evaluation and management (e/m) services. general documentation guidelines the documentation of each...
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Evaluation and Management (E/M) Services
General Documentation Guidelines
The documentation of each patient encounter should include:
• The reason for encounter and relevant history, physical examination findings, and prior diagnostic test results
• An assessment, clinical impression, or diagnosis
• Plan for care• If not documented, the rationale for
ordering diagnostic and other ancillary services should be easily inferred
• Past and present diagnoses should be accessible to the treating and/or consulting physician
• Appropriate health risk factors should be identified
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Key Components of an E/M Service
• History
• Physical Examination
• Medical Decision Making
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Key Components of an E/M Service
Three out of three key components required (History, Physical Exam, Medical Decision Making): • New Patient Office Visits (99201-99205)• Outpatient Consultations (99241-99245)• Initial Hospital Care (99221-99223)• Inpatient Consultations (99251-99255)• Emergency Room Visit (99281-99285)
**Please note: Only 2 out of 3 PFSH required
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Key Components of an E/M Service
Only two out of the three components required (History or Physical Exam AND Medical Decision Making): **Please note: Medical Decision Making must be counted as one of the key components when determining code level.
• Established Patient Office Visits (99211-99215)• Subsequent Hospital Care (99231-99233)
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History – Key Component #1
• Chief Complaint (CC) – Required for EVERY note• History of Present Illness (HPI)• Review of Systems (ROS)• Past, Family and Social History (PFSH)
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HPI Elements Location: Where do the patient's symptoms occur? Head, shoulders,
knees, toes etc. Quality: Includes a description of the type of pain: burning, stabbing, dull,
achy, radiating, throbbing, etc. Describe a sore throat as scratchy Severity: Patient's symptoms (getting better or worse, increasing or
decreasing, pain scale of 1-10). The patient might be feeling well Duration: Any description about the duration of the length of the patient's
symptoms, illness or condition. For ex. history of mild burning pain in the groin that has become more intense and frequent for the last two weeks
Timing: Is it intermittent, continuous, constant, upon awakening or after exercising
Context: Where the patient is and what the patient does when the symptoms or signs begin for ex. after slipping on ice, playing sports, sitting in chair or in relation to another illness or surgery
Modifying factors: Any treatment prescribed by a physician or tried by the patient without physician direction. Things that make it better or worse.
Associated signs and symptoms: Other findings that the patient presents with, related or unrelated to today's chief complaint. Positive complaints
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Case Study – History of Present Illness (HPI)
CC: Chest painThe patient is a 68 year old male who presents with chest pain (location) which began approximately two hours ago (duration). The pain is described as crushing (quality) and 8/10 (severity). He states the pain has been constant (timing) and has also had nausea and shortness of breath (associated signs and symptoms). He has no known heart disease . Pain improved following administration of IV morphine (modifying factors).
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Case Study – History of Present Illness (HPI)
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HPI (History of present illness) Location Severity Timing Modifying factors Quality Duration Context Assoc. signs & symptoms
Brief 1-3
Brief elements
Extended 4
elements chronic or
Extended or status of 3 inactive conditions
Review of Systems (ROS)A review of systems is 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 has experienced.
o Constitutional symptoms (ex. eating/sleeping well)o Eyeso Ears, Nose, Mouth, Throato Cardiovascularo Respiratoryo Gastrointestinalo Genitourinaryo Musculoskeletalo Integumentary (skin and/or breast)o Neurologicalo Psychiatrico Endocrineo Hematologic/Lymphatico Allergic/Immunologic
Case Study – Review of Systems (ROS)
General – Positive for occasional fatigue, negative for fevers or chillsCardiovascular – Intermittent lower extremity edema, no orthopnea or paroxysmal nocturnal dyspneaPulmonary – Negative for cough, hemoptysis or pleuritic chest painAll other systems were reviewed and are negative
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Case Study – Review of Systems (ROS)
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Positive and pertinent negative responses should be documented in the patient’s medical record. In addition the statement “all other systems reviewed and are negative” is the only acceptable verbiage that can be used to qualify for a complete ROS
ROS (Review of systems) Constitutional Ears, Nose GI Integumentary Endo
(wt. loss, etc.) Mouth, Throat GU (Skin, breast) HHem/lymph Eyes Card/vasc Musculo Neuro AAll/imm
Resp Psyc “All others negative”
None Pertinent to
problem 1 system
Extended 2-9 systems
Complete 10 systems
or some systems with statements, “all other negative”
Past, Family and Social History (PFSH)
PFSH consists of a review of 3 areas: Past medical history - personal illnesses,
injuries operations and medication Family history - review of family medical
illnesses (hereditary & potential risks) Social history - age appropriate review of past
and current activities (drinking, smoking, employment, marital status, education)
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Case Study – Past, Family and Social History
PMH: Hypertension, NIRDM, dyslipidemia, GERD and gout as well as a tonsillectomy over 25 years ago, NKDAFH: Father died at age 48 of acute MI, mother is still alive in her 90’s with Alzheimer’s disease, he has no siblings and on grown son in good health.SH: Patient quit smoking in 1978 after 15 year, 1 pack a day history. Drinks 2 to 3 martini’s per day. Lives with his wife of 35 years.
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Case Study – Past, Family and Social History
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PFSH (Past family and social history) Past medical history Family history Social History
No PFSH required: 99231-33
Established/ Subsequent/ER
None
None One history area
Two or three history areas
New/Initial
None None One or two history area
Three history areas
Four History Types
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HPI (History of present illness) Location Severity Timing Modifying factors Quality Duration Context Assoc. signs &
symptoms
Brief 1-3
Brief elements
Extended 4 elements
chronic or
Extended or status of 3 inactive conditions
ROS (Review of systems) Const. Ears, Nose GI Integumentary Endo
(wt. loss, etc.) Mouth, Throat GU (Skin, breast) HHem/lymph Eyes Card/vasc Musc Neuro AAll/imm
Resp Psych “All others negative”
None Pertinent to
problem 1 system
Extended 2-9 systems
Complete 10 systems or some
systems with statements, “all other
negative”
PFSH (Past family and social history) Past medical history Family history Social History
No PFSH required: 99231-33
Established/ Subsequent/ER
None
None One history area
Two or three history areas
New/Initial
None None One or two history area
Three history areas
Circle the entry farthest to the right for each history area. To determine history level, draw a line down the column with the circle farthest to the left.
P.F. 99201 99212 99231
EXP. P.F 99202 99213 99232
DETAILED 99203,99214 99233,99221
COMPREHENSIVE 99204,99205,99215,
99222,99223
Problem focused (PF) Detailed
Expanded Problem Focused (EPF)Comprehensive
History• The ROS and/or PFSH may be recorded by ancillary staff or on a
form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.
• This may be included in the progress note (e.g.; ROS and PFSH reviewed and discussed with patient)
If the patient is unable to give a history, the practitioner must describe the patient’s condition or other circumstance which precludes obtaining a history.
Common examples include: Altered mental status Dementia Urgency of the condition
A foreign language barrier does not qualify. 17
Physical Exam – Key Component #2
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Body Areas
Head, including faceNeckChest, including breast
and axillaeAbdomenGenitalia, groin, buttocksBack, including spineEach extremity
Organ SystemsConstitutional, vital signs, general
appearanceEyesEars, nose, mouth, throatCardiovascularRespiratoryGastrointestinalGenitourinaryMusculoskeletalSkinNeurologicPsychiatricHematologic/lymphatic/immunologic
Physical Exam Types
Problem focused – 1 body area or organ system
Expanded problem focused – 2-4 body areas or organ systems
Detailed –5-7 body areas or organ systems
Comprehensive – 8 or more organ systems ONLY
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Case Study – Physical ExamVitals: 180/75General appearance: Anxious and agitated, well nourished white male looks stated ageEyes: Anicteric sclerae, moist conjunctiva with no lid-lag, PERRLAHENT: AT/NC, oropharynx clear with moist mucous membranes and normal hard/soft palateNeck: Trachea midline, supple, no thyromegaly or carotid bruits, no JVDLungs: CTA in front with bibasilar posterior crackles worse on the left, normal respiratory effortCV: RRR, no MRGs, hyperdynamic PMI in midclavicular lineAbdomen: Soft, non-tender, no masses or HSM, normal pulsatile abdominal aorta without bruitsExt: 1+ bipedal edema with symmetrically diminished pedal pulses, no digital cyanosis Skin: Normal temperature, turgor and texture, no rash, no ulcers or nodulesNeuro: Cranial nerves II – XII grossly intact, symmetrically decreased light touch sensation in both lower extremitiesPsych: Appropriate affect, alert and oriented x 3
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PROBLEM FOCUSED-99201, 99212, 99231 1 body area/organ system EXP. PROBLEM FOCUSED-99202, 99213, 99232 2-4 body area/organ systems DETAILED-99203, 99214, 99233, 99221 5-7 body area/organ systems - detailed COMPREHENSIVE - 99204, 99205, 99215, 99222, 99223
8 organ systems or complete single system exam
Physical Exam Types (continued)
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Constitutional Eyes ENT RESP CV GI GU MS
Integumentary Neuro Psych Lymph
Medical Decision Making (MDM) – Key Component #3
Four levels of Medical Decision Makingo Straightforwardo Low Complexityo Moderate Complexityo High Complexity
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Case Study – Medical Decision Making (MDM)Assessment
1. Chest pain with high suspicion for unstable angina or acute MI2. Sub-optimally controlled hypertension3. Stable Diabetes
Plan4. Follow results of cardiac enzymes ASAP5. Admit to CCU with IV morphine as needed for pain6. ASA7. IV metoprolol8. NTG drip9. Heparin drip per protocol10. Echocardiogram today11. Sliding scale insulin12. Monitor and control hypertension
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Case Study – Medical Decision Making (MDM)
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1. Chest pain with high suspicion for unstable angina or acute MI
2. Sub-optimally controlled hypertension3. Stable diabetes
Case Study – Medical Decision Making (MDM)
Provider ordered and reviewed labs, EKG and chest
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Case Study – Medical Decision Making (MDM)
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Putting it all together
Selecting the Level of Service
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E/M Coding Based on Time
In the case of visits which consist predominantly of counseling or coordination of care, time is the key or controlling factor to qualify for a particular level of E/M service.
– Time spent counseling must be greater than 50% of the encounter.
– Documentation Example: I spent ___ minutes total time with the patient and ___ minutes was spent counseling the patient regarding _________________ (add details of counseling)
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Discharge Day Management
99238 - 30 minutes or less99239 - More than 30 minutes• Time must be documented when billing code
99239Example: I spent approximately 40 minutesperforming these discharge day managementservices. Education was given on the patientdiabetes, blood glucose goals and self-
monitoring. Inaddition we discussed diet and knowing when
to administer insulin. 30
Discharge Day ManagementDocumentation should include: Final examination of the patient (face to face time
must be documented) Discussion of the hospital stay even if the time
spent by the physician on that date is not continuous
Instructions for continuing care to all relevant caregivers
Preparation of discharge records Prescriptions Referral forms Signature 31
Consultation Documentation RequirementsDocumentation should include the FOUR R’S:
Consultation REQUESTS are to be noted in the patient’s written record (who requested).
The REASON for the request must be noted.
RENDERING the service (History, Physical Exam and Medical Decision Making).
Consulting physicians must provide a written REPORT of findings back to the requesting entity.
Consultation Codes are not be used in these circumstances: Transfer of care (physician has agreed to accept transfer of care
prior to an initial evaluation) A consultation initiated at the request of patient or family
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Consultation Documentation RequirementsAcceptable Consultation Verbiage:
• Patient sent by Dr. Doe for my evaluation of COPD (consult performed on an inpatient, with a report in the medical record)
• Dear Dr. Primary, Thank you for requesting my opinion about Mr. Smith’s headaches. I think it’s all in his head! (Request documented, opinion rendered, letter serves as the report)
• Dear Dr. Bones, at your request, I have evaluated Ms. Hip’s medical condition prior to her surgery. I find her medical problems to be ABC. She is cleared for surgery. (Request documented, opinion rendered, letter serves as the report)
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Diagnosis Coding
Support the medical necessity and level of service coded
Must be supported by documentation
Should be coded to the highest degree of specificity
If no definitive diagnosis, must code based on signs and symptoms
Cannot code “rule out” diagnosis
Should not be assigned when a diagnosis is mentioned in the history
and is not addressed, except when care is affected or the diagnosis is
actively treated by you
All diagnosis codes must be sequenced/linked (1,2,3, etc.) to the
corresponding CPT code34
Questions?
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