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Evaluation and Management Services

This lecture delves into the Evaluation and Management (E/M) services crucial for orthopaedic practice. It covers professional face-to-face interactions between doctors and patients, emphasizing proper documentation to support clinical encounters. Key topics include categories of E/M services, elements of E/M visits, and modifiers, with practical examples involving different patient scenarios, including consultations and types of encounters. Understanding these aspects is vital for compliant and effective patient management and accurate billing in orthopaedic surgery.

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Evaluation and Management Services

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  1. Evaluation and Management Services Montri D. Wongworawat Department of Orthopaedic Surgery Grand Rounds July 6, 2011

  2. Evaluation and Management • E/M • Professional face-to-face service between doctor and patient • Documentation to support the above • S: History • O: Physical • A: Decision Making • P: Decision Making

  3. Lecture Outline • Categories of E/M Services • Elements of the E/M Visit • Modifiers

  4. Categories of E/M Services PPO patient seen by your partner last year, consult requested by the ED, you see the patient and document • Encounter type? • Hospital/inpatient new • Hospital/inpatient consultation • Office/outpatient new • Office/outpatient consultation • Office/outpatient established

  5. Categories of E/M Services PPO patient seen by your partner last year, consult requested by the ED, you see the patient and document • Encounter type? • Hospital/inpatient new • Hospital/inpatient consultation • Office/outpatient new • Office/outpatient consultation • Office/outpatient established

  6. Categories of E/M Services Medicare patient seen by your partner last year, consult requested by the ED, you see the patient and document • Encounter type? • Hospital/inpatient new • Hospital/inpatient consultation • Office/outpatient new • Office/outpatient consultation • Office/outpatient established

  7. Categories of E/M Services Medicare patient seen by your partner last year, consult requested by the ED, you see the patient and document • Encounter type? • Hospital/inpatient new • Hospital/inpatient consultation • Office/outpatient new • Office/outpatient consultation • Office/outpatient established

  8. Categories of E/M Services Medicare patient never seen by you or your partner, consult requested by the ED, you see the patient and document • Encounter type? • Hospital/inpatient new • Hospital/inpatient consultation • Office/outpatient new • Office/outpatient consultation • Office/outpatient established

  9. Categories of E/M Services Medicare patient never seen by you or your partner, consult requested by the ED, you see the patient and document • Encounter type? • Hospital/inpatient new • Hospital/inpatient consultation • Office/outpatient new • Office/outpatient consultation • Office/outpatient established

  10. Categories of E/M Services • Office or other outpatient (includes ED) • New (requires all 3 key components) • Established (2 of 3 components) • Hospital inpatient • Initial hospital care (3 components) • Subsequent hospital care (2 of 3 components) • Hospital discharge • Consultations • Office or other outpatient • Initial inpatient

  11. Categories of E/M Services • Office or other outpatient • New (requires all 3 key components of E/M) • Never seen by your group • Seen by you or group member more than 3 years ago • Established (2 of 3 components of E/M) • Not New visit • Not Consultation

  12. Categories of E/M Services • Consultations • Definition • “A consultation is defined as a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.”

  13. Categories of E/M Services • Consultations • Guidelines • The consultant’s opinion is requested by another physician • Documentation of verbal or written request • Documentation of consultant’s opinion • Consultant may initiate treatment • Communication of consultant’s opinion to the requesting physician

  14. Categories of E/M Services • Consultations • Situations • Requests between physicians of the same group • Report consultation code if guidelines are met • Initiation of treatment • Usually stems from medical decision making portion of the E/M service • “Even though treatment is initiated, the initial service is still considered a consultative visit.” • If the consulting physician assumes care, the initial service should be reported as a consult.

  15. Categories of E/M Services • Consultations • Medicare eliminated this whole category

  16. Lecture Outline • Categories of E/M Services • Elements of the E/M Visit • Modifiers

  17. History Wrist pain, dull, constant, with numbness ROS Gen: weight gain, CV: none H/O DM • History type? • Problem focused (level 1) • Expanded problem focused (level 2) • Detailed (level 3) • Comprehensive (levels 4 and 5)

  18. History Wrist pain, dull, constant, with numbness ROS Gen: weight gain, CV: none H/O DM • History type? • Problem focused (level 1) • Expanded problem focused (level 2) • Detailed (level 3) • Comprehensive (levels 4 and 5)

  19. History • Detailed level • HPI-ROS-PFS 4-2-1

  20. History Wrist pain, sharp, dull, throbbing, aching ROS 10+ PMH: none, PSH: none, Meds: none • History type? • Problem focused (level 1) • Expanded problem focused (level 2) • Detailed (level 3) • Comprehensive (levels 4 and 5)

  21. History Wrist pain, sharp, dull, throbbing, aching ROS 10+ PMH: none, PSH: none, Meds: none • History type? • Problem focused (level 1) • Expanded problem focused (level 2) • Detailed (level 3) • Comprehensive (levels 4 and 5)

  22. History Wrist pain, constant, worsening, with numbness ROS 10+ PMH: none, FHx: Heart disease, SocHx: +EtOH • History type? • Problem focused (level 1) • Expanded problem focused (level 2) • Detailed (level 3) • Comprehensive (levels 4 and 5)

  23. History Wrist pain, constant, worsening, with numbness ROS 10+ PMH: none, FHx: Heart disease, SocHx: +EtOH • History type? • Problem focused (level 1) • Expanded problem focused (level 2) • Detailed (level 3) • Comprehensive (levels 4 and 5)

  24. Elements of the E/M Visit • History • CC (1 element) • Describe reason for visit • Every visit must have the CC stated

  25. Elements of the E/M Visit • History • HPI (4 elements) • Location: site of the problem • Quality: sharp, dull, throbbing • Severity: minor, moderate, severe • Duration: intermittent, constant • Timing: with exercise, nightly, after meals • Context: worsening, recurrent • Modifying factors: rest, heat, cold, elevation • Associated symptoms: numbness, tingling

  26. Elements of the E/M Visit • History • ROS (10 elements) • Constitutional • Eyes • Ear, nose, throat • Cardiovascular • Respiratory • Gastrointestinal • Genitourinary • Musculoskeletal • Integumentary • Neurologic • Psychiatric • Endocrine • Hematologic • Immunologic

  27. Elements of the E/M Visit • History • PFSH (3 elements) • Past history • Illnesses • Operations • Allergies • Family history • Social history • Occupation • Tobacco and alcohol use

  28. Elements of the E/M Visit

  29. Physical Examination No distress, intact cap refill in all fingers B UE: nontender except over palpable dorsal wrist mass, functional ROM, no dislocations, no atrophy, no wounds • Exam type? • Problem focused (level 1) • Expanded problem focused (level 2) • Detailed (level 3) • Comprehensive (levels 4 and 5)

  30. Physical Examination No distress, intact cap refill in all fingers B UE: nontender except over palpable dorsal wrist mass, functional ROM, no dislocations, no atrophy, no wounds • Exam type? • Problem focused (level 1) • Expanded problem focused (level 2) • Detailed (level 3) • Comprehensive (levels 4 and 5)

  31. Elements of the E/M Visit • Physical examination—Musculoskeletal • Constitutional (2 elements) • Cardiovascular and/or lymphatic (1 element) • Musculoskeletal (17 elements) • Skin (4 elements) • Neuropsychiatric (5 elements)

  32. Elements of the E/M Visit • Physical examination—Musculoskeletal • Constitutional (2 elements) • Vital signs (any 3 of the following items) • Temperature • Pulse • Respiration • Blood pressure • Height • Weight • General appearance

  33. Elements of the E/M Visit • Physical examination—Musculoskeletal • Cardiovascular and/or lymphatic (1 element) • Pulse • Capillary refill • Skin perfusion • Edema • Lymph node palpation

  34. Elements of the E/M Visit • Physical examination—Musculoskeletal • Musculoskeletal (17 elements) • Gait examination • In 4 of 6 body areas: (head/neck, trunk, 4 extremities) • Inspect/palpate • Assess ROM • Assess stability • Assess strength, tone, atrophy, or spasticity

  35. Elements of the E/M Visit • Physical examination—Musculoskeletal • Skin (4 elements) • In 4 of 6 body areas: (head/neck, trunk, 4 extremities) • Inspection and/or palpation

  36. Elements of the E/M Visit • Physical examination—Musculoskeletal • Neuropsychiatric (5 elements) • Coordination • Reflexes (deep tendon or pathologic) • Sensation • Orientation • Mood and affect

  37. Elements of the E/M Visit

  38. Decision Making Problem: New fracture, HTN, DM Risk: Major surgery with risk factors Data: Reviewed films • Decision type? • Straightfoward (levels 1 and 2) • Low (level 3) • Moderate (level 4) • High (level 5)

  39. Decision Making Problem: New fracture, HTN, DM (HIGH) Risk: Major surgery with risk factors (HIGH) Data: Reviewed films (LOW) • Decision type? • Straightfoward (levels 1 and 2) • Low (level 3) • Moderate (level 4) • High (level 5)

  40. Decision Making Problem: F/U fracture with displacement Risk: ORIF Data: Reviewed films • Decision type? • Straightfoward (levels 1 and 2) • Low (level 3) • Moderate (level 4) • High (level 5)

  41. Decision Making Problem: F/U fracture with displacement (LOW) Risk: ORIF (MOD) Data: Reviewed films (LOW) • Decision type? • Straightfoward (levels 1 and 2) • Low (level 3) • Moderate (level 4) • High (level 5)

  42. Decision Making Problem: New onset numbness, DM stable Risk: Major surgery Data: Read EMG report • Decision type? • Straightfoward (levels 1 and 2) • Low (level 3) • Moderate (level 4) • High (level 5)

  43. Decision Making Problem: New onset numbness, DM stable (HIGH) Risk: Major surgery (MODERATE) Data: Read EMG report (STRAIGHTFORWARD) • Decision type? • Straightfoward (levels 1 and 2) • Low (level 3) • Moderate (level 4) • High (level 5)

  44. Elements of the E/M Visit • Decision making • Number of diagnosis/management options • Risk of complications • Amount/complexity of data reviewed

  45. Elements of the E/M Visit • Decision making • Number of diagnosis/management options • Self-limited or minor problem 1 • Established problem 1 • Worsening problem 2 • New problem, no additional workup 3 • New problem, additional workup planned 4 • Add up points • Score = 1, 2, 3, 4+

  46. Elements of the E/M Visit • Decision making • Risk of complications • Minimal • Suture removal, lab tests, rest • Low • Two minor problems, sprain, order PT/OT, minor surgery without risk factors • Moderate • Two chronic illness, CT, MRI, aspiration, Rx, fx management, major surgery without risk factors, minor surgery with risk factors • High • Illness with severe exacerbation, abrupt neurological change, major surgery with risk factors, emergency surgery

  47. Elements of the E/M Visit • Decision making • Amount/complexity of data reviewed • Order test 1 • Review test result 1 • Discuss test with performing physician 1 • Decide to obtain records 1 • Review and summarize records 2 • Review x-ray or specimen 2 • Add up points • Score = 1, 2, 3, 4+

  48. Elements of the E/M Visit

  49. Elements of the E/M Visit • How do you decide level of service? • Components • History • Physical examination • Decision making • New patients and consultations • Need all 3 components • Code for lowest component • Established patients • Code for 2 out of 3 components

  50. Elements of the E/M Visit

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