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Evaluation & Management Services,July 7, 2009Brenda Edwards, CPC, CPC-I, CEMCCoding & Compliance SpecialistKaMMCO,Medical Record Documentation,Records pertinent facts, findings and observations about an individuals health history including past and present illnesses, examinations, tests, treatments and outcomesChronologically documents the care of the patientIs an important element contributing to high quality care.,Golden Rule of Coding:,If it is not documented, it is not done and therefore not billable!,Accuracy is of the Utmost Importance,Legibly document what you have done.Something that may seem trivial for you to document could be the reason you could bill a higher level of service.,Principles of Documentation,Complete and legibleAt least two patient identifiersThe reason for the encounter Relevant history, physical examination findings and prior diagnostic test resultsAssessment, clinical impression or diagnosis and plan for care includedAppropriate health risk factors identified as well as the patients progress, response to and changes in treatment and revision of diagnosis should be documentedThe CPT and ICD-9 codes submitted must be supported by the documentation in the medical record,Evaluation & Management Services,An E&M (evaluation & management) service is any non-procedural service provided to a patient. Office visit, hospital admission, subsequent days, discharge, ER visits and nursing home services are all examples of E&M servicesDocumentation guidelines for E&M services were first introduced by the Health Care Finance Administration and the AMA in 1995.,Documentation Guidelines,New patients vs. established patientNew patient - One who hasnt been seen by any provider of the same practice (same tax id) in the past 3 yearsEstablished patient May be “new” to the provider but not “new” to the practice,Evaluation & Management Services,Three components to an E&M visitHistoryHistory of Present Illness (HPI)Review of Systems (ROS)Past, Family, Social History (PFSH)ExamMedical Decision Making (MDM),Assignment of the E&M Code,Based on the documentation by the provider, the level of the E&M service is determined by the level of history, exam and MDMNew patient office visits, must all meet 3 out of 3 levels of the History, Exam and MDMExample: History was comprehensive, exam was detailed and MDM was moderate, the criteria only a 99203 was met only 2 out of the 3 levels for a 99204 were met,3 of 3 versus 2 of 3,3 of 3 means each required element (History, Exam & MDM) are at least the same level or higher (can only code as high as the lowest level of the three that is documented)New patient office visit, ER, Inpatient H&P or consult require 3 of 3Detailed history, detailed exam and detailed MDM = Detailed new patient encounterProblem Focused HPI, detailed exam and detailed MDM = Detailed established patient encounterEstablished patient only requires 2 of 3Example: History was comprehensive, exam was detailed and MDM was moderate, the criteria only a 99203 was met only 2 out of the 3 levels for a 99204 were met,History Elements,Chief Complaint is a clear and concise statement in the patients own words and documented by the provider3 Major sections of the EncounterHistoryIncludes chief complaint (CC), history of present illness (HPI), review of systems (ROS) and past medical, family and social history (PFSH)ExamMedical Decision MakingThe providers “thought” process on paper,History of Present Illness,The medical record should clearly reflect the chief complaint (the reason the patient came through the door)History of present illness can either be brief (1-3 elements) or extended (4+)Location QualitySeverity Duration TimingContext Modifying FactorsAssociated Signs and/or Symptoms,Review of Systems,ConstitutionalEyesENTCardiovascularRespiratoryGastrointestinalGenitourinary,MusculoskeletalIntegumentaryNeurologicalPsychiatricAllergic/ImmunologicEndocrineHematologic/Lymphatic,Review of systems is the patients positive and pertinent negative response to a series of questions.,Past, Family & Social History,Can be obtained once in the medical record and then referred to at subsequent visits, with additions or changes added, as encounteredMust be initialed and dated to validate review by provider,Examination,Problem focused (examination of the affected body area) Expanded problem focused (2-4 body areas/systems)Detailed (5-7 body areas/systems)Comprehensive (8+ body areas/systems),Medical Decision Making,Medical decision making is the providers “thought process”Hardest element to translate into an audit formThe reason for encounter typically dictates the level of service selected,Medical Decision Making,Based on Complexity of the diagnosis/management optionsAmount of complexity of data reviewed Risk to the patientDocumentation of the MDM is hardest to quantify Putting providers “thought process” on paper,Medical Decision Making,Levels of Risk (examples are not all inclusive)Minimal riskSunburn, common cold, something a patient might not typically see a doctor for.Low riskWell controlled hypertension, ankle sprain, cystitisModerate RiskExacerbation (mild) COPD, undiagnosed breast lump, pneumoniaHigh RiskSevere exacerbation of COPD, acute renal failure, abrupt change in neurological status,Medical Decision Making,To qualify for a given level of decision making, 2 of the 3 elements must be met or exceededExample: A patient has stable diabetes, stable hypertension and stable COPD (2 or more stable chronic conditions-moderate), the provider orders lab (minimal) and continues the patient on current medication regimen (moderate) the level of Medical Decision Making is moderate,Time Based Visits,Provider must document amount of time related to counseling (more than 50%) and total time spent with patientProvider must document subject matter discussed, the more detailed the betterExample: 99213=a provider typically spends 15 minutes face-to-face. If more than 8 minutes was spent counseling the patient on a new diagnosis of hypertension, then the visit can be coded based on time, regardless of the complexity of the history, exam or MDM,The Hospital Card,History & Physical (99221-99223),3 of 3 elements need to be metNo other E&M services provided on the same day (ER or office visit) if the admission is knownDate of H&P should match date of admission to the floor,Subsequent Visits 99231-99233,2 of 3 elements need to be metReview of medical record, reviewing results, changes in pt status since last assessment, examinationTime can be spent face to face or on the unit or floor,Discharge 99238 & 99239,Must be a face to face encounterTime must be documented 99238 30 minutes99239 Greater than 30 minutesPreparation of discharge instructions, medications and/or placement arrangementsIf a patient was seen in the AM and dies in the afternoon (without provider present) cannot be billed as a “discharge”. Only subsequent care provided in the AM encounter.,Newborn Care,Initial assessment of newbornInitial treatment of a normal newborn, born in the hospitalSubsequent visitsEvaluation of a normal newborn, per dayDischarge is the same as inpatient (99238 or 99239)No charges are done by SFHC provider for NICU babies followed by a pediatrician Can bill for “normal” newborn care on day 1 if baby was “healthy” and complications arise on day 2 that warrant pediatrician involvement. Documentation should support the change in billingCircumcision is separately billable by performing provider,Hospital Consultations,Entire care of patient is not assumedIn order to bill must have 3 “R”s in writingRequest for an opinionRender your opinion Reply back to requesting provider of findings or recommendations,Concurrent Care,Patient is managed by multiple providers/specialtiesEach can bill for their services, if specific conditions are being followed by each providerCant bill for “courtesy visits”,Emergency Room Visits,5 levels of services that follow standard billing guidelines for a new patient (3 of 3 elements)Procedures done during the visit are separately billable with supporting diagnosesNo card requiredBilling is done off of dictated ER report,OB H&P and Delivery,No card required if normal delivery and aftercareSubsequent days may be billed if diagnosis supports additional care and treatment for complications/conditionsManagement of a patient admitted for observation is separately billable (premature contractions, injury or accident),Critical Care,Can be performed in any setting (inpatient, ER or office)Not billed just because a patient is in the ICUTime-based codes-documentation of time is requiredDirect delivery of medical care for a critically ill or injured patientTime spent providing critical care is based on total time spent engaging in work directly related to the individual patient,Cri