Presenting Problem 7) Time KEY

20. Documentation of Examination: Level of service is based on 4 types: 1) problem focused 2) expanded problem focused 3) detailed 4) comprehensive Exam Types:  cardiovascular, ENT & mouth, eyes, male & female genitourinary, hematological/lymphatic/immunologic, musculoskeletal, neurological, psychiatric, respiratory, skin

21. Documentation Guidelines: • Elements w/ mult. components require documentation of at least 1 component • “abnormal” can be used for exams of the affected or symptomatic body area • abnormal/unexpected finding in asymptomatic areas should be described • “negative” or “normal” is sufficient for unaffected or asymptomatic areas

22. General Multi-System Exams: PROBLEM FOCUSED: 1-5elements in  1 body areas/systems EXPANDED PROBLEM FOCUSED:6 elements in  1 body areas/systems DETAILED: 2 elements in 6 ore more body areas/systems (or  12 elements in  2 areas) COMPREHENSIVE:allelements in selected areas,  9 body areas/systems

23. Single Organ Exams: PROBLEM FOCUSED: 1-5elements in any box EXPANDED PROBLEM FOCUSED:6 elements in any box DETAILED: 12 elements in any box (eye & psychiatric  9 elements) COMPREHENSIVE:allelements ( document every element in bold boxes & at least 1 in normal boxes)

24. The 7 Components: 1) History 2) Examination 3) Medical Decision Making 4) Counseling 5) Coordination of Care 6) Nature of Presenting Problem 7) Time KEY

25. Documentation of Medical Decision Making: Level of service is based on 4 types: 1) straight - forward 2) low complexity 3) moderate complexity 4) high complexity -complexity of establishing a diagnosis and/or selecting a management option

26. Complexity factors…. • Pt’s # of diagnoses • the amount and/or complexity of MR, tests, & other information that must be obtained, reviewed, & analyzed • risk of significant complications, morbidity/mortality as well as co-morbidities associated with the presenting problem(s)

27. DG for # of Diagnoses or Mgmt. Options…. • Established dx. - state if improved/well controlled/ resolving or worsening/failing to change as expected • new diagnosis - stated in form of differential dx. possible/probable/rule out • initiation or changes in treatment • to whom or where referrals or consults are made or from whom the advice is requested

28. DG for amount & complexity of data to review…. • Types of service ordered at the time of encounter • reviewed results, initial & date report w/ the results • any further history or information obtained from MR, patient, etc. • relevant findings from above • results of discussions w/ physicians associated w/ reviewed results • direct visualization or independent interpretation of tests/films interpreted by another physician

29. Risk DG... • Any factor that would increase the risk of complications, morbidity, mortality • procedures planned at that time • specific procedure performed at time of encounter • need for an urgent procedure to be done

30. Table of Risk

31. Table of Risk

32. Table of Risk

33. Medical Decision Making Determination * 2 of 3 elements must be met or exceeded

34. E & M Determination Initial Patients must have 3 of 3

35. E & M Determination Initial Patients must have 3 of 3

36. NEW PATIENTS99201-99205 One who has NOT received any professional services from the physician or any other physician of the same specialty who belongs to the same group practice within the past 3 years.

37. E & M Determination Established Patients must have 2 of 3

38. ESTABLISHED PATIENTS99211-99215 One who HAS received professional services from the physician of the same specilaity who belongs to the same group practice within the last 3 years.

39. EST. PT Billing - 99211 Can be billed by the nursing staff when a chief complaint exists. Normally Required Care: Blood pressure, weight, reactions to current meds, additional services not usually provided by a physician NOT: finger sticks & injections *physician must be on the premises

40. Observation Care99218-99220 Report encounters by the supervising MD • Characteristics of Observation Pts: • not been admitted as an inpatient • may be physically detained in ER • clinical condition is being observed • additional time needed to clarify condition • to determine if hospitalization is needed

41. Observation to Inpatient- • MD admits pt to both w/in 24 hours – bill as initial hospital visit • Do NOT bill for an initial hospital visit & initial obs. code • Can NOT bill for an obs. discharge mgmt when admitting to inpt.

42. Global Surgical Period • Fee includes obs payment • Must use modifiers with the CPT code to receive payment • –57 indicates that the decision for surgery was made while the patient was in obs. • -24 denotes observation services are unrelated to the surgery • -79 subsequent surgical procedure • -25 separately identifiable service

43. MODIFIER -25 Indicates that E/M codes reported on the same bill are for significant and separately identifiable services

44. One last thing… If using a template to dictate your note DON’T FORGET to state that it was “normal” or “negative”