how to teach your physician e/m: part iii: monitoring...
TRANSCRIPT
6/20/2011
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How to Teach Your Physician
E/M:
Part III: Monitoring & Follow Up
Kerin Draak, MS, WHNP-BC,
CPC, CPC-I, CEMC, COBGC
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Re-cap: How to Prepare
• Know your resources
– Authoritative vs Opinion
• Tools
– Educational materials
– Audit tool
• Know your audience
• Effective communication
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Re-cap: How to Conduct a Meeting
• Do‟s and Don‟ts
• Medical Necessity
• Problems areas of history, exam, and
medical decision-making documentation
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Monitor
• Plan
• Implement
• Measure
• Maintain
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Documentation Compliance Cycle
Education
Audit
Monitor
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Baseline Audit
• Starting point
– Percentage coded correctly
– Percentage of records supporting either a higher or a lower level of service
• Identifies risk areas in the documentation
– ROS
– Family Hx
– Exam
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Baseline Audit
Provider name
Sample size % coded correctly
% over
Coded
% under
coded
Provider
John
N= 15 87%
N=13
None 13%
N=2
HistoryHistory of Present Illness Prob
Focus
Exp
Prob Foc
Detail Comp
Status of 3 chronic conditions Not applicable
Loc Dur Sev Qual Brief
1-3
Brief
1-3
Extended
4+
Extended
4+Assoc MF Timing Context
Review of Systems
Const Eye ENT Resp MS None Pertinent
1
Extended
2-9
Complete
10+Cardio GI Allergy
/Imm
Neuro Hem
/Lymp
Skin GU Psych Endo
Past Medical, Family, Social History
Past hx Prior illnesses, injuries, operations, hospitalizations, immunizations
None None Pertinent
Est =1
New = 1
Complete
Est =2
New = 3Family hx Health status or cause of death of immediate family, hereditary diseases
Social hx Marital status, current employment, drug/alcohol/tobacco use, education
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Examination
1995 Organ Systems ProbFoc
Expanded Prob Foc
Detailed Comp
Const Eye Cardio ENT Skin 1 body area or organ system
2-7 body areas or organ systems
2-7 body areas or organ systems
8 organ systems
Resp GI Neuro GU Psych
Hem/lymph/Imm
1995 Body Areas
Head/
Face
Ab Each
extrem
Neck Chest
Genitalia/ groin/buttocks
Back/Spine
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1995 Examination
• Example #1:– VSS, HR RRR, LS clear, Abd benign, GU normal
• Example #2:– VSS, GU; external genitalia pk, w/o lesions; BUS neg;
Vagina pink w/ physiological discharge; Cervix
ectropian w/o lesions, Bimanual: No CMT, Uterus
NSSC w/o adexa fullness or tenderness; RV confirms
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1997 Examination
• General
• Specialty
Medical Decision Making
Number of Diagnoses or Treatment Options - A
Problem(s) Status Number Multiply Points Total
Self-limited or minor (stable, improved, or
worsening)
Max = 2 x 1 =
Established prob. to examiner, stable,
improved
x 1 =
Established prob. to examiner, worsening x 2 =
New prob. to examiner, no additional work-up
planned
Max = 1 x 3 =
New prob. to examiner, additional work-up
planned
x 4 =
Grand
Total
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Medical Decision Making
Amount and/or Complexity of Data Reviewed - C
Reviewed Data Points
Review and/or order of clinical lab tests 1
Review and/or order of tests in the radiology section of CPT 1
Review and/or order of test in the medicine section of CPT 1
Discussion of test results with performing physician 1
Decision to obtain old records and/or obtain history from someone other than
patient
1
Review and summarization of old records and/or obtaining history from
someone other than patient and/or discussion of case with another health
care provider
2
Independent visualization of image, tracing or specimen itself (not simply
review of report)
2
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Medical Decision Making
Level of Risk Presenting
Problem(s)
Diagnostic
Procedure(s)
Ordered
Management
Options Selected
Minimal One self-limited
or minor problem
e.g., cold, insect
bite, tinea corporis
Laboratory tests
requiring
venipuncture
Chest X-rays
EKG/EEG
Urinalysis
Ultrasound e.g.,
echocardiography
KOH prep
Rest
Gargles
Elastic bandages
Superficial
dressings
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Medical Decision Making
Level
of Risk
Presenting Problem(s) Diagnostic Procedure(s)
Ordered
Management
Options Selected
Low Two or more self-limited
or minor problems
One stable chronic
illness, e.g., well
controlled HTN, non-
insulin dependent
diabetes, cataract, BPH
Acute uncomplicated
illness or injury, e.g.,
cystitis, allergic rhinitis,
simple sprain
Physiologic tests not under
stress, e.g., pulmonary
function tests
Non-cardiovascular
imaging studies with
contrast, e.g., 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
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Medical Decision MakingLevel of
Risk
Presenting Problem(s) Diagnostic Procedure(s)
Ordered
Management Options
Selected
Moderate 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,
e.g., lump in breast
Acute illness with systemic
symptoms, e.g.,
pyelonephritis, pneumonitis,
colitis
Acute complicated injury,
e.g., head injury with brief
loss of consciousness
Physiologic test under stress,
e.g., cardiac stress test, fetal
contraction stress test
Diagnostic endoscopies w/ no
identified risk factors
Deep needle or incisional
biopsy
Cardiovascular imaging studies
with contrast and no identified
risk factors, e.g., arteriogram,
cardiac catherization
Obtain fluid from body cavity,
e.g., lumbar puncture,
thoracentesis, culdocentesis
Minor surgery with
identified risk factors
Elective major surgery
(open, percutaneous, or
endoscopic)
Prescription drug
management
Therapeutic nuclear
medicine
IV fluids with additives
Closed treatment of
fracture or dislocation
without manipulation
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Medical Decision Making
Level of
Risk
Presenting Problem(s) Diagnostic Procedure(s) Ordered Management Options
Selected
High 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, e.g.,
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
neurological status, e.g.,
seizure, TIA, weakness,
sensory loss
Cardiovascular imaging studies
with contrast with identified risk
factors
Cardiac electrophysiological tests
Diagnostic endoscopies w/
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
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Documentation ExampleS. 32yo, MF, G2P2, LMP: last week on OCPs, here today with CC of having a cold for the
last 5-6d. She has not seen any improvement in her symptoms, even with OTC
meds. She c/o having nasal congestion that is sometimes yellow and sometimes
clear, facial pain and a sore throat. She denies a fever or ear pain. Occasionally
coughs, but thinks it mostly d/t post nasal drip. NKDA.
O. T. 99.1, Resp unlabored at 20, HR regular at 66
HEENT: eyes clear, ears clear, TMs bilat with fluid but not red, throat with post nasal
drainage, without tonsillar enlargement or exudate. Nose with boggy passages bilat
and yellow discharge. No frontal sinus tenderness, but positive for maxillary sinus
tenderness. Neck supple, with small, tender nodes. LS clear AP, HRR
A. Probable viral URI, possibly allergy related symptoms. Will hold on Antibiotics for a
couple of more days.
P. To continue with OTC meds, suggested NSAIDS to decrease nasal inflammation as
well as an antihistamine to see her symptoms respond. If no significant
improvement in 3-4 days, TCB and will consider adding a Rx.
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Documentation ExampleS. 32yo, MF, G2P2, LMP: last week on OCPs, here today with CC of having a cold for the
last 5-6d. She has not seen any improvement in her symptoms, even with OTC
meds. She c/o having nasal congestion that is sometimes yellow and sometimes
clear, facial pain and a sore throat. She denies a fever or ear pain. Occasionally
coughs, but thinks it mostly d/t post nasal drip. NKDA.
O. T. 99.1, Resp unlabored at 20, HR regular at 66
HEENT: eyes clear, ears clear, TMs bilat with fluid but not red, throat with post nasal
drainage, without tonsillar enlargement or exudate. Nose with boggy passages bilat
and yellow discharge. No frontal sinus tenderness, but positive for maxillary sinus
tenderness. Neck supple, with small, tender nodes. LS clear AP, HRR
A. Probable viral URI, possibly allergy related symptoms. Will hold on Antibiotics for a
couple of more days.
P. To continue with OTC meds, suggested NSAIDS to decrease nasal inflammation as
well as an antihistamine to see her symptoms respond. If no significant
improvement in 3-4 days, TCB and will consider adding a Rx.
History of Present Illness Prob
Focus
Exp
Prob Foc
Detail Comp
Status of 3 chronic conditions Not applicable
Loc Dur Sev Qual Brief
1-3
Brief
1-3
Extended
4+
Extended
4+Assoc MF Timing Context
Review of Systems
Const Eye ENT Resp MS None Pertinent
1
Extended
2-9
Complete
10+Cardio GI Allergy
/Im
Neuro Hem
/Lymp
Skin GU Psych Endo
Past Medical, Family, Social History
Past hx Prior illnesses, injuries, operations, hospitalizations, immunizations
None None Pertinent
Est =1
New = 1
Complete
Est =2
New = 3Family hx Health status or cause of death of
immediate family, hereditary diseases
Social hx Marital status, current employment, drug/alcohol/tobacco use, education
Loc Dur Sev Qual
MFAssoc
Extended
4+
Const ENT Resp Extended
2-9
GU
Past hx
Social hx
Est = 2
New = 1
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1995 Examination
1995 Organ Systems Prob Foc
Expanded Prob Foc
Detailed Comp
Const Eye Cardio ENT Skin 1 body area or organ system
2-7 body areas or organ systems
2-7 body areas or organ systems
8 organ systems
Resp GI Neuro GU Psych
Hem/lymph/Imm
1995 Body Areas
Head/
Face
Ab Each
extrem
Neck Chest
Genitalia/ groin/buttocks
Back/Spine
Const Eye Cardio ENT
Resp
Face
Neck
lymph
2-7 body
Areas or
Organ
systems
Detailed
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1997 Examination
• General Multi-System Exam– Measurement of any 3 of the 7 vital signs
– Inspection of conjunctivae and lids
– Otoscopic examination of external auditory canals and TMs
– Inspection of nasal mucosa
– Examination of oropharynx
– Examination of neck
– Assessment of respiratory effort
– Auscultation of lungs
– Auscultation of heart with notation of abnormal sounds and murmurs
– Inspection and/or palpation of head and neck
– Palpation of lymph nodes: neck (need to document 2 areas***)
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1997 Examination
• Ear, Nose and Throat Examination– Measurement of any 3 of the 7 vital signs
– Palpation and/or percussion of face with notation of presence or absence of
sinus tenderness
– Otoscopic examination of external auditory canals and tympanic membranes
– Inspection of nasal mucosa, septum and turbinates
– Examination of oropharynx
– Examination of neck
– Inspection of chest including symmetry, expansion, and/or assessment of
respiratory effort
– Auscultation of lungs
– Auscultation of heart
– Palpation of lymph nodes in neck, axillae, groin, and/or other
Medical Decision-Making
Number of Diagnoses or Treatment Options - A
Problem(s) Status Number Multiply Points Total
Self-limited or minor (stable, improved, or worsening) Max = 2 x 1 =
Established prob. to examiner, stable, improved x 1 =
Established prob. to examiner, worsening x 2 =
New prob. to examiner, no additional work-up
planned
Max = 1 x 3 = 3
New prob. to examiner, additional work-up planned x 4 =
Grand Total 3
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Risk
Level of
Risk
Presenting Problem(s) Diagnostic Procedure(s)
Ordered
Management Options
Selected
Low Two or more self-limited or
minor problems
One stable chronic illness,
e.g., well controlled HTN,
non-insulin dependent
diabetes, cataract, BPH
Acute uncomplicated
illness or injury, e.g., cystitis,
allergic rhinitis, simple
sprain
Physiologic tests not under
stress, e.g., pulmonary function
tests
Non-cardiovascular imaging
studies with contrast, e.g.,
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
Final Complexity for MDM Number of diagnoses or treatment options
Minimal
≤1
Limited
2
Multiple
3
Extensive
4
Highest risk Minimal Low Moderate High
Amount and/or complexity of data
Minimal
≤1
Limited
2
Multiple
3
Extensive
4
Type of decision
Straight
Forward
Low Moderate High
Multiple
3
Low
Low
Minimal
≤1
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Presenting Results
• Graphs
• Tables
• Written reports
• Verbal reports
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Audit Results Example
0
10
20
30
40
50
60
70
80
90
99211 99213 99215
Codedcorrectly
Overcoded
Undercoded
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Auditing for Compliance
• Prospective
• Retrospective
• Random
• Focused
• Sample size
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Format
• Prospective Reviews
– Allows providers to make
changes/addendums before billing
• Retrospective Reviews
– Potential for refunds with received
overpayments
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Format
• Random
– Allows for generalized „look‟
• Focused
– Potential for refunds with received
overpayments
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Who‟s Looking?
• Office of Inspector General (OIG)
• Centers for Medicaid & Medicare (CMS)
– Recovery Audit Contractors (RAC)
• Region A: Diversified Collection Services (DCS)
• Region B: CGI
• Region C: Connolly, Inc.
• Region D: HealthDataInsights, Inc.
– Comprehensive Error Rate Testing (CERT)
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RAC Region A
Diversified Collection Services
• Connecticut, Delaware, District of
Columbia, Maine, Maryland,
Massachusetts, New Hampshire, New
Jersey, New York, Pennsylvania, Rhode
Island, and Vermont.
• Website: www.dcsrac.com
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RAC Region B
CGI Federal
• Indiana, Michigan, Minnesota Illinois,
Kentucky, Ohio and Wisconsin
• Website: http://racb.cgi.com
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RAC Region CConnolly, Inc.
• 15 States:
– Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, North Carolina, New Mexico, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia
• 2 Territories:
– Puerto Rico, U.S. Virgin Islands
• Website: www.connollyhealthcare.com/RAC
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RAC Region D
HealthDataInsights
• 17 States:
– Alaska, Arizona, California, Hawaii, Iowa, Idaho,
Kansas, Missouri, Montana, North Dakota, Nebraska,
Nevada, Oregon, South Dakota, Utah, Washington,
Wyoming
• 3 Territories
– Guam, American Samoa, Northern Marianas
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Other E/M issues
• Problem-oriented services performed during the
same encounter as a prevent service.
• Problem-oriented services performed during the
same encounter as an office procedure.
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Other E/M Issues
• Split/Shared care:– A split/shared E/M visit is defined by Medicare Part B
payment policy as a medically necessary encounter
with a patient where the physician and a qualified
NPP each personally perform a substantive portion of
an E/M visit face-to-face with the same patient on the
same date of service.
– Avoid „seen and agree with above‟.
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Other E/M Issues• The physician and the qualified NPP must be in the
same group practice or be employed by the same
employer.
• The split/shared E/M visit applies only to selected E/M
visits and settings (i.e., hospital inpatient, hospital
outpatient, hospital observation, emergency department,
hospital discharge, office and non facility clinic visits, and
prolonged visits associated with these E/M visit codes).
• The split/shared E/M policy does not apply to
consultation services, critical care services or
procedures.
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Other E/M Issues
• When an E/M service is a shared/split encounter
between a physician and a non-physician practitioner
(NP, PA, CNS or CNM), the service is considered to
have been performed “incident to” if the requirements for
“incident to” are met and the patient is an established
patient. If “incident to” requirements are not met for the
shared/split E/M service, the service must be billed
under the NPP‟s UPIN/PIN, and payment will be made at
the appropriate physician fee schedule payment.
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Other E/M Issues
• When a hospital inpatient/hospital outpatient or
emergency department E/M is shared between a
physician and an NPP from the same group practice and
the physician provides any face-to-face portion of the
E/M encounter with the patient, the service may be billed
under either the physician's or the NPP's UPIN/PIN
number. However, if there was no face-to-face encounter
between the patient and the physician (e.g., even if the
physician participated in the service by only reviewing
the patient‟s medical record) then the service may only
be billed under the NPP's UPIN/PIN.
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Other E/M Issues• “I have personally seen and examined the patient independently,
reviewed the PA's Hx, exam and MDM and agree with the
assessment and plan as written" signed by the physician
• "Patient seen" signed by the physician
• "Seen and examined" signed by the physician
• "Seen and examined and agree with above (or agree with plan)"
signed by the physician
• "As above" signed by the physician
• Documentation by the NPP stating "The patient was seen and
examined by myself and Dr. X., who agrees with the plan" with a co-
sign of the note by Dr. X
• No comment at all by the physician, or only a physician signature at
the end of the note.
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Other Documentation Issues
• EHR or EMR documentation issues
– Cloning
– Templates
– Macros
– Contradictory
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Other E/M Issues
• Billing based on time
– Total time
– Indication that majority of time was spent in
counseling and/or coordinating care
– Description of the extent
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Billing E/M on Time
• Good examples of how to document time:
– I spent 20 minutes with the patient and greater than
50% of the time was spent discussing her new
diagnosis of depression and counseling her about the
management options.
– Total floor/unit time was 20 minutes; spent with
patient and family discussing patient‟s prognosis and
treatment plan.
– 30 minutes spent with patient in discussion regarding
her new diagnosis of depression and the entire time
was spent in counseling.
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Billing E/M on Time
• Bad examples of documenting based on time:
– The office visit today took course over a period of
20 minutes.
– I spent 20 minutes counseling the patient.
– Total floor/unit time was 35 minutes.
– Spent 20 minutes above and beyond the usual
time for performing the physical exam.
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Other Issues
• Legibility
• Missing documentation
• Late completion of documentation
• Correct date of service
• Correct place of service
• Correct E/M category
• Correct diagnosis code
– Support medical necessity
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Summary
• Be prepared
– Know your resources, your audience and why you are educating
• Conduct meeting in professional manner
– Dress for success, communication skills, presentation skills
• Follow-up and continued monitoring
– Maintain compliance