Comprehensive Guide to E/M Services Coding and Documentation Compliance

1. CHAPTER 15 EVALUATION AND MANAGEMENT (E/M) SERVICES

2. Coding for Services • Your job is to code what is documented in the medical record

3. Your Job • Optimize—never maximize • Optimize = “get the most out of” • Maximize = “to increase or make as great as possible” • Accurately report documented services

4. A Crime! • Coding for services not provided is a CRIME • Fraud: Billing for services never rendered

5. Chapter 15 Reviews • E/M (Evaluation and Management) section • Reports physician services (Cont’d…)

6. Chapter 15 Reviews (…Cont’d) • Subsections by type of service • Types of service: • Office • Hospital • Consultations

7. Three Factors of E/M Codes • Place of service • Type of service • Patient status

8. Place of Service • Explains setting of service: • Office • Emergency Department • Nursing Home, etc.

9. Type of Service • Physicians provide many types of services: • Office visits • Admissions • Consultations • Prolonged Services

10. Patient Status • Four status types: • New patient • Established patient • Outpatient • Inpatient

11. New Patient • Has not received any professional service in last _ years from: • The same physician • From another physician of the exact same Specialty and subspecialty and in same group • New patients more labor intensive for physician and staff 3

12. Established Patient • Has received professional services in last 3 years from: • The same physician or • Another physician of exact same specialty and subspecialty in same group • Medical record available with current, relevant information

13. Outpatient • One who has not been formally admitted to a health care facility • Example: Patient receives service at clinic or same-day surgery center • Example: Patient admitted to “observation” status

14. Inpatient • One who has been formally admitted to a health care facility (e.g., hospital, nursing facility, etc.) • Attending physician dictates: • Admission orders • H & P • Requests consultations

15. Levels of E/M Service Based On • Nature of the presenting problem (foundation) • Skill required to provide service • Time spent (if 50% of total time is counseling or coordination of care) • Level of knowledge necessary to treat patient • Effort required/assumed • Responsibility required

16. E/M Levels Are Divided Based On • Key Components (KC) • Contributory Factors (CF) • Every encounter contains varying amount of KC and CF

17. Encounters • More of each component/factor • Higher level of service • Less of each component/factor • Lower level of service

18. Key Components • History • Examination • Medical decision making

19. Contributory Factors • Counseling • Coordination of care • Nature of presenting problem

20. Four Elements of a History • Chief Complaint (CC) • History of Present Illness (HPI) • Review of Systems (ROS) • Past, Family, and/or Social History (PFSH)

21. Chief Complaint (CC)—Subjective • Reason for encounter • Patient’s current complaint • Usually presented in patient’s own words • Documented in medical record for each encounter • Required for all levels of service • May not be stated as “CC” but is inferred from documentation

22. History of Present Illness (HPI)—Subjective • Description of development of current illness • e.g., date of onset • Patient describes HPI • If patient cannot answer for themselves, a parent, guardian, or other may provide • Eight elements in HPI • Provider must document

23. Physician and Patient Dialogue • Development of a CC of abdominal pain: • “Started Thursday night and was mild. During night, it got worse. Friday morning I went to work, but had to leave because pain got so bad.” (Cont’d…)

24. Physician and Patient Dialogue (…Cont’d) • Location—specific location of pain • “Pain was in lower left-hand side, a little toward back.” (Cont’d…)

25. Physician and Patient Dialogue (…Cont’d) • Quality—Is pain sharp, dull, pressure, burning? (a sensation) • “Pain is really sharp and constant.” (Cont’d…)

26. Physician and Patient Dialogue (…Cont’d) • Severity—Is pain intense, moderate, mild? • On a scale of 1-10 may be stated • “Pain is terrible, worst pain I have ever had.” (intense) (Cont’d…)

27. Physician and Patient Dialogue (…Cont’d) • Duration—How long has pain been present? • “Pain has been going on now for 3 days.” (Cont’d…)

28. Physician and Patient Dialogue (…Cont’d) • Timing—Is pain present all the time, or does it come and go? • “Pain just continues. It just doesn’t go away.” (Cont’d…)

29. Physician and Patient Dialogue (…Cont’d) • Context—When does it hurt most?—Is there a correlation to a specific activity (e.g., climbing stairs)? • “Pain is just there; it doesn’t matter what I am doing.” (Cont’d…)

30. Physician and Patient Dialogue (…Cont’d) • Modifying factors—Does anything make it better or worse? • “Nothing I do makes it any better or any worse.” • Aspirin taken, no relief. (Cont’d…)

31. Physician and Patient Dialogue (…Cont’d) • Associated signs and symptoms relating to presenting problem(s)—Does anything else feel different when pain is present? • “Yes, I have nausea when pain is worst.” (Cont’d…)

32. Review of Systems (ROS)—Subjective • Organ systems • Respiratory system • Cardiovascular system • There are 14 elements in ROS

33. Extent of ROS depends on CC • Example: Do not usually review musculoskeletal system for CC of chest pain • Example: A patient who has sustained trauma from an auto accident and cannot discern difference • Medical necessity for the number of OSs inventoried must be implied or documented

34. Systems in ROS • Constitutional—General, Fever, Weight Loss or Gain • Eyes—Organ System (OS) • Ears, Nose, Mouth, Throat (OS) • Cardiovascular (OS) (Cont’d…)

35. Systems in ROS (…Cont’d) • Respiratory (OS) • Gastrointestinal (OS) • Genitourinary (OS) • Musculoskeletal (OS) • Integumentary (OS) (Cont’d…)

36. Systems of ROS (…Cont’d) • Neurologic (Neurological) (OS) • Psychiatric (OS) • Endocrine (OS) • Hematologic/Lymphatic (OS) • Allergic/Immunologic (OS)

37. Past, Family, and/or Social History (PFSH) • Past and Social History contains relevant information about past: • Major illnesses/injuries • Operations • Hospitalizations • Allergies • Immunizations • Dietary status (Cont’d…)

38. Past and Social History (…Cont’d) • Social history contains relevant information about: • Sexual history • Other relevant social factors (Example: Employment) • Past-present medications • Social tobacco/alcohol use

39. Family History • Health status of family members: • Parents • Siblings • Children • Family history items related to CC

40. History Levels Four history levels: • Problem focused • Expanded problem focused • Detailed • Comprehensive

41. Problem Focused History • Brief history focused on CC • Brief HPI • No ROS • No PFSH • Brief history includes 1-3 of the eight elements of the HPI

42. Expanded Problem Focused History • Brief history focused on CC • Brief HPI • Less than 3 of 8 elements or 1-2 chronic problems • ROS as it pertains to Presenting Problem • No PFSH

43. Detailed History • Extended history • Extended HPI • HPI: • 4 or more of 8 elements • 3 or more chronic conditions • Extended ROS • Pertinent PFSH

44. Comprehensive History • Extended history • Extended HPI • Complete ROS • Complete PFSH

45. Summary of Elements Required for Each Level of History Figure: 15.4

46. Examination—Objective (Hands-on) • Four levels of examination: • Problem Focused • Expanded Problem Focused • Detailed • Comprehensive

47. Problem Focused Examination • Affected body area and/or organ system • 10 Body areas (BOs) (1995 Guidelines) • 12 Organ systems (OSs) (1995 Guidelines)

48. Expanded Problem Focused Examination • Limited examination • Affected BO and/or OS • Other related BO(s) and/or OS(s) • Often vitals or general appearance of patient

49. Detailed Examination • Extended examination of affected BO(s) and/or related OS(s)

50. Comprehensive Examination • Complete single specialty or complete multisystem examination