how to effectively teach evaluation &...

How to Effectively Teach Evaluation and Management in Under One Hour, written by Stephanie L. Jones, CPC-E/M

© Copyright AAPC 2007

1

How to Effectively Teach

Evaluation & Management Coding in Under 1 Hour

Exclusively For the AAPC

by Stephanie L. Jones, CPC-E/M



2

DISCLAIMER

This course was current at the time it was published. This course was prepared as a tool to assist the

participant in educating providers and is not intended to grant rights or impose obligations. Although

every reasonable effort has been made to assure the accuracy of the information within these pages,

the ultimate responsibility for the correct submission of claims and response to any remittance advice

lies with the provider of services. The American Academy of Professional Coders (AAPC) employees,

agents, and staff make no representation, warranty, or guarantee that this compilation of information is

error-free and will bear no responsibility or liability for the results or consequences of the use of this

course. This guide is a general summary that explains commonly accepted aspects of selecting

Evaluation and Management (E/M) codes, but it is not a legal document. View points are discussed from

the standpoint of the 1995 and 1997 Centers for Medicare and Medicaid Services (CMS) Evaluation and

Management Documentation Guidelines with medical necessity and the nature of the presenting

problem as the primary criterion of code selection (Medicare Claims Processing Manual Chapter 12 -

Physicians/Nonphysician Practitioners, 30.6.1 - Selection of Level of Evaluation and Management

Service, A. Use of CPT Codes.) For the purpose of objective consistency, specific logics are primarily

based on the same used by the E/M Documentation Auditors’ Worksheet, Marshfield Clinic, available

through the Medical Group Management Association (MGMA). Specific payers, including Medicare

Carriers, may use different and sometimes varied audit tools logics to gain objective consistency around

the 95 and 97 Documentation Guidelines. Official provisions are contained in the relevant laws,

regulations, rulings and contractual agreements of providers.

NOTICES

1. Current Procedural Terminology (CPT®) is copyright © 2007 American Medical Association. All

Rights Reserved. CPT® is a registered trademark of the American Medical Association (AMA).

2. It is recommended that the participant of this course will familiar with:

� 1995 Documentation Guidelines for Evaluation and Management Services

� 1997 Documentation Guidelines for Evaluation and Management Services

These may be downloaded from the CMS website at:

http://www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp



3

HOW TO EFFECTIVELY TEACH EVALUATION & MANAGEMENT CODING

IN UNDER ONE HOUR

CHAPTER 1: EFFECTIVE COMMUNICATION

Communicating effectively with physicians requires an understanding of their needs, wants and

mindset. Typically life-long learners, physicians are highly intelligent, with a deep appreciation for logic

and reason. They are naturally intuitive, some even feeling spiritually drawn to practice the art of

medicine and healing. Generally hungry for and appreciative of tips and techniques in learning new

skills, physicians crave correctness. So holds true to billing, and it applies equally to coding correctly as

well as being paid correctly. Accurate Evaluation and Management (E/M) coding can prove a frustrating

dichotomy; it is both a zealous challenge to achieve correctness, while also an intrusion.

Why?.

� Payment: Unease about being paid properly for the value of the service

� Ambiguity: Concerns regarding subjective, hidden, or unknown aspects of proper coding

� Fear: Consequences for defensive under-coding or emotional over-coding

Before a coach can effectively begin the process of communicating coding rules, these concerns should

be addressed. The following three-step approach can be very helpful in setting the stage for positive

outcomes.



4

THREE STEPS TO SETTING THE STAGE FOR EFFECTIVE COMMUNICATION

� PAYMENT: THE PRICE OF THE TICKET HAS NOTHING TO DO TO WITH THE RULES OF THE BALL GAME.

� Correct coding is static with literally nothing to do with flexible payments. Regardless of

payment, the level of service coded is based on proper coding requirements and never on

payment

� Payments are important to physicians. This must be acknowledged by an effective coach :

� Those concerns will be addressed by other means, such as contract re-negotiations, but

not in this conversational arena.

� AMBIGUITY: IT IS OKAY TO YELL AT THE UMPIRE—IF YOU CAN PROVE TO HIM YOU’RE RIGHT.

Part of the problem physicians have with coding rests with difficulties in the subjective aspects of

correct code selection for E/M services. On the surface, code selection appears black and white with a

clearly correct answer. However, interpretations of the rules for documentation requirements and

determinations of medical necessity can be frustrating..

� From the aspect of medical necessity, the correct level of service is determined by how “sick” a

patient is. Conditions posing an immediate threat to life or limb qualify for the highest level,

whereas patients whose conditions reflect minor or well controlled problems are at the lowest.

For many physicians, selecting a level of service to bill becomes hazy.. On a scale of one to five,

with five being the highest level of service, selecting between a Level 3 and a Level 4 or 2 is

more difficult.

� Peers may see the same patient and, assuming the same diagnosis, may still argue how sick the

patient really is. One may argue that managing three stable chronic illnesses in a patient without



5

complaint is a Level 3 or a Level 4. The other may feel differently. Beyond medical necessity

aspects, the rules governing documentation requirements are also in many some ways

subjective.

� Reproducible audit results between unrelated documentation requirement auditors are not

unfailingly prevailing. Properly trained and certified auditors may agree on the actual code

selection better than 90 percent of the time; however, the means and measurements of their

conclusion can be different upwards of 50 percent.

� Familiarities with clinical examples from creditable sources are valuable in making

determinations. Where no examples can be found, the written opinions of specialty

associations are very powerful and establish objective measures where there is

subjectivity. A solid understanding of code requirements and the backing of medically-

accepted standards of practice allows a physician to shore up subjectivity to assure

uncontestable coding and billing, ultimately achieving the most favorable and correct

ongoing outcomes for all involved.

� FEAR: WHAT’S MORE LIKELY TO BE HIT: THE BATTER OR THE BALL?

� Code selection is usually predictable within the first few moments and during the history taking

of the patient encounter. The nature of the presenting problem and severity of illness drives

documentation in the same way that it evokes the medically-indicated examination and clinical

decision making. When physicians recognize the clinical relationship of code selection,

documentation is an easier process with a key purpose of supporting the correct code and the

service rendered.

� Coding software and paper templates are helpful but not necessary. When a physician is familiar

with what is needed in documentation to support a given level of service, the process becomes

rote.

� With minimal instruction, a physician’s clinical training makes him or her an expert in

correctly identifying a level of service. Following the easy techniques outlined in this



6

course, a coach can teach physicians easy recall on the specific elements needed to

document and support the correct level of service.

OVERCOMING OBJECTIONS

It is easier to teach E/M coding to a physician who is ready and eager for the information. Sometimes,

physicians may be attending training as a requirement made by a practice manager, partner or

compliance department and may not be as receptive. Overcoming objections may be necessary before

effective training can begin.

More often than not when a physicians object to training, it is because they have not been convinced

that you’re training will have a sufficient benefit for them. You can often overcome this by asking

questions around what their current situation are (“I’m too busy!”), or what concerns they are facing…or

not facing (“No one is going to audit me!”). By asking questions you are including physicians in the

solution from the very beginning. You are also qualifying their objections, which will help you overcome

them.

Tip #1: Add information to the objection to boost interest

Example Objection: I don’t have time for this!

Response: “With cuts in fees from Medicare and private insurers, many doctors must see more

patients to maintain their incomes, and that means that they have less time. I understand your

problem and want to make this painless. This training takes less than an hour and may

ultimately save you time and money. You’ll learn how to avoid under-coding and under-

documentation. Typically you’ll get the most out of it if we do it all at once in under one hour—

but we can do it in 10 minute sessions if you prefer.”

With this response you build credibility by demonstrating that you understand and care about the value

of the physician’s time. You also imply that you have had the same objection from other physicians who

still agreed to attend your training.

Tip # 2: Turn the objection into a question to get the right attention

Objection: No one is going to audit me!



7

Response: “Can you afford to be wrong?”

Traditionally, the relative high cost of auditing E/M records meant that only large groups or suspected

fraud cases were audited. However, because of the Internet and new technology, auditing E/M records

has never been easier and is no longer cost prohibitive. Government officials, employers and patient

consumer stakeholders are demanding controls on healthcare costs. Inaccuracies in the coding of

physician visits are estimated to account for up to 3 percent of the medical loss ratio in commercial

plans and up to 1 percent in Medicaid plans. Abuses, honest mistakes in billing for physician visits and

consultations services account for estimated national losses as high as $20 billion a year. Fraud accounts

for annual losses of more than $90 billion. All of this adds up to increased post-payment payer audits

and a much greater risk of being selected for audit. Physicians must have a defensible medical record in

order to avoid unfavorable audit results.

Further response: “I hope you are not audited. No one likes to be audited. But, this education is

not about that. This education is to ensure that you are coding the highest correct level with

confidence. It is an added bonus for me to know you’d pass an audit. Why not give me a few

minutes so that you can easily avoid unfavorable outcomes?”

CHAPTER 2: MEDICAL NECESSITY, THE FIRST 0-10 MINUTES OF COACHING TIME

The typical bell curve mindset should not be forefront to code selection. It is only helpful when making a

determination of how similar the billing pattern is among same specialty peers. A bell curve that

demonstrates that a physician is an outlier from the norm should only be an indication to look closer for

a possible cause. Some trauma surgeons, for example, may only ever see Level 5 patients. Although the

curve can be helpful in identifying coding patterns that are outside of the norm, code selection is always

based solely on medical necessity as supported by documentation. The good news for physicians is that

there is no one better qualified to determine medical necessity than they are.

In its simplest terms, the five base levels of service can be visualized using the same logic in the Wong-

Baker children’s pain chart.



8

…a level 5 may not be

justifiably supported when the patient is

healthy enough to not be asked to follow-

up sooner than six months…

Most physicians readily understand that Levels 3-5 are reserved for actively “sick” patients (Levels 1-3 in

the hospital setting). The lower levels of service are reserved for

patients with minor and/or well controlled conditions. It is

tremendously helpful for physicians to have access to clinical

examples in order to better define just how sick a patient needs to be

(with conditions that the physician plans to treat) in order to support

the specific use of a Level 3, 4 or 5.

What is confusing for some physicians is that a qualified coder, or a

code optimizing electronic health record (EHR), may review a document and establish that a

comprehensive high level service was rendered. However, it is important for physicians to remember

that a medical review may find the same document lacking in demonstrable necessity. For example, a

comprehensive history and physical may not be necessary to repeat on a two-week follow-up visit to

recheck the patient’s normal blood pressure, even when doing so produces documentation that

technically supports a higher level. The length of time before the next necessary follow-up visit is

sometimes a very good indication of the level of medical necessity. For example, a level 5 may not be

justifiably supported when the patient is healthy enough to not be asked to follow-up sooner than six

months.

Although a comprehensive service may be a physician’s personal art and style of practice it may not be

considered necessary and billable by a majority of peers. It is the necessity of the work versus the actual

volume of work that should be coded and billed. In situations where a history and physical are not

foremost such as billing based on time the criteria for documentation is quite different and limited only

by the need for counseling and coordination of care. It is also limited in that 50 percent or more of the

encounter required it. The American Medical Association’s (AMA) “CPT® Reference of Clinical Examples:

Official Scenarios for Correct Coding” can be a valuable resource. The AMA CPT® manual offers several



9

clinical examples. The unbiased opinion of peers can be the most valuable with clinical examples

available from a physician’s specialty organization being particularly ideal.

HELPFUL LINKS ON MEDICAL NECESSITY:

Remember the rules that apply to the physician you are coaching are contained in the relevant laws,

regulations, rulings and contractual agreements of the physician. From a Medicare perspective the links

below are helpful and are normally only superseded by state law if the state law it is more stringent.

Medicare Claims Processing Manual, Chapter 12 - Physicians/Nonphysician Practitioners, 30.6.1 -

Selection of Level of Evaluation and Management Service A. Use of CPT Codes

“Medical necessity of a service is the overarching criterion for payment in addition to the individual

requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of

E/M service when a lower level of service is warranted. The volume of documentation should not be the

primary influence upon which a specific level of service is billed. Documentation should support the

level of service reported. The service should be documented during, or as soon as practicable after it is

provided in order to maintain an accurate medical record….”

http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf

1862 (a) (1) of the Social Security Act

“…Sec. 1862. [42 U.S.C. 1395y] (a) Notwithstanding any other provision of this title, no payment may be

made under part A or part B for any expenses incurred for items or services—

(1)(A) which, except for items and services described in a succeeding subparagraph, are not reasonable

and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a

malformed body member,

(B) in the case of items and services described in section 1861(s)(10), which are not reasonable and

necessary for the prevention of illness…”

http://www.ssa.gov/OP_Home/ssact/ssact.htm



10

CHAPTER 3: HISTORY TAKING, THE NEXT 11-20 MINUTES OF COACHING TIME

Your goal is to have physicians feel confident that they will not under or over-code a visit after

completing your training. It is not always necessary in an initial one-hour training to coach a physician on

every “if/then” scenario. Doing so can sometimes become overwhelming and confusing. Ensuring you

communicate key points is essential in order to maximize outcomes of the training. The entire focus of

these next 10 minutes of coaching time is on history. The coach must be prepared to offer examples

when asked.

Special Circumstances to be watchful for in History include:

� If documentation shows that the provider is unable to obtain a history from the patient or other

source (for example, “patient has difficulty with speaking English and presents today without a

translator”, patient is “not conscious”, etc.). The overall level of medical necessity and the work

of the provider are not penalized by the fact that the physician could not obtain a history from

the patient. Note: If the provider summarizes additional history supplied by a family member, or care

giver, remember to credit this under MDM.

� Systems review and (PFS) History taken from an earlier encounter can be and updated without

complete re-documentation. It is necessary for the provider to indicate the new status of the

history and to leave an audit trail regarding where the original documentation is stored.

Physicians should be cautioned that, although a comprehensive service may be performed, a

comprehensive service is not always medically necessary or billable. Unless the encounter is for

a preventive medical history and physical, it is important to ensure that physicians understand

that the Chief Complaint (CC) must be readily identifiable. This is the first step in establishing

medical necessity.

� The history (Hx) component is riddled with subjective terms. There are times when two separate

audits of the same service may produce different results and neither party can be proven

technically or medically wrong. Reviewer A may argue with Reviewer B that an element of (HPI)



11

HPI *New Out-Patient, and Consultations

*Established Out Patient

is a “quality” versus an “associated sign or symptom”, or other element. Reviewer B may state

that the documented “NKDA” constitutes an element of ROS or conversely an element of Past

history.

� Any free-form text is to some degree interpretive. This holds true with physicians’ notes.

Since coding relies on counting subjective elements, the correct interpretation requires

consistency, citable references, a logical argument and - ultimately - medical necessity.

The following is a guide to assist a physician in developing personal objectivity. With a known logic and

solid argument, the correct code for the medically necessary rendered services can prevail.

HISTORY OF PRESENT ILLNESS:

� Location: For example “chest” pain, sore “knee”, etc.

Conversely, examples such as “COPD”, “Diabetes”, and

“Hypertension” are not locations - these are “chronic

conditions” Note: To credit chronic conditions use the 97 DG or one

of the other elements of 95 HPI (such as Severity: ie. CC = Return BP

check, patient states it has been running 120/80 at Walgreen’s self

service cuff. )

� Severity: A statement of degree or measurement regarding

how bad it is… that it is improved, it is extreme pain, “BS is

200,” feeling “better,” pain is bad enough “that the pt cant

sleep” etc.

� Timing: A measurement of when or at what frequency; i.e. “intermittent,” “constant,” in the

“morning,” lasted “5 minutes,” “occasional,” “on and off,” etc.

� Associated signs and symptoms: Any associated or secondary complaints.

� Modifying factors: Anything that makes the problem better or worse, a factor that changes,

improves, or alters the problem. For example,. improved “with Tylenol,” worse “when

standing,” better “when resting,” “calms down when mother feeds her” Note: Medication may be

a modifying factor when it changes, improves, or alters the problem. Otherwise, it is most often credited to

PAST Hx. Some auditors will credit medications that were used in an unsuccessful attempt to modify the

condition as a “modifying factor”.

Level 3+ = 4 HPI

All Other levels = 1 HPI

Level 4+ = 4 HPI

All Other levels = 1 HPI



12

� Context: What the patient was doing, the environmental factors/circumstances surrounding the

complaint, for example, “while sleeping,” “MVA,” “slipped and fell,” after “eating peanuts,”

“while dusting,” “when arguing with his wife,” etc.

� Duration: A measurement of time regarding when the complaint first occurred. For example, .:

began “in childhood,” “since 1995,” first noticed “2 weeks” ago, “symptoms x 3d,” etc.

� Quality: Any characteristic about the problem and/or expresses an attribute. For example: how

it looks or feels; for example. “green” phlegm, “popping” knee, “dull” ache, “sharp” pain,

“metallic” taste, etc.

REVIEW OF SYSTEMS

The review of system (ROS) is an account of body systems obtained through a series of questions

seeking to spot signs and/or symptoms that the patient may be experiencing or has experienced. This

query is made by the physician and/or the staff (verbally or via patient intake forms) in order to best

define the patient’s total problem. It includes defining the need for expanded examination, testing,

possible affected management options, etc. The review may be about the system(s) directly related to

the problem(s) identified in the HPI and/or additional body systems.

� The ROS may be supplied in any format including but not limited to a separate patient intake or

questioner form. It is commonly interspersed within the HPI.

� There is a fine line between the signs and symptoms that patient shares in the HPI and those

obtained via the ROS. The ROS is a distinct review of the system. For example.: If the

documentation reads: “Patient states that her hip has been painful” credit is not given to both

the HPI “location” and to the (MS) review of system. If, on the other hand, the documentation

reads: “Patient states that her hip has been painful. She denies any other MS complaint,” there

is a distinct component of both the HPI and also a separate MS review of system.

� ROS elements typically reference signs and symptoms, of which both positive and negative

comments are considered. Auditors commonly watch for indications of a question that has been

asked by the physician and answered by the patient (for example, “pt denies fever,” “upon

further questioning the…”)



13

ROS *New Out Patient, and Consultations


� ROS should be medically necessary. It may be considered

necessary to obtain a complete ROS when a patient

presents as an initial new patient. It may not be

considered necessary to repeat a complete review on

every follow-up.

Please note the following are common examples only and do not

constitute a complete list of all possible signs or symptoms.

� CONSTITUTIONAL: Pt answers about general

constitutional signs or symptoms: Examples - fatigue,

general appearance, exercise tolerance, fever, weakness,

impaired ability to carry out functions of daily living, etc

� RESPIRATORY: Pt answers about signs or symptoms of the

respiratory system: Examples - cough, phlegm, wheeze,

SOB, rapid or difficult breathing, chest pain on deep inhalation, etc

� INTEGUMENTARY: Pt answers about signs or symptoms of the skin or breast: Examples - skin

reactions to hot or cold, itching, rash, changes in scars, moles, sores, lesions, nail color or

texture, changes in the color of the skin, bruising, breast pain, tenderness, swelling, lumps,

nipple discharge or changes, etc.

� PSYCHIATRIC: Pt answers about signs or symptoms of the psychiatric condition: Examples -

depression, stress, excessive worrying, suicidal thoughts, persistent sadness, anxiety, lost

pleasure from usual activities, energy loss, physical problems not responding to treatment,

restlessness, irritability, excessive mood swings, etc.

� EYES: Pt answers about signs or symptoms of the eye: Examples - use of glasses, discharge,

itching, tearing or pain, spots or floaters, blurred or double vision, twitching, light sensitivity,

visual disturbances, swelling around eyes or lids, etc

Level 4+ = 10 ROS

Level 3 = 2 ROS

Level 2 = 1 ROS

Level 5 = 10 ROS

Level 4 = 2 ROS

Level 3 = 1 ROS



14

� GASTROINTESTINAL: Pt answers about signs or symptoms of the GI system: Examples – heart

burn, indigestion or pain with eating, burning sensation in the esophagus, frequent nausea

and/or vomiting, changes in bowel habits or stool characteristics, abdominal swelling, diarrhea

or constipation, use of digestive aids or laxatives, etc.

� NEUROLOGICAL: Pt answers about signs or symptoms of the neurologic system: Examples -

numbness, tingling, dizziness, syncope or unconsciousness, seizures, convulsions, attention

difficulties, memory gaps, hallucinations, disorientation, speech or language dysfunction, tremor

or paralysis, inability to concentrate, sensory disturbances, motor disturbances including gait,

balance, coordination, etc.

� ALLERGIC/IMMUNOLOGIC: Pt answers about signs or symptoms of the allergic/immunologic

system: Examples - allergies to medicine, foods, environmental or other substances, frequent

sneezing, hives and/or itching, chronic clear PND, conjunctivitis, chronic infections, etc.

� ENT: Pt answers about signs or symptoms of the ears, nose of throat: Examples - Ears: sensitivity

to noise, ear pain, vertigo, ringing in the ears, “fullness” in the ears, ear wax abnormalities, etc.

Nose: nosebleeds, post nasal drip, nasal drainage, impaired ability to smell, sinus pain, snoring,

difficulty breathing, sinus infections, etc. Throat/Mouth: sore throats, mouth lesions, teeth

sensitivity, bleeding gums, hoarseness, change in voice, difficulties swallowing, changed ability

to taste, etc.

� GENITOURINARY: Pt answers about signs or symptoms of the GU system: Examples - painful

urination, urine color, urinary patterns, hesitance, flank pain, decreased or increased output,

dribbling, incontinence, frequency at night, genital sores, erectile dysfunction, irregular menses,

toilet training or bed-wetting, etc.



15

� ENDOCRINE: Pt answers about signs or symptoms of the endocrine system: Examples - BS

readings at home, changes in height and/or weight, increased appetite or thirst, intolerance to

heat or cold, etc.

� CARDIOVASCULAR: Pt answers about signs or symptoms of the cardiovascular system:

Examples – heart rate, chest pain, tightness, numbness, palpitations, heart murmurs, irregular

pulse, color changes in fingers or toes, edema, leg pain when walking, etc.

� MUSCULOSKELETAL: Pt answers about signs or symptoms of the MS system: Examples - cramps,

twitching or pain, difficult walking, running or participation in sports, joint swelling, redness or

pain, joint deformities, stiffness, noise with joint movement, etc.

� HEMATOLOGIC/LYMPHATIC: Pt answers about signs or symptoms of the hemat/lymph

systems: Examples - easy bruising, fevers which can come and go, swollen glands, night sweats,

itching without rash, excessive bleeding, unusual bleeding, etc.

� “REST NEGATIVE”: For a complete systems review, most payers do not require individual

documentation of each negative system reviewed. If there is distinct documentation of at least

one or more ROS elements and the physician indicates that “all others” or “remaining” systems

are “negative,” credit should be given for all systems. For many auditors, documentation of the

term "non-contributory" is equivalent to the term negative; however, physicians should be

advised that this is interpretive. The following notation alone (without mention of at least one

specific ROS element) is not creditable for a full system review: ROS: negative.



16

PFS *New Out Patient, and Consultations


PAST, FAMILY & SOCIAL HISTORY

� Past history: The patient's past experiences with illnesses,

operations, injuries and treatments, and medications; If a patient

presents for follow up on a chronic condition both HPI and Past

History would be considered. Positive findings of past diagnoses

and current medication discovered on ROS would be considered.

� Family history: A review of medical events in the patient's family,

including age at death, diseases which may be hereditary or place

the patient at risk.

� Social history: An age-appropriate review of past and current activities, for example occupation,

smoking, alcohol use (EtOH), sexual activity, marital status, etc.

A visual reference on the elements of history, and how they tie into a level of code can be very helpful

when describing the history component to physicians.

Level 4+ = 3 PFS

Level 3 = 1 PFS

Level 5 = 2 PFS

Level 4 = 1 PFS



17

History Coding

Note: All three area of history must line up with a level of service, or default to the lowest of the three.

HPI: 1.Location

2. Quality

3. Severity

4. Timing

5. Context

6. Modifying Factors

7. Duration

8. Associated S&S

ROS: 1. Constitutional

2. Eyes

3. ENMT

4. Cardio

5. Respiratory

6. GI

7. GU

8. MS

9. Skin

10. Neuro

11. Psych

12. Endo

13. Hemat/Lymp

14. Allergic/Immuno

PFSH: 1. Past

2. Family

3. Social

Type

New or

Consult

Patient

LEVEL

Est

Patient

LEVEL

Brief:

� 1

N/A

N/A Problem

Focused 1 2

Brief:

� 1

Problem Pertinent:

� 1

N/A

Expanded

Problem

Focused

2 3

Extended:

� 4 or

1997:

status of 3 chronic

Extended:

� 2 Pertinent:

� 1 Detailed 3 4

Extended:

� 4 or

1997:

status of 3 chronic

Complete:

� 10 Complete:

� 3 or

� 2+ (Est.)

Compre-

hensive 4 or 5 5

*Please note: Rules discussed apply to New and Established Outpatients and Consult Visits.



18

Exam

Take copies of the ’97 DG

examination and ask the physician

to highlight the elements he or she

would perform for those 5 most

common complaints. .

CHAPTER 4: EXAM, THE NEXT 21-30 MINUTES OF COACHING TIME

Most payers will allow the 1995 or 1997 Documentation Guidelines (DGs) to be used in code selection

and a physician should be familiar with both. Strictly from a coding perspective, the examination

component is the least subjective aspect of the documentation requirements with only two readily

identifiable grey areas associated with the ’95 DGs. These two subjective areas are:

� The difference between an Expanded Problem Focused exam and a Detailed exam

� The ‘95 DGs distinguish between the two levels only in that they both require at least 2 body areas and/or

systems and that one is a “limited exam” and the other is “extended”.

� The definition of a Comprehensive single system exam

� The ‘95 DGs distinguish only that the single system exam is “complete”.

To side step the subjectivity, many practices choose to document

according to the ‘97 DGs to ensure that coding is more easily defensible.

Conversely, many insurers audit using the ‘95 DGs to ensure that audit

findings are more easily defensible. This is because these two areas of

the ‘95 documentation guidelines are subjective enough to often be

interpretively more favorable, and only in some cases will the ‘97 DGs

produce an allowable higher code.

A coach first must evaluate the nature of the specialty and the philosophy of the practice in order to

determine which set of DGs upon which to concentrate training. A coach should always focus training on

the medical necessity of the exam. Never base training on getting to a higher code because of “just one

more bullet”. Instead, ask a physician, “What would make you want to perform a more detailed exam for

one patient versus another?” Also ask, “Would the majority of your peers agree with you that this was

necessary?”

Prior to coaching, know the top five most commonly seen patient complaints. These are typically

obtained by running or asking for billing reports, but because many specialists see the same types of

complaints over and over again it is sometimes only necessary to ask the physician or the office

manager. This is important so that you can be prepared during the coaching session to refer to clinical

examples that help guide a physician in visualizing the difference between levels of service for these

complaints.



19

THE 1995 DOCUMENTATION GUIDELINES

A visual reference on the elements of 1995 exam, and how they tie into a level of code can be very

helpful when describing the exam component to physicians.

Body Areas:

� Head/Face

� Neck

� back

� abdomen

� genitalia

� chest/axillae/breast Systems:

� Constitutional

� Eyes

� Ears, nose, mouth and throat

� Cardiovascular � Respiratory

� Gastrointestinal

� Genitourinary

� Musculoskeletal

� Skin � Neurologic

� Psychiatric

� Hematologic, lymphatic immunologic

Number of

Areas/Systems

Examined

Type

New or Consult Patient LEVEL Est. Patient LEVEL

� 1 PF 1 2

� 2 Limited EPF 2 3

� 2 Extended Detailed 3 4

� 8 (Systems only) Comprehensive 4 or 5 5

THE 1997 DOCUMENTATION GUIDELINES

Use the specialty specific pages of the 1997 Documentation Guidelines for Evaluation and Management

Services (p. 14-45) as a visual example when coaching on these rules. It can be especially helpful to ask

the physician to highlight the elements on the 97 DGs that he or she would perform comparative to the

physician’s five most common patient complaints.



20

CHAPTER 5: MEDICAL DECISION MAKING, THE NEXT 31-40 MINUTES OF COACHING TIME

The art of medical practice comparative to the subjective nature of the Medical Decision Making (MDM)

component makes this aspect of code selection among the most frustrating for many physicians. This

combined with the different and varied audit tools used by payers can be difficult for some. The nature

of the presenting problem and the medical necessity of the encounter is a physician’s best guide with

regard to this component. Clinical examples are an important part of training. The most important

aspect of coaching is to be prepared to discuss each of the sections. Visual references are key, with the

physicians’ questions driving the discussion.

THE NUMBER OF DIAGNOSES AND MANAGEMENT OPTIONS

The Number of Diagnoses and Management Options is based on the relative level of difficulty in making

a diagnosis and by the status of the problem (controlled versus worsening.). Usual indicators include the

following:

� Problems that are new to the patient or that the physician is seeing in this patient for the first time

� Seeking additional work-up such as a consultant’s opinions

� Ordering additional work-up such as diagnostic tests to confirm or to rule out the suspected

diagnoses and/or differential diagnoses that the with which the patient leaves the visit

� Established problems for which the patient shows no improvement or that have not responded as

expected

It is important to note that audit tools and coding references used by payers can be varied and different.

For example, one audit tool may place a larger emphasis on the number of necessary differential

diagnoses and list specific treatments and therapeutic options no mentioned in another. The majority of

industry accepted audit tools are reported to produce consistent findings greater than 95 percent of the

time. However, as a precaution a coach should always contact the local Medicare Carrier to request any

and all available coding guides, specifically relative to E/M audit tools before conducting training with a

billing physician.



21

A visual reference and how it ties into a level of code can be very helpful when describing this aspect of

code selection. The chart below is one version:

NUMBER OF DX and MANAGEMENT OPTIONS

� Minor =1 ea. (max 2)

� Est. stable/improved = 1 ea.

� Est. worsening =2 ea.

� New problem, w/o workup =3 ea. (max 1)

� New problem, w workup=4 ea.

Example

Type

New or

Established

Outpatient and

Consult Patient

LEVEL

Minimal:

• 1 point as totaled from above

Uncomplicated, non-infected insect bite

Straight-forward

1 & 2

Limited:

• 2 points as totaled from above

Controlled HTN and tachycardia

Low

3

Moderate:


New patient with migraine headaches

Moderate

4

Extensive: • 4 + points as totaled from above

Patient seen today for f/u on OA knees and 1 year THR check. C/O knee pain. MRI ordered for possible meniscus tear. R/O symptom of osteoarthritis and sprain

High

5

AMOUNT AND/OR COMPLEXITY OF DATA TO BE REVIEWED

The Amount and Complexity of Data to Be Reviewed is measured by the need to order and review tests

and the need to gather information and data. Planning, scheduling, and performing clinical Labs and

tests from the CPT® Medicine and Radiology sections are indicators. The need to request old records or

to obtain additional history from someone other than the patient (for example. family member, care

giver, teacher, etc.) is credited in this section. Also documented are discussions with the performing

physician about unusual or unexpected patient results.



22

If a physician needs to make an independent visualization and interpretation (for example, MRI film,

gram stain, etc.) and he or she is not billing separately for this service, it too is credited to this

component of code selection.

A visual reference and how it ties into a level of code can be very helpful when describing this aspect of

code selection. The chart below is one version:

AMOUNT/COMPLEXITY OF DATA

One Point Each: � Clinical Labs test ordered or reviewed � CPT® Medicine Section Test- ordered or reviewed � CPT® Radiology Section Test- ordered or reviewed � Discuss patient results with performing or consulting physician � Decision to obtain old records or additional history from other

than patient Two Points Each: � Review and summarize data from old records or additional

history gathered from other than patient � Independent (2nd) interpretation (from another physician) of an

image, tracing, specimen (not just review of the report)

Type

New or

Established

Outpatient and

Consult Patient

LEVEL

Minimal:

• 1 point as totaled from above

Straight-forward

1 & 2

Limited:


Low

3

Moderate:


Moderate

4


High

5

RISK SIGNIFICANT COMPLICATIONS, MORBIDITY, AND/OR MORTALITY

Risk is measured based on the physician’s determination of the patient’s probability of becoming ill or

diseased, having complications, or dying between this encounter and the next planned encounter. The

nature of the presenting problem and the urgency of the visit, comorbid conditions, as well as the need

for diagnostic tests or surgery, are indicators of risk. A visual reference and how it ties into a level of



23

code can be very helpful when describing this aspect of code selection. Refer to the CMS Table of Risk

on page 14 of the ‘95 DGs

Overall Risk Any example listed from a row below for any of the three columns will equal a level of risk.

1. Presenting Problem(s)

2. Diagnostic Procedure(s) Ordered

3. Management Options Selected Type

New or Established

Outpatient and

Consult Patient

LEVEL

• One self-limited or minor problem, eg cold, insect bite, tinea corporis

• Laboratory tests requiring venipuncture • Chest x-rays • EKG/EEG • Urinalysis • Ultrasound, eg, echocardiography • KOH prep

• Rest • Gargles • Elastic bandages • Superficial dressings

Straight-forward 1 & 2

• Two or more self-limited or minor problems • One stable chronic illness, eg well controlled hypertension or non-insulin dependent diabetes, cataract, BPH • Acute uncomplicated illness or injury, eg, cystitis, allergic rhinitis, simple sprain

• Physiologic tests not under stress, eg, pulmonary function tests • Non-cardiovascular imaging studies with contrast, eg, barium enema • Superficial needle biopsies • Clinical laboratory tests requiring arterial puncture • Skin biopsies

• Over-the-counter drugs • Minor surgery with no identified risk factors • Physical therapy • Occupational therapy • IV fluids without additives

Low 3

• One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment • Two or more stable chronic illnesses • Undiagnosed new problem with uncertain prognosis, eg, lump in breast • Acute illness with systemic symptoms, eg, pyclonephritis, pneumonitis, colitis • Acute complicated injury, eg head injury with brief loss of consciousness

• Physiologic tests under stress, eg, cardiac stress test, fetal contraction stress test • Diagnostic endoscopies with no identified risk factors • Deep needle or incisional biopsy • Cardiovascular imaging studies with contrast and no identified risk factors, eg arteriogram, cardiac catheterization • Obtain fluid from body cavity, eg lumbar puncture, thoracentesis, culdocentesis

• Minor surgery with identified risk factors • Elective major surgery (open, percutaneous or endoscopic) with no identified risk factors • Prescription drug management • Therapeutic nuclear medicine • IV fluids with additives • Closed treatment of fracture or dislocation without manipulation

Moderate 4

• One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment • Acute or chronic illnesses or injuries that pose a threat to life or bodily function, eg multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure • An abrupt change in neurologic status, eg seizure, TIA, weakness, or sensory loss

• Cardiovascular imaging studies with contrast with identified risk factors • Cardiac electrophysiological tests • Diagnostic Endoscopies with identified risk factors • Discography

• Elective major surgery (open, percutaneous or endoscopic) with identified risk factors • Emergency major surgery (open, percutaneous or endoscopic) • Parenteral controlled substances • Drug therapy requiring intensive monitoring for toxicity • Decision not to resuscitate or to de-escalate care because of poor prognosis

High 5



24

CHAPTER 6: PUTTING IT TOGETHER, THE LAST 41-50 MINUTES OF COACHING TIME

To help a physician learn the process of selecting a code, it is important to emphasize that the code is

selected based on the nature of the presenting problem and the overall needs of the patient. Based on

this, the correct code is known to the physician prior to documentation. The second step is to document

the encounter and the last step is to ensure that documentation supports the code the physician feels is

most appropriate based on the patient’s needs. The chart below is not all-inclusive and is not an

endorsed coding tool. It should be used for discussion purposed only. However, a chart, like the one

below can be helpful to facilitate discussion during the coaching process (relevant to new outpatient and

consult service codes.).



25

Level 3

Because the vast majority of services are

a level 3, coaching a physician on level 3

requirements first is a good place to

start. A coach can more easily build off

of the level 3 to train on the other

levels.

ORGANIZING PHYSICIAN COMMUNICATION

Some physicians find it easier to learn coding when the coach cuts to the chase. Common questions by

physicians may include the following:

� Can you just tell me what I need for a Level 3?

� What makes it a Level 4?

� When do I know it is a Level 5?

� This patient has an ACL tear---what E/M level is that?

For this reason, many coaches start training from Chapter 6 earlier in the coaching session. Depending

on the personality of the physician, getting right to it is a much better approach that often results in

better questions during the duration of the training. You may find it helpful to perform this aspect of the

training during the time frame discussed in Chapter 3 for the “next 11-21 minutes”, rather than to wait

until the end.

VISUAL REFERENCES AND PRACTICAL EXAMPLES

Take examples of correctly documented levels of service to illustrate what makes them correct. Level 3.

Example Est. Outpatient:

� Incorrect: A patient on TOPROL-XL 50 mg qd

comes in today for follow up on hypertension

and tachycardia. BP 130/82, 80 BPM, S1 & S2

normal. Continue medication. Return x 3

months. (31 words)

� Physician knows that documenting 1 HPI, 1 ROS, 2

Body Areas/Systems will support this medically

necessary level 3 visit

� Correct: Patient on TOPROL-XL 50 mg qd in for follow up with controlled

hypertension and tachycardia. Confirms palpitations have decreased. BP 130/82, 80

BPM, S1 & S2 normal. Continue medication. Return in 3 months. (33 words---Hint: Just 2

more words!)

The following page contains a quick reference code sheet that allows a coach to provide an easy visual

reference on all three key components of documenting code selection.


© Copyright AAPC 2007 26

Quick-Reference Code Sheet

New OT and Consult: Default to the lowest LEVEL identified by the Hx, Ex, & MDM.

Est OT: Use the LEVEL identified by the best 2 of 3 on the Hx, Ex, & MDM (99211 not a Dr Code)

Hx History ( 3 of 3)

HPI: location

quality

severity

timing

context

mod factor

duration

asso. S&S

ROS: constit

eyes

ENMT

cardio

respir

GI

GU

MS

skin

neuro

psych

endo

hemat/lymph

allerg/immuno

PFSH: past

family

social

Type

New

Out Pt

or

Consult

Pt

LEVEL

Est Pt

LEVEL

0 0 PF 1 2

1 1 0 EPF 2 3

2 1 D 3 4

4 or 1997:3 chronic 10 3 or2+ (Est.) C 4 & 5 5

MDM Medical Decision Making ( 2 of 3)

Ex 95 DG ExamMM

Body Areas: � head/face � neck � back � abdomen � genitalia � chest/axillae/breast � each extremity

Systems: � constitutional � eyes � ENMT � cardiovascular � respiratory � gastrointestinal � genitourinary

� musculoskeletal � skin � neurologic � psychiatric � hematologic, lymphatic immunologic

Number of Body Areas/Systems Examined

Type

New Out Pt or

Consult Patient

LEVEL

Est. Out

Patient

LEVEL

1 PF 1 2

2 Limited EPF 2 3

2 Extended D 3 4

8 (Systems only) C 4 & 5 5

NUMBER OF DX and

MANAGEMENT OPTIONS

� Minor =1 ea. (max 2 points)

� Est. stable/improved = 1 ea.

� Est. worsening =2 ea.

� New problem(S), w/o workup =3

� New problem, w workup=4 ea.

AMOUNT/COMPLEXITY OF DATA: One Point Each:

� Clinical Labs test ordered or reviewed

� CPT® Medicine Section Test- ordered/reviewed

� CPT® Radiology Section Test- ordered/reviewed

� Discuss patient results w performing / consulting Dr

� Decision obtain old records or additional hx other than pt

Two Points Each:

� Review/summarize data old records/add hx other than pt

� Independent interpretation of an image, tracing, specimen

OVERALL RISK:

The quick reference guide below shows excerpts from the CMS Table of Risk.

*Remember: Risk is based on the disease process anticipated between the present

encounter and the next one.

Type

New or

Est. Out

Pt or

Consult

LEVEL

1

1

Clinical testing/management examples: Venipuncture, X-ray, EKG, U/A, U/S, rest, superficial

dressings, elastic bandage, gargles, etc.

Presenting Problem Example: 1 minor / self limited

SF 1 & 2

2

2

Clinical testing/management examples: Biopsy, pulmonary function, barium enema, minor

surgery without risk factors, OTC drugs, PT, OT, IV without additives, etc.

Presenting Problem Example: 1 –2 minor, 1 stable chronic / 1 acute uncomplicated

L 3

3

3

Clinical testing/management examples: Stress tests, endoscopies, cardiovascular imaging,

centesis, closed Tx of Fx, Rx drug management, minor surgery with risk factors, major elective

surgery without risk factors, therapeutic radiation tx, etc.

Presenting Problem Example: 1 chronic exacerbated / 2 stable chronic / New Undiagnosed

with uncertain outcome / Acute with systemic symptoms / acute complicated injury

M 4

4

4

Clinical testing/management examples: Cardiovascular imaging with risk factors,

endoscopies with risk factors, discography, medication toxicity management, major surgery

with risk factors, emergency surgery with risk factors, etc.

Presenting Problem Example: 1+ chronic severely exacerbated / Illness or injury that poses a

threat to life / Abrupt change in neurological status

H 5

Reprinted with Permission: Quick Reference Code Sheet © Copyright 2006 Stephanie L. Jones, CPC-E/M



27

CHAPTER 7: FINAL POINTS

Be aware pf different learning styles and customize your approach to best serve the physician you are coaching.

1. Learning Types

Be prepared to adjust for different learning styles:

•Audio:

–Learn best from listening to your instruction.

–Give lots of verbal details and ask the physician to add to them

–Review forms together aloud.

•Visual learners:

–Skim the reference tool prior to starting so that the physician has a general understanding

–Use visual reference forms continuously during coaching

–Use highlighter pens in different colors to make different points

–Eye contact is important

•Kinesthetic:

–Compare one of the physician's notes with a quick reference form

•As you review it together: Ask the physician to circle salient points on note and highlight them on the reference

form

2. It is okay to say, “I don’t know”. No matter what you prepare for a question will almost always come up that

you have not considered before.

To some people, being a teacher -- or a leader -- means appearing as though you have all the answers.

Any sign of vulnerability or ignorance is seen as a sign of weakness. Those people can make the worst

teachers. Sometimes the best answer a teacher can give is, “I don't know." Instead of losing credibility,

she gains trust, and that trust is the basis of a productive relationship.

- Parker Palmer, longtime instructor and author of “The Courage to Teach: Exploring the Inner Landscape of a

Teacher's Life” (Jossey-Bass, 1997).

3. Follow a Strategy for Effective Communication

� Sympathize with the physician’s mindset. Coding and billing affects a physician’s livelihood.

� Be prepared to overcome objections.



28

� Know how to best organize coaching based on the personality type of the physician.

� Be aware of the time allotted to make your salient points but flexible with questions.

� Be willing to rearrange delivery of the information in order to answer questions.

� Address the physician’s concerns openly, directly and with respect.

� A physician may be frustrated; a good coach recognizes that these emotions are not personal..

4. Ensure Awareness of Medical Necessity as the Driver of Code Selection

� Empower the physician with the understanding that the nature of the presenting problem and the

severity of the patient’s illnesses are the most important factors of code selection.

� The physician’s medical training makes him or her an expert in determining medical necessity and in

recognizing the most proper code. Clinical examples specific to a specialty correlated to proper code

selection are valuable to demonstrate this concept to physicians especially when they are

customized to the types of patients/conditions that the physician most often sees

� Documentation is not the key to code selection—medical necessity is. The key lies with how “sick” a

patient is, and what service was needed and rendered.

� If medical necessity is the key, documentation can be thought of as the lock. Documentation is the

most powerful (and sometimes only) evidence of medical necessity. Nothing can be supported

without it.

5. The Three Key Components of History, Exam, and Medical Decision Making and Selecting a Level of Service

� Proper documentation is not always clinically intuitive, training focuses on what aspects of

documentation are important in order to support the needed and rendered service.

� It is not always necessary in an initial one-hour training to coach a physician on every technical term

(for example, a “detailed” exam).. Many physicians find it easier to instead refer to the outcome

documentation (for example, a “Level 4 established patient exam”). Anything that a coach can do to

prevent a physician from becoming overwhelmed is valuable. Bypassing details like some technical

terms can make recall on salient points easier.

� Quick reference forms and visual examples are highly valuable and should be used specific to the

physician’s specialty and practice for the greatest impact.



29

Notes:

1

Presenter Name, Credentials

How to Effectively Teach

Evaluation & Management Coding in Under 1 Hour

2

Agenda

– Set the Stage for Coaching:

• Physician Concerns, Overcoming Objections

– 0-10 Minutes: Medical Necessity: Determine Clinical Examples

– 11-20 Minutes : History Taking: HPI, ROS, PFS

– 21-30 Minutes: Exam, ‘95 Subjectivity and Medical Necessity

– 31-40: MDM, No of Dx, Data, Risk

– 41-50: Put it together:

• Learning Types,

• Physician Note Example, Physician Form Example,

• Teaching Tips

– Conclusion 9:00-9:15: Workshop Introductions

10:15-10:30: Rest Room Break

Noon: Dismissal

→

3

Set the Stage for Coaching

• Discuss physician concerns

– Don’t volunteer sympathy for concerns you think the physician may have–he or she may not have thought of them

• Be understanding, polite and respectful – No matter how much you know about coding, compliance, nursing

or the healthcare marketplace ---You are not the doctor

• Overcome objections– Be ready to counter complaints

• Be prepared– Whenever possible, use examples from the physician’s own work

→

2

4

Concerns

Payment Ambiguity Fear

Unease about being paid properly

for the value of the service

Concerns regarding subjective, hidden or

unknown aspects of proper coding

Consequences for defensive under-coding

or emotional over-coding

→

5

Payments are important to physicians.

��The level of service coded is based on how The level of service coded is based on how

sick a patient is and meeting documentation sick a patient is and meeting documentation requirementsrequirements

• Payment and coding must be unrelated

– They just need to be addressed by other

means, such as contract re-negotiations

Concerns

→

6

Ambiguity frustrates physicians.

��The level of service coded is based on how The level of service coded is based on how sick a patient is and meeting documentation sick a patient is and meeting documentation requirementsrequirements

• It can be subjective

– “Within the next hour you’ll have the tools you need to enjoy successful outcomes anyway”

Concerns

→

3

7

Concerns

Fear slows down physicians.

��The level of service coded is based on how The level of service coded is based on how sick a patient is and meeting documentation sick a patient is and meeting documentation requirementsrequirements

• There is no one better qualified to determine medical necessity than a physician

• During the next hour, you’ll learn how to use your clinical knowledge to quickly ascertain the correct code and what you need to document in order to support the services you render

→

8

Overcoming Objections

Reverse the Objection

AddInfo

Be Positive

Ask Questions

→

9


• I don’t have time for this!

– Add information

• With cuts in fees from Medicare and private insurers, many doctors must see more patients to maintain their incomes

– You have less time

• This training takes less than an hour and may ultimately save you time (and money)

→

4

10


• No one is going to audit me!

– Ask questions! • Can you afford to be wrong?

• How can you be sure you are right?

• Would you like to never under-code?

• Would you like to not have to ever worry about it?

The Way it WAS The Way it IS

$�� claims in �� quantity =

cost prohibited review

��Outsourcing and technology =

�� Cost of review

Hospital and Surgery Claims Auditsproduce high ROI

Pressure to collect and correct

$20B+ in abusive E/M claims

E/M Claims are cost prohibitive to

Audit

E/M Claims audits now produce

ROI

→

11

• Most physicians will readily understand:

– Levels 3-5* are reserved for “sick” or injured patients

– Lower levels are for patients who present with

minor and/or well controlled condition/s

*This presentation refers to levels of service for outpatient and consult visits.

0-10: Medical Necessity

→

12

Determine Examples:

*This chart should only be used for the purpose of guiding discussion: it references new outpatient and consult visits →

5

13

Clinical examples: • AMA vignettes

• Opinions by peers

• The CMS Table of Risk

• The physician’s work

– “Describe to me the most common patient complaint(s) you see…”

• Tip: Many times this will represent a level 3

– What would make you more concerned? – What makes you decide how soon a patient should

return for a follow up visit or see a specialist?– What would make you the most concerned?

• What would your peers say?

Determine Examples:

→

14

Determine Examples:

– Example Level 1: Patient with simple abrasion, dressed. F/U PRN

– Example Level 2: Patient returns for 4 year follow up visit hip replacement, no complaints

– Example Level 3: 14 year old with first degree ankle sprain, Rx rest and OTC meds

– Example Level 4: Patient with painful total hip 1 year post replacement, worsening x 6 months

– Example Level 5: Femur and Hip Fracture in 80 year old diabetic brought in from the parking lot after hit and run while walking in

→

Ask questions:

-- You’re the medical expert: What other examples of injuries or illness fall in this level?

-- Clinically, what makes this problem a level 4 instead of a level 3?

Give examples the physician will personally relate to and can expand on:

Examples are made for the purpose of discussion only on new patients and may not always support the level cited above *

15

11-20: History Taking

• Now that the physician is comfortable identifying a level of service, he or she needs to learn what elements of service are needed in the documentation in order to support it

• The history component has subjective aspects in both sets of guidelines

– The DGs are just guidelines. • There are multiple audit forms used in the industry that

conform to the DGs but that can also produce different outcomes

– Marshfield Clinic model– TrailBlazers model

• A coach must assist a physician in developing his or her personal objectivity so that a logical and solid argument can be made for the documentation and the correct use of a code

– This is accomplished by pointing out areas of subjectivity and special circumstance

→

6

16

Special Circumstance

• Patient is unable to give a history• (ROS) and (PFS) History taken from an earlier encounter

– May not be medically necessary

• A comprehensive service may be performed and documented but…– A comprehensive service is not always medically necessary or billable

• Unless Preventive, a Chief Complaint (CC) must be identifiable – This is the first step in establishing medical necessity

• Subjective aspects…– Reviewer A may argue with Reviewer B that an element of (HPI) is a

“quality” versus an “associated sign or symptom,” or other (HPI) element – Reviewer B may state that the documented “NKDA” constitutes an

element of ROS or conversely an element of Past history.

– Any free-form text is to some degree interpretive. This holds true with physicians’ notes. Since coding relies on counting subjective elements, the correct interpretation requires consistency, citable references, a logical argument and - ultimately - medical necessity.

→

17

HPI

• Be prepared to discuss examples of HPI and to answer questions but avoid excessive instruction –much of it is like teaching an expert pianist basic scales

• Location: For example “chest” pain, sore “knee,” etc. Conversely, examples such as “COPD,” “Diabetes,” and “Hypertension” are not locations - these are “chronic conditions” Note: To credit chronic conditions use the ‘97 DG or one of the other elements of ‘95 HPI (such as Severity: i.e., CC = Return BP check, patient states it has been running 120/80 at Walgreen’s self service cuff. )

18

HPI

• Severity: A statement of degree or measurement regarding how bad it is… that it is improved, it is extreme pain, “Blood Sugar is 200,” feeling “better,” pain is bad enough “that the pt can’t sleep” etc.

• Timing: A measurement of when or at what frequency; i.e. “intermittent,” “constant,” in the “morning,” lasted “5 minutes,” “occasional,” “on and off,” etc.

• Associated signs and symptoms: Any associated or secondary complaints.

• Modifying factors: Anything that makes the problem better or worse, a factor that changes, improves, or alters the problem. For example, improved “with Tylenol,” worse “when standing,” better “when resting,” “calms down when mother feeds her.”

– Subjectivity Alert: Medication may be a modifying factor when it changes, improves, or alters the problem. Otherwise, it is most often credited to PAST Hx. Some auditors will credit medications that were used in an unsuccessful attempt to modify the condition as a “modifying factor.”

→

7

19

HPI

• Context: What the patient was doing, the environmental factors/circumstances surrounding the complaint, for example, “while sleeping,” “MVA,” “slipped and fell,” after “eating peanuts,” “while dusting,” “when arguing with his wife,” etc.

• Duration: A measurement of time regarding when the complaint first occurred. For example, began “in childhood,” “since 1995,” first noticed “two weeks” ago, “symptoms x 3d,” etc.

• Quality: Any characteristic about the problem and/or expresses an attribute. For example: how it looks or feels; for example. “green” phlegm, “popping” knee, “dull” ache, “sharp” pain, “metallic” taste, etc.

→

20

ROS

• The ROS may be supplied in any format: separate patient intake or questioner form within the HPI

• ROS elements typically reference signs and symptoms, of which both positive and negative responses are considered. Auditors commonly watch for indications “pt denies fever,” “upon further questioning the…”)

• ROS should be medically necessary. – It may be considered necessary to

obtain a complete ROS when a patient presents as an initial new patient.

– It may not be considered necessary to repeat a complete review on every follow-up.

→

21

ROS

• There is a fine line between the signs and symptoms that a patient shares in the HPI and those obtained via the ROS. – If the documentation reads:

• “Patient states that her hip has been painful since her fall last week.” Documentation is HPI.

– If, on the other hand, the documentation reads: • “Patient states that her hip has been painful since

her fall last week. – She denies any other musculoskeletal

complaint.” There is a distinct documentation that shows the HPI and also a separate musculoskeletal review of system occurred.

→

8

22

PFS

• Past history: The patient's past experiences with illnesses, operations, injuries and treatments, and medications; If a patient presents for follow up on a chronic condition both HPI and Past History would be considered. Positive findings of past diagnoses and current medication discovered on ROS would be considered.

• Family history: A review of medical events in the patient's family, including age at death, diseases which may be hereditary or place the patient at risk.

• Social history: An age-appropriate review of past and current activities, for example occupation, smoking, alcohol use (EtOH), sexual activity, marital status, etc.

→

23

Hx

HPI:

1.Location

2. Quality

3. Severity

4. Timing

5. Context


7. Duration

8. Associated S&S

ROS:

1. Constitutional

2. Eyes

3. ENMT

4. Cardio

5. Respiratory

6. GI

7. GU

8. MS

9. Skin

10. Neuro

11. Psych

12. Endo

13. Hemat/Lymp

14. Allergic/Immuno

PFSH:

1. Past

2. Family

3. Social Type

New or

Consult

Patient

LEVEL

Est

Patient

LEVEL

Brief:

1

N/A N/A Problem

Focused 1 2

Brief:

1

Problem Pertinent:

�1

N/A Expanded

Problem

Focused2 3

4

or

1997:

status of 3 chronic

Extended:

�2

Pertinent:

�1Detailed 3 4

Extended:

�4

or

1997:

status of 3 chronic

Complete:

�10

Complete:

�3 or

�2+ (Est.) Comp 4 or 5 5

24

Hx

HPI:

1.Location

2. Quality

3. Severity

4. Timing

5. Context


7. Duration

8. Associated S&S

ROS:

1. Constitutional

2. Eyes

3. ENMT

4. Cardio

5. Respiratory

6. GI

7. GU

8. MS

9. Skin

10. Neuro

11. Psych

12. Endo

13. Hemat/Lymp

14. Allergic/Immuno

PFSH:

1. Past

2. Family

3. Social Type

New or

Consult

Patient

LEVEL

Est

Patient

LEVEL

Brief:

1

N/A N/A Problem

Focused 1 2

Brief:

1

Problem Pertinent:

�1

N/A Expanded

Problem

Focused2 3

4

or

1997:

status of 3 chronic

Extended:

�2

Pertinent:

�1Detailed 3 4

Extended:

�4

or

1997:

status of 3 chronic

Complete:

�10

Complete:

�3 or

�2+ (Est.) Comp 4 or 5 5

CC: knee painPt states “I fell off a step stool about four hours ago and landed on my knee.

It has been tight, red and painful. It’s swollen”. Pt denies motor disturbances including balance, coordination. Pt takes Zoloft 25 mg QD.

9

25

21-30: Exam

• Best results come when you focus on only one of the DGs

– This avoids overwhelming the physician

• Know what documentation guidelines are best suited for your

physician

– Is there an internal policy mandating the use of one or the other?

– Which set will this physician benefit the most from?

• Standards (and individual style) of practice often result in repeating patterns of exam for the same kind of complaints

– Take copies of the ’97 DG examination and ask the physician to

highlight the elements he or she would perform for his or her five

most common complaints

• Even if you are teaching the ’95 DGs, this gives the physician a visual idea of what’s required in documentation for a given

level of service

→

26

Subjectivity

• The examination component is the least subjective aspect of the DGs

• There are only two readily identifiable grey areas:

– Expanded Problem Focused exam vs. a Detailed exam • Both require at least two body areas and/or systems with a

“limited” or an “extended exam”. – Comprehensive single system exam

• A single system exam is “complete”.

• Ask questions to help a physician develop objectivity

– Was a more extended exam medical necessary?

– Would peers agree that more than a limited exam was documented?

• Be prepared to give an opinion

– You may want to refer to the ‘97 DGs for comparative value→

27

Exam

• NEVER base training on getting to a higher code because of “just one more bullet”

��The level of service coded is based on how sick a The level of service coded is based on how sick a

patient is and meeting documentation requirements.patient is and meeting documentation requirements.• Ask:

– “What would make you want to perform a more detailed

exam for one patient versus another?”

– “Would the majority of your peers agree with you that this was necessary?”

10

28

95 DGs

→

Body Areas:

� Head/Face

� Neck

� Back� Abdomen

� Genitalia

� Chest/axillae/breast

Systems: � Constitutional

� Eyes


� Cardiovascular� Respiratory


� Genitourinary

� Musculoskeletal� Skin

� Neurologic

� Psychiatric


Number of Areas/Systems

Examined Type New or Consult Patient LEVEL Est. Patient LEVEL

� 1 PF 1 2

� 2 LimitedEPF 2 3

� 2 ExtendedDetailed 3 4


29

95 DGs

→

Body Areas:

� Head/Face

� Neck

� Back� Abdomen

� Genitalia

� Chest/axillae/breast

Systems:

� Constitutional� Eyes


� Cardiovascular� Respiratory


� Genitourinary

� Musculoskeletal� Skin� Neurologic

� Psychiatric


BP 120/80. The patient’s gait is

normal. Some tenderness. Thereis no knee effusion. The medial and

lateral collateral ligaments are

intact.

Number of Areas/Systems

Examined Type New or Consult Patient LEVEL Est. Patient LEVEL

� 1 PF 1 2

� 2 LimitedEPF 2 3

� 2 ExtendedDetailed 3 4


30

31-40: MDM

• Different audit forms vary dramatically in this component and may produce different codes– Before coaching, obtain the audit form used by the physician’s

local Medicare carrier

• Code selection is based on the relative level of difficulty in making a diagnosis and by the status of the problem (controlled versus worsening.)

• The amount of work involved in reviewing the necessary data and the immediate risk of the patient are very important aspects of documentation

11

31

No of Dx

- Minor =1 ea. (max 2)

- Est. stable/improved = 1 ea.

- Est. worsening =2 ea.

- New problem, w/o workup =3 ea. (max 1)

- New problem, w workup=4 ea.

Example Type

New or Established

Outpatient and Consult

Patient LEVEL

Minimal: • 1 point as totaled from above

Uncomplicated, non-infected insect bite


Limited:• 2 points as totaled from above

Controlled HTN andtachycardia

Low

3Moderate:• 3 points as totaled from above

New patient with migraineheadaches

Moderate

4Extensive: • 4 + points as totaled from above

Patient seen today for f/uon OA knees and 1 yearTHR check. C/O knee pain.MRI ordered for possiblemeniscus tear. R/Osymptom of osteoarthritisand sprain

High

5

32

DataOne Point Each:� Clinical Labs test ordered or reviewed� CPT® Medicine Section Test- ordered or reviewed

� CPT® Radiology Section Test- ordered or reviewed � Discuss patient results with performing or consulting

physician

� Decision to obtain old records or additional history from other than patient

Two Points Each:� Review and summarize data from old records or

additional history gathered from other than patient

� Independent (2nd) interpretation (from another physician) of an image, tracing, specimen (not just review of the report)

Type

New or Established

Outpatient and

Consult

Patient

LEVEL

Minimal: • 1 point as totaled from above


Limited:• 2 points as totaled from above

Low 3

Moderate:• 3 points as totaled from above

Moderate 4


High 5

33

RiskCMS TABLE OF RISK

Overall Risk between planned encounters

Any example listed from a row below for any of the three columns will equal a level of risk.

1. Presenting Problem(s) 2. Diagnostic Procedure(s) Ordered 3. Management Options Selected Type

New or Established

Outpatient and Consult

Patient LEVEL

• One self-limited or minor problem, eg cold, insect bite, tinea corporis

• Laboratory tests requiring venipuncture• Chest x-rays• EKG/EEG• Urinalysis

• Ultrasound, eg, echocardiography

• KOH prep

• Rest• Gargles• Elastic bandages• Superficial dressings


• Two or more self-limited or minor problems• One stable chronic illness, eg, well controlled hypertension or non-insulin dependent diabetes, cataract, BPH• Acute uncomplicated illness or injury, eg, cystitis, allergic rhinitis, simple sprain

• Physiologic tests not under stress, eg, pulmonary function tests• Non-cardiovascular imaging studies with contrast, eg, barium enema• Superficial needle biopsies• Clinical laboratory testsrequiring arterial puncture• Skin biopsies

• Over-the-counter drugs• Minor surgery with no identified risk factors• Physical therapy• Occupational therapy• IV fluids without additives

Low 3

• One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment• Two or more stable chronic illnesses• Undiagnosed new problem with uncertain prognosis, eg, lump in breast• Acute illness with systemic symptoms, eg, pyclonephritis, pneumonitis, colitis• Acute complicated injury, eg, head injury with brief loss of consciousness

• Physiologic tests under stress, eg, cardiac stress test, fetal contraction stress test• Diagnostic endoscopies with no identified risk factors• Deep needle or incisional biopsy• Cardiovascular imaging studies with contrast and no identified risk factors, eg arteriogram, cardiac catheterization• Obtain fluid from body cavity, eg, lumbar puncture, thoracentesis, culdocentesis

• Minor surgery with identified risk factors• Elective major surgery (open, percutaneous or endoscopic) with no identified risk factors• Prescription drug management• Therapeutic nuclear medicine• IV fluids with additives• Closed treatment of fracture or dislocation without manipulation

Moderate 4

• One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment• Acute or chronic illnesses or injuries that pose a threat to life or bodily function, eg multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure• An abrupt change inneurologic status, eg, seizure, TIA, weakness, or sensory loss

• Cardiovascular imaging studies with contrast with identified risk factors• Cardiac electrophysiological tests• Diagnostic Endoscopies with identified risk factors• Discography

• Elective major surgery (open, percutaneous or endoscopic) with identified risk factors• Emergency major surgery (open, percutaneous or endoscopic)• Parenteral controlled substances• Drug therapy requiring intensive monitoring for toxicity• Decision not to resuscitate or to de-escalate care because of poor prognosis

High 5

12

34

41-50: Put it together

• Answer questions even if they are “out of order” with emphasis on:– 1st Medical Necessity

• This helps bring clinical relevance

– 2nd Documentation Requirements

• Be prepared to have many questions fired at once:

– Can you just tell me what I need for a Level 3?– What makes it a Level 4?

– When do I know it is a Level 5?

– This patient has an ACL tear - what E/M level is that?• “It all depends on how ‘sick’ the patient is”

– Let’s review clinical examples so you know how to define that

– Then let’s review this quick reference form so you can easily see what documentation is necessary

→

35

Learning Types

Be prepared to adjust for different learning styles:• Audio:

– Learn best from listening to your instruction – Give lots of verbal details and ask the physician to add to them

– Review forms together aloud

• Visual learners:– Skim the reference tool prior to starting so that the physician has

a general understanding

– Use visual reference forms continuously during coaching– Use highlighter pens in different colors to make different points

– Eye contact is important

• Kinesthetic:– Compare one of the physician's notes with a quick reference

form

• As you review it together: Ask the physician to circle salient points on note and highlight them on the reference form

→

36

Note

13

37

Form

99213

38

Teaching Tip

• Be aware of the time allotted to make your salient points but be flexible with questions

– If you feel you are getting off course:

• “I’ll be happy to discuss that in detail with you. Let me first give you the general points you need so that we can make the best use of your time today.”

• Be willing to rearrange delivery of the information in order to answer questions

• Address the physician’s concerns openly, directly and with respect

• A physician may be frustrated; a good coach recognizes that these emotions are not meant personally

→

39

Teaching Tip

• It is okay to say, “I don’t know”

• No matter what you prepare for, a question will almost always come up that you have not considered before

– To some people, being a teacher -- or a leader -- means appearing as though you have all the answers. Any sign of vulnerability or ignorance is seen as a sign of weakness. Those people can make the worst teachers.

– Sometimes the best answer a teacher can give is, “I don't know." Instead of losing credibility, she gains trust, and that trust is the basis of a productive relationship.

– Parker Palmer, longtime instructor and author of “The Courage to Teach: Exploring the Inner Landscape of a Teacher's Life” (Jossey-Bass, 1997).

→

14

40

Conclusion

• Empower the physician with the understanding that the nature of the presenting problem and the severity of the patient’s illnesses are the most important factors of code selection

– The physician’s medical training makes him or her an expert

• Documentation must support the services rendered and the code selection

• Sympathize with the physician’s mindset: Coding and billing affects a physician’s livelihood

• Be prepared to overcome objections• Know how to best organize coaching based on the personality

type of the physician• Be aware of the time allotted to make your salient points but

flexible with questions • Be willing to rearrange delivery of the information in order to

answer questions• Address the physician’s concerns openly, directly and with

respect • A physician may be frustrated; recognize that it is not personal

41

Questions?

Written by: Stephanie Jones, CPC-EM, VP Member Services AAPC 800-626-2633 x 143 [email protected]


how to effectively teach evaluation &...

Documents