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Billing and Coding: Webinar #1 NOTE: Make sure your computer speakers are turned ON. Audio will be streaming through your speakers. If you do not have computer speakers, call the ACCMA at 510-654-5383 for alternatives.

We will begin shortly after 10:00 am.

FUNDAMENTALS OF BILLING AND CODING A Basic Training series for Billing & Coding Staff in the Medical Office ACCMA - 2013 2

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About This Manual © Copyrighted 2013, The Sage Associates, Pismo Beach, California and Practice & Liability Consultants LLC, San Francisco, California All rights reserved. All material contained in this manual is protected by copyright. Participants who receive this book as part of a workshop presented by The Sage Associates have permission to reproduce any forms contain herein, solely for their own uses within their medical practices. Any other reproduction or use of material in this book without the permission of the author is strictly prohibited. The material in this manual was written by practice management consultants. Any advice or information contained in this manual should not be construed as legal advice. When a legal question arises, consult your attorney for appropriate advice. The information presented in this manual is extracted from official government and industry publications. We make every attempt to assure that information is accurate; however, no warranty or guarantee is given that this information is error-free and we accept no responsibility or liability should an error occur. CPT codes used in this manual are excerpts from the current edition of the CPT (Current Procedural Terminology) book, are not intended to be used to code from and are for instructional purposes only. It is strongly advised that all providers purchase and maintain up 3 to date copies of CPT. CPT is copyrighted property of the American Medical Association.

Session II; Webinar I • Evaluation & Management Coding • What are E/M Services • Making code selections based on documented work to ensure that medical record documentation substantiates the level of E/M code selected

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Evaluation & Management (E/M)

Selecting The Right Code For Your Services 5

OFFICE OR OTHER OUTPATIENT SERVICE New Patient

99201 – 99205

Established Patient 99211 – 99215 •

New vs. Established Patient

•

Code Correctly

•

New = 3/3 components; Established = 2/3 components 6

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Office/Outpatient Service

CPT

Histor y

Exam

MD

Time

New Patient – Level I

99201

PF

PF

SF

10

New Patient – Level II

99202

EPF

EPF

SF

20

New Patient – Level III

99203

D

D

L

30

New Patient – Level IV

99204

C

C

M

45

New Patient – Level V

99205

C

C

H

60

Established Patient – Level I

99211

N/A

N/A

N/A

5

Established Patient – Level II

99212

PF

PF

SF

10

Established Patient – Level III

99213

EPF

EPF

L

15

Established Patient – Level IV

99214

D

D

M

25

Established Patient – Level V

99215

C

C

H

40 7

Hospital Observation Services Discharge Care

99217

Initial Observation Care

99218 – 99220

Subsequent Care

99224 – 99226

• Outpatient Department of Hospital • Some payers establish time threshold • eg – Medicare = minimum 8 hours 8

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HOSPITAL INPATIENT SERVICE Initial Care

99221 – 99223

Subsequent Care

99231 – 99233

Admit/Discharge

99234 – 99236

Can be observation also

Discharge Care

99238 – 99239

• For Medicare – Admitting Physicians uses AI Modifier • Discharge Service by One Physician Only 9

CONSULTATIONS Office/Outpatient

99241 – 99245

Inpatient - Initial

99251 – 99255

• Physician Initiated • Must State in Record "Consult“ • Document the Three “R”s - Request, Reason, Report • Follow Up Management of Condition – Not a Consult • One Initial Inpatient Consult/Admission/Physician 10

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Emergency Department Service New and Established Patients

99281 – 99284

Physician Direction of EMS care, ALS 99288 • • • •

All Physicians May Use Critical Care Codes Should be Used if Appropriate New/Established Patients Coded Similarly Specialist Referral by ER Physician not Considered Consults 11

CRITICAL CARE SERVICES First 60 Minutes

99291

Additional 30 Minutes (each)

99292

• Critically ill or unstable critically injured • Not Necessarily "Continuous" Time • 15 Minutes is the Critical "Cut-Off" (1/2 hr - 1 hr, 14 min. = 99291) • 99291 Used Once Per Day Only • "Status" (diagnosis) Not "Unit" is Deciding Factor • Know what other services are part of Critical Care 12

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NURSING FACILITY SERVICES (SNF, ICF, LTCF) Initial

99304 – 99306

Subsequent Care

99307 – 99310

Discharge Services

99315 – 99316

Annual Nursing Facility Assessment

99318

• New or Established Patients

POS 31 and 32 - beware of the difference!!

13

DOMICILIARY, REST HOME, CUSTODIAL CARE SERVICES New Patient

99324 – 99328

Established Patient

99334 – 99337

• Includes services in an assisted living facility • The facility’s service does not include a medical component 14

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Domiciliary, Rest Home (eg, Assisted Living Facility), or Home Care Plan Oversight Services

15 – 29 Minutes

99339

30+ Minutes

99340

• Per Calendar Month • Not a payable service by Medicare 15

HOME SERVICES New Patients

99341 – 99345

Established Patient

99347 – 99350

Some carriers require patient to be “homebound”

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PROLONGED SERVICES

Direct Patient Contact -Outpatient 1st hour Each Add'l 30 minutes

99354 99355

Direct Patient Contact - Inpatient 1st hour Each Add'l 30 minutes

99356 99357

Without Direct Patient Contact 1st hr Each Add'l 30 minutes

99358 99359

The primary evaluation and management service must have a typical or specified time published in CPT 17

Physician Standby Service Physician Standby Service

99360

• Requires prolonged physician attendance (can not be devoting time to any other patient)

• Operative Standby • Frozen Section Standby • C-Section/High Risk Delivery Standby • Monitoring EEG

• Not for hospital mandated “on call” services 18

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Case Management Services Anticoagulant Management

Initial 90 days of therapy (8 INR)

99363

Each subsequent 90 days (3 INR)

99364

• For Long-Term Anticoagulant Management • If patient only on anticoagulant for 60 days or less, do not use

• If INR measurements quantity not met, do not use • If there is a break in outpatient therapy (hospitalization), re-start initial 90day period

• Currently “bundled” for Medicare patients (i.e. not paid) • Does not replace G0250 – patients with mechanical heart valves, managing their INR at home

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Case Management Services Medical Team Conferences

• Face to face w/patient and/or family, 30 min+, by nonphysician qualified health care professional

99366

• Patient and/or family not present, 30 min+, participation by physician

99367

• Patient and/or family not present, 30 min+, participation by non-physician qualified health care professional 99368 These services are “bundled” by Medicare and not separately payable!

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CARE PLAN OVERSIGHT SERVICES Under Care of Home Health Agency 15-29 Minutes 30 Minutes or More

99374 99375

Hospice Patient 15-29 Minutes 30 Minutes or More

99377 99378

Nursing Facility Patient 15-29 Minutes 30 Minutes or More • • • •

99379 99380

Provided within a calendar month Separate codes for home health, hospice and nursing facility Time Sensitive (< 30 minutes; 30+) Medicare covers 30+ minutes only for HHA and Hospice and uses Level II HCPCS code to report (G Codes) 21

CPO for Medicare Patients • G0181 Physician supervision of a patient receiving Medicare-covered services provided by a participating home health agency, 30 minutes or more

• G0182 Physician supervision of a patient under a Medicare-approved hospice, 30 minutes or more Document your services – even though they are only minutes at a time! 22

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HHAof Certification • Certification HHA Plan G0180 • Review of “Initial or Subsequent Reports of Patient Status • Review of Patient’s Responses to Oasis Assessment Instrument • Contact with HHA to Ascertain Initial Implementation Plan of Care • Documentation in Patient’s Office Record

• Re-certification

G0179

• Review Subsequent Reports of Patient Status • Review of Patient’s Responses to the Oasis Assessment Instrument • Contact with HHA to Ascertain the Follow Up Implementation Plan of Care

• Documentation in the Patient’s Office Record 23

PREVENTIVE MEDICINE SERVICES New Patients

99381 - 99387

Established Patient

99391 - 99397

Individual Counseling

99401 - 99404

Group Counseling

99411 - 99412

Health Risk Assessment

99420

Unlisted Service

99429 24

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Preventive Guidelines “Comprehensive” History & Exam – not synonymous with “comprehensive” required for other E/M services • Comprehensive History • • • • •

Not Problem Oriented Does Not Involve Chief Complaint or Present Illness Does Include Comprehensive System Review Does Include Comprehensive or Interval Past, Family, Social History Does Include Comprehensive History of Pertinent Risk Factors

• Comprehensive Exam – is multi-system, but the extent of exam is based on age of patient and risk factors identified

• Includes counseling, anticipatory guidance, and risk factor reduction interventions provided at the time of the preventive medicine service

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Preventive Medicine, Individual Counseling (separate visit from H&P) • • • •

15 Minutes

99401

30 Minutes

99402

45 Minutes

99403

60 Minutes

99404

• Not for an acute problem or a present diagnosis 26

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Behavior Change Interventions, Individual • Smoking & tobacco use cessation; • Intermediate (3-10 min.)

99406

• Intensive (> 10 min)

99407

• Alcohol and/or substance abuse screening • Brief (15-30 min.)

99408

• > 30 min.

99409 27

Other Preventive Medicine • Group Counseling • 30 Minutes 99411

• Other • Administration &

interpretation of health risk assessment instrument 99420

• 60 Minutes 99412 • Unlisted preventive medicine

99429 28

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Non Face-to-Face Physician Services • Telephone Services 5-10 minutes of medical discussion

99441

11-20 minutes of medical discussion

99442

21-30 minutes of medical discussion

99443

• On-Line Medical Evaluation

99444

• Using the Internet • Established Patient, Guardian, Health Care Provider • No other E/M the previous 7 days • Initiated by Patient 29

SPECIAL EVALUATION AND MANAGEMENT SERVICES Basic Life and/or Disability Evaluation

99450

Work Related or Medical Disability Evaluation Services

• By Treating Physician • By Other Than Treating Physician

99455 99456

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NORMAL NEWBORN CARE Initial Care Hospital or Birthing Center, per day

99460

Other than Hospital or birthing Center, per day 99461 Subsequent Hospital Care, per day

99462

Initial Hospital or Birthing Center, per day, Admit/Discharge same day

99463 31

Delivery/Birthing Room Attendance and Resuscitation Services • Attendance at delivery (when requested by the delivering physician) and initial stabilization of newborn

99464

• Delivery/birth room resuscitation, provision of positive

pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output 99465 • 99465 may be reported in conjunction with 99460, 99468, 99477 • 99464 and 99465 can not be reported together • Report procedures performed as a necessary part of the resuscitation (intubation, vascular lines) in addition to 99465

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Pediatric Critical Care Patient Transport • Critical Care services delivered by a physician, face-to-face, during an interfacility transport • 30-74 minutes of hands-on care

99466

• Each additional 30 minutes

99467

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Inpatient Neonatal and Pediatric Critical Care • Initial inpatient neonatal critical care, per day 99468 • Subsequent inpatient neonatal critical care, per day 99469 • Neonate = 28 days of age or less

• Initial inpatient pediatric critical care, per day 99471 • Subsequent inpatient pediatric critical care, per day 99472 • Infant or young child age 29 days through 24 months of age

• Initial inpatient pediatric critical care, per day 99475 • Subsequent inpatient pediatric critical care, per day 99476 • Infant or young child age 2 through 5 years of age

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Initial & Continuing Intensive Care Services • Initial hospital care, for neonate who requires intensive

observation, frequent intervention, and other intensive care services 99477

• Subsequent intensive care, per day of recovering very low birth weight infant (< 1500 grams)

99478

• Subsequent intensive care, recovering low birth weight (1500 – 2500 grams)

99479

• Subsequent intensive care, recovering infant (1501 – 5000 grams)

99480

• Per day • Neonates (28 days or less of age) 35

Complex Chronic Care Coordination Services

• 99487

Complex chronic care coordination services; first hour of clinical staff time directed by a physician or other qualified health care professional with no face-toface visit, per calendar month

• 99488

first hour of clinical staff time directed by a physician or other qualified health care professional with one face-to-face visit, per calendar month

• 99489

ea. Additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month 36

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Transitional Care Management Services

• 99495

Transitional Care Management Services with elements: • Communication (direct contact, telephone, electronic with the patient and/or caregiver within 2 business days of discharge)

• Medical decision making of at least moderate complexity during the service period

• Face-to-face visit, within 14 calendar days of discharge 37

Transitional Care Management Services

• 99496

Transitional Care Management Services with elements: • Communication (direct contact, telephone, electronic with the patient and/or caregiver within 2 business days of discharge)

• Medical decision making of high complexity during the service period

• Face-to-face visit, within 7 calendar days of discharge 38

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Testing Your Knowledge

39

Poll Questions

40

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Poll Questions

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Poll Questions

42

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Poll Questions

43

Poll Questions

44

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Evaluation & Management

DOCUMENTATION

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General Principles of Medical Record Documentation  The Medical record should be complete and legible.  There is no specific format required for documenting the

components of an E/M service.  The documentation of each patient should include. • the chief complaint and/or reason for the encounter and relevant history, physical examination findings and prior diagnostic test results;

• assessment, clinical impression or diagnosis; • plan for care; and • date and a verifiable legible identity of the health care provider who provided the services.

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If not specifically documented, the rationale for

ordering diagnostic and other ancillary services should be easily inferred.

To the greatest extent possible, past and present

diagnosis and conditions, should be accessible to the treating physician.

Appropriate health risk factors should be identified. The patient’s progress, response to and changes in

treatment, planned follow-up care and instructions, and diagnosis should be documented.

The CPT & ICD-9 codes reported on the health

insurance claim form or billing statement should be supported by the documentation and the medical record. 47

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An addendum to a medical record should be dated the day the information is added to the medical record and not dated for the date the service was provided.

Timeliness: A service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.  The confidentiality of the medical record should be fully maintained consistent with the requirements of medical ethics and of law.

PRIMARY RULE: If the service isn’t documented, it wasn’t done. If the documentation is illegible, the service was not performed. 48

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Evaluation & Management Codes/Key Terms • New Patient: 99201-99205 New Patient: One who has not received any professional services from the physicians or another physician of the same specialty who belongs to the same group practice, within the last three years.

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Established Patient • Codes 99211-99215 An established patient is one who has received professional services from the physician or another group member of the same specialty within the last three years.

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50

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CONSULTATION • CPT CODES 99241-99245 “A consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source”

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Elements of Consultation 3 R rule • Request; by the patient’s attending physician or other appropriate source such as an insurance company and the need documented. Your dictation should read: “Thank you for your request to render an evaluation of [patient’s name] for [patient’s condition]”

Never use the word “referral” this word is interpreted as transfer of care.

• Render: In your conclusion state: “My recommendation(s): CONSULT MEANS: TELLING, NOT DOING Does not involve active management of the patient problem although diagnostic test may be ordered to help you render an opinion.

• Report: a formal report containing the opinion or advice back to the requesting party. A cover letter is suggested.

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CONSULTATION VS TRANSFER OF CARE

• In addition to meeting the previous criteria, there would have to be NO intent to transfer care by the original physician. For instance, a knee specialist has been treating a patient for ACL injury. During the visit, the patient complains of wrist pain that the knee specialist determines to be carpal tunnel syndrome. He suggests that the patient make an appointment to see the hand specialist in the same practice for treatment.

This type of scenario, which is common in orthopedic practices, would not be a consultation but would be transfer of care, because one orthopedist would be skilled in an area the other is not. The codes for the hand specialist would be from the established patient series (99212-99215) since the patient not qualify for a consultation or new patient codes. 53 53

Overview of E/M Section • The E/M levels are selected based on the clinicians documentation

• Therefore, it is important that the clinician documents each patient encounter as accurate and complete as possible

• What should be considered when analyzing the patient’s medical record?

• Does the documentation justify the medical necessity of the service and/or procedure performed?

• Does the documentation support the level of service reported? • Is the documentation legible? • Are there specific payer documentation guidelines and have they been met?

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Overview of E/M Section • Medical Necessity Medicare defines "medical necessity" as

• services or items reasonable and necessary for the diagnosis or treatment of illness or injury or to

• improve the functioning of a malformed body member

• Clinician vs. Coder • Questions regarding an extensive write up for a minor problem should be referred back to the clinician for clarification

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Overview of E/M Section E/M Guidelines •

There are two guidelines that may be utilized, 1995 or 1997 •

Providers/Coders may use either guideline

• Whichever is most advantageous to the provider • Must follow one guideline per patient encounter • Cannot mix and match 56

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1995 VS. 1997 • 1995 • Based on the number and/or extent of body areas or organ systems examined

• 1997 • Based on the examination of specific bulleted items identified within a body area or organ system

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E/M Services Remember, documentation must support the medical necessity and the level of service billed. The Level of Service is based on the documentation of the 3 Key Components and the Contributing Factors: • 3 Key Components

• History • Examination • Medical Decision Making • Contributing Factors

• Nature of Presenting Problem • Time • Outpatient Setting (Counseling by Provider face-to-face) • Inpatient Setting (Counseling by Provider face-to-face and/or Coordination of Care) 58

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E/M – History Component •

The History is divided into four levels: • Problem Focused • Expanded Problem Focused • Detailed • Comprehensive

• These levels are determined by…… 59

E/M – History Component History levels are determined by the following 4 elements 1. 2. 3. 4.

Chief Complaint (CC) History of Present Illness (HPI) Review of Systems (ROS) Past, Family, and/or Social History (PFSH)

• The extent of the history is dependent upon clinical judgment and on the nature of the presenting problem (s)

• Not all histories will have or need all elements 60

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E/M – History Component •

The Four Elements of History

•

Chief Complaint (CC) • A concise statement describing the symptom, problem, condition,

diagnosis, or other factor as the reason for the encounter. Example: a return visit recommended by the physician

2. History of Present Illness (HPI) • Describes the patient’s developing condition/problem from the first sign and/or symptom or from the previous encounter to the present or the status of three chronic or inactive conditions

3. Review of Systems (ROS) • An inventory of body systems obtained through a series of

questions seeking to identify signs and/or symptoms the patient may be experiencing or has experienced

4. Past, Family, and Social History (PFSH) 61 • Review of the patient’s past history, family history, and social history

E/M – History Component

• Chief Complaint The reason for seeking medical care should be recorded in the patient’s own words “Patient complains of left foot pain due to fall last month.” 62

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E/M – History Component The History of Present Illness (HPI)

•

Two types

1. Brief HPI

1 to 3 HPI Elements 2. Extended HPI

4 or more HPI Elements or the status of at least 3 chronic or inactive conditions 63

E/M – History Component The HPI Elements •

Location – Where the symptom or problem is occurring •

•

Severity - A rating or description of severity of the symptom or pain •

•

Bad, intolerable, minimal, slight

Timing – When symptom or pain occurs •

•

Abdomen, chest, leg, arm, head

Before bed, upon waking, two hours after taking medicine, continuous

Quality – The character of the sign or symptom •

Burning, dull, puffy, puss-filled, red, itchy

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The HPI Elements •

Duration – How long a pain or symptom lasts, has been present, or persisted •

•

Associated signs/symptoms – Any organ system or body area complaints associated with the chief complaint •

•

Rash with blistering, nausea and vomiting, abdominal pain

Context – Instances or items that can be associated with the chief complaint •

•

For two months, since prescription began

When walking, in company of smokers, at work

Modifying factors – Actions taken or things done to effect the symptom or pain, making it better or worse •

Improves when lying down, worse after eating 65

E/M – History Component The HPI - Example of an extended HPI with 4 or more elements

•

HPI: For the past two days she has had chills, fever and muscle aches. She feels worse in the evening. Her illness is so severe she has not been able to work. •

Duration

• Associated Signs • Timing • Severity 66

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E/M – History Component The HPI Extended HPI with status of at least three chronic or inactive conditions.

Example: The patient is currently under my care for the management of hypertension controlled with diet and exercise, diabetes controlled with insulin, and asthma requiring inhaler twice daily. 67

E/M – History Component • The Review of Systems (ROS) • ROS includes 14 systems • • • • • • • • • • • • • •

Constitutional symptoms (fever, weight loss, etc) Eyes Ears, nose, mouth, throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary (skin and/or breast) Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergic/Immunologic

68

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E/M – History Component The ROS has 3 types 1. Problem Pertinent • 1 system

2. Extended • 2-9 systems

3. Complete • 10 or more systems 69

E/M – History Component • Problem Pertinent ROS • The patient's positive responses and pertinent negatives for the system related to the problem should be documented.

• Extended ROS • The patient's positive responses and pertinent negatives for two to nine system should be documented.

• Complete ROS • At least ten organ systems must be reviewed. Those systems with

positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually 70 documented.

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E/M – History Component Example of a complete ROS: The provider can list pertinent findings in 2 or more systems and note all other systems are negative A patient is seen in the physician’s office with flu-like symptoms. For the past two days she has had chills, fever, and muscle aches. She feels worse in the evening. Her illness is so severe she has not been able to work. (Provider queries patient on at least ten systems, notes pertinent findings) She has lost 7 pounds in the last month. She denies abdominal pain, diarrhea, and vomiting. All other systems are negative.

• Constitutional • Gastrointestinal • “All other systems are negative” gives provider credit for a complete ROS

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E/M – History Component The Past, Family, and Social History (PFSH) • Past History • The patient’s past experience with illnesses, operations, injuries and treatments

• Family History • A review of medical events in the patient’s family, including diseases that may be hereditary or place the patient at risk

• Social History • Age appropriate review of past and current activities 72

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E/M – History Component The PFSH There are two types of PFSH - pertinent and complete The required elements for each differs based on the patient status • New patient status

• Pertinent • 1 specific item from any of the 3 history areas • Complete • 1 specific item from each of the 3 history areas • Established patient status

• Pertinent • 1 specific item from any of the 3 history areas • Complete • 1 specific item from any 2 of the 3 history areas

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E/M – History Component If the PFSH is non-contributory a statement is required in the documentation to qualify it for a complete PFSH

• Example:

• “Reviewed PFSH, non-contributory to current condition.”

For those categories of E/M services that require only an interval history, it is not necessary to record information about PFSH

• Example: • Subsequent hospital care • Subsequent nursing facility care

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Overall History Component Each history element must be met or exceeded to determine an overall history level

• Let’s look at an example • CC • Must be present in patient’s medical record

• HPI • Extended

• ROS • Complete

• PSFH • Pertinent

• Overall History level = Detailed

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E/M – History Component Example Outpatient Grid HPI Location

Severity

Timing

Modifying Factors

Quality

Duration

Context

Associated Signs & Symptoms

Brief 1-3

ROS Constitutional Ears, Nose Throat, Mouth Skin/breast Endo Hem/Lymph Eyes Card/Vasc GI Neuro Allergy/Immune Resp Musculo GU Psych All Others Neg

PFSH Past Medical History Family History Social History Established Patient: only need 2 to be considered “Complete” New Patient: Requires all 3 to be considered “Complete”

OVERALL HISTORY LEVEL

Pertinent to Problem 1

None

None

Problem Focused

Expanded Problem Focused

Extended 4 or more

Extended 2-9

Complete

Pertinent

Complete

Detailed

Comprehensive

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E/M History

• Caveat • Patient is unable to speak • Physician must document this • “Patient intubated, unable to obtain History”

• Provider gets credit for a complete History!

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E/M – Examination Component •

Now let’s look at the Examination • Four Levels • • • •

Problem Focused Expanded Problem Focused Detailed Comprehensive

Exam Elements • Body Areas • Organ Systems (Cannot combine Body Areas and Organ Systems for Comprehensive Exam)

• 2 Types • Multi-system • Single Organ System

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E/M Examination Elements Body Areas: Head/face Neck

chest, including breasts & axillae back, spine

0-1

2-4

5-7

>8

Problem Focused

Expanded

Detailed

Comprehensive

each extremity

genitalia, groin, buttocks

abdomen

Organ Systems: Constitutional

ears, nose, mouth, throat

Eyes

resp

GI

Cardio

skin

neuro

Hem, lymph, immune

GU psych

musculo

OVERALL EXAMINATION LEVEL

Problem Focused 79

Exam - 1995 vs. 1997

Examination

Problem Focused

Expanded Problem Focused

Detailed

1995

1 Body Area or Organ System

Limited Exam 2-4 Body Areas or Organ Systems

Extended Exam 8 Organ Systems or a 5-7 Body Areas or Comprehensive Single Organ Systems Organ System Exam

1997

Any 1-5 Bullets

Any 6+ Bullets

General: 2 bullets from 6 or more organ systems/body areas or 12 bullets from 2 or more organ systems/body areas Eye/Psych: 9+ bullets All Others: 12+ bullets

Comprehensive

General: Perform all, document 2 bullets from 9 Organ Systems/body areas All Others: Perform all, document all elements in each bolded box and801 element in each unbolded box

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Medical Decision Making Component Now let’s look at the Medical Decision Making Four Levels 1. Straightforward 2. Low Complexity 3. Moderate Complexity 4. High Complexity

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Medical Decision Making • To determine the level of Medical Decision Making, two of the three following Elements must meet or exceed

Elements

• Number of Diagnoses or Treatment Options • Amount and/or Complexity of Data to be Reviewed • Risk of Complication and/or Morbidity/Mortality 82

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Medical Decision Making Component Number of Diagnoses or Treatment Options

3 Categories

1. Self-limited or minor stable, improved or worse

2. Established problem stable, improved, worsening

3. New problem to examiner no additional work up planned additional work-up planned

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Medical Decision Making Component •

Self-limited or minor (stable, improved or worse) •

Sore throat

•

Earache (simple)

•

Simple laceration

This category does not indicate that the problem is new or established •

American Medical Association (AMA)

“A problem that runs a definitive and prescribed course, is transient in nature, and is not likely to permanently alter health status or has a good prognosis with management/compliance.”

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Medical Decision Making Component •

Established problem; stable, improved

For this provider/specialty group – usually diagnosis and treatment has already been started •

Established problem; worsening

Must be documented or CLEARLY implied, (pain has increased, etc.) 85

Medical Decision Making Component New problem to examiner; no additional work- up planned •

New problem to examiner; additional work-up Planned  

Starting treatment does not constitute “additional work-up”. Any diagnostic study or plan to help find a definitive diagnosis.

Example: •

Radiology

•

Laboratory

•

Consultation with another physician

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NUMBER OF DIAGNOSES AND/OR TREATMENT OPTIONS A Problem (s) status Self–limited or minor (stable, improved or worse) Est. problem; stable, improved

B

C

=D

Number

Points

max=2

1 1

Est. problem; worsening New problem; no additional workup planned New Problem; additional workup planned

Result

2 max=1

3 4

Total 87

Medical Decision Making Component •

Amount and/or Complexity of Data to be Reviewed •

Review &/or order of clinical lab tests

•

Review &/or order in the radiology section of the CPT

•

Review &/or order of tests in the medicine section

•

Discussion of test results with performing physician

•

•

•

Decision to obtain old records &/or history from someone other than patient Review and summarization of old records &/or obtaining history from someone other than patient &/or discussion of case with another health care provider Independent visualization of image, tracing or specimen itself (not simple review of report) 88

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Medical Decision Making Component •

Review &/or order of clinical lab tests Any documentation of the review of tests previously ordered

•

Example (s): •

Test results documented in notes

•

Documentation that Provider reviewed results

Documentation that indicates tests are ordered

•

89

Medical Decision Making •

Review &/or order in the radiology section of the CPT •

Review of Report not actual film

Example (s):

•

•

Documentation of review of x-ray report

•

Documentation that a x-ray was ordered

No review of actual film

90

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Medical Decision Making •

Review &/or order of tests in the medicine Section •

Report (s) is reviewed or ordered

Example (s): •

EKG Report

•

Stress Test

•

Documentation that a medicine test was ordered

91

Medical Decision Making •

Discussion of test results with performing physician •

Discussion = verbal communication and NOT a report or letter

Example: •

•

Pathologist viewing specimen then pages ordering MD to discuss results PCP MD pages MD Specialist to discuss test results

92

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Medical Decision Making

Review and summarization of old records &/or obtaining history from someone other than patient &/or discussion of case with another health care provider

•

of old record or history and document how it pertains to the patients current problem

•

Summarize the review

•

Does not include: •

Parents of pediatric patient

It must be Additional/Relevant information 93

Medical Decision Making •

Independent visualization of image, tracing or

specimen itself (not simple review of written report) •

•

Does not include: •

Rapid Strep Test

•

Urine Pregnancy Test

Does include: •

Reviewing x-ray image (can be in electronic system)

•

EKG Strip 94

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AMOUNT AND/OR COMPLEXITY OF DATA REVIEWED Points Review &/or order of clinical lab tests

1

Review &/or order in the radiology section of CPT

1

Review &/or order of tests in the medicine section of CPT

1

Discussion of test results with performing physician

1

Review and summarization of old records &/or obtaining history from someone other than patient &/or discussion of case with another health care provider

2

Independent visualization of image, tracing or specimen itself (not simply review of report)

2

Total

95

Medical Decision Making •

Risk of Complication and/or Morbidity/Mortality •

Four Levels •

Minimal

•

Low

•

Moderate

•

High

96

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Table of Risk

Level of Risk

Presenting Problem(s)

Minimal

* One self–limited or minor problem, e.g. cold, insect bite

* Lab tests requiring venipuncture * CXRs * ECG/EEG, U/A, echo

* Rest * Gargles * Elastic bandages * Superficial dressings

Low

* 2 or more self–limited or minor problems * 1 stable chronic illness • * Acute uncomplicated illness or injury, e.g. cystitis, sprain

* Physiologic tests not under stress, e.g. PFTs * Non–CV imaging with contrast, e.g. barium enema * Superficial needle biopsy * Clinical lab test requiring arterial puncture * Skin biopsies

* OTC

Moderate

* 1 or more chronic illnesses with mild exacerbation, progression, or side effects of treatment * 2 or more stable chronic illnesses * Undiagnosed new problem with uncertain prognosis, e.g., lump in breast * Acute illness with systemic symptoms, e.g. pyelonephritis, pneumonia, colitis * Acute complicated injury, e.g. head injury with brief LOC

* Physiologic test under stress, e.g. cardiac stress test, fetal contraction stress test * Diagnostic endoscopies with no identified risk factors * Deep needle or incisional biopsy * CV imaging studies with contrast and no identified risk factors, e.g. arteriogram and cardiac cath * Obtain fluid from body cavity

* Minor

High

* 1 or more chronic illnesses with severe

* CV imaging studies with contrast with identified risk factors * Cardiac EP test * Diagnostic endoscopies with identified risk factors * Discography

* Elective major surgery w/

exacerbation, progression, or side effects of treatment * Acute or chronic illnesses or injuries that may pose a threat to life or bodily functions, e.g. peritonitis, acute failure, multiple injuries, acute MI * An abrupt change in neurological status, e.g. seizure

Diagnostic Procedure(s) Ordered

Management Option Selected

drugs * Minor surgery w/ no identified risk factors * PT, OT • IV fluids w/out additives

surgery with identified risk factors * Elective major surgery (open, percutaneous, or endoscopic) with no identified risk factors * Prescription drugs * Therapeutic nuclear medicine * IV fluids w/ additives * Closed tx of fracture or dislocation without manipulation identified risk factors * Emergency major surgery * Parenteral controlled substances 97 * Drug therapy requiring intensive monitoring for toxicity * Decision not to resuscitate or to de–escalate care because of poor prognosis

Final Medical Decision-Making Level • 2 of the 3 Elements must be met or exceeded •

Number of Diagnosis or Treatment Options

•

Amount and/or Complexity of Data Reviewed

•

Risk of Complication and/or Morbidity/Mortality

98

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Final Result for Medical Decision Making (must meet or exceed two out of three elements) Number diagnoses/treatment options

=4 Extensive

Amount & complexity =4 Extensive

Highest risk

Minimal

Low

Moderate

High

Type of decision making

Straight forward

Low Complex

Moderate Complex

High Complex 99

Example of Medical Decision Making Number of Diagnoses or Treatment Options Assessment: The diabetes is controlled with diet and exercise, blood glucose levels are within acceptable limits. The high blood pressure that we have been monitoring and trying to control with diet and exercise is now far above an acceptable range.

The first problem is considered an established stable problem while the blood pressure is an established problem worsening.

 

Established Problem – Stable Improved Established Problem – Worsening

100

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Example of Medical Decision Making • Amount &/or Complexity of Data Reviewed

The patient comes in for a recheck of diabetes that is controlled with diet and exercise, blood glucose levels are within acceptable limits, and high blood pressure that you have been monitoring and trying to control with diet and exercise is through the roof. A CBC, Chemical profile, urinalysis, electrocardiogram, and chest x-ray are ordered. • Review &/or order of clinical lab tests • Review &/or order of tests in the medicine section of CPT • Review &/or order in the radiology section of CPT

101

Medical Decision Making Risk of Complications &/or Morbidity of Mortality •

The patient comes in for a recheck of diabetes that is controlled with diet and exercise, blood glucose levels are within acceptable limits, and high blood pressure that you have been monitoring and trying to control with diet and exercise is through the roof. A CBC, Chemical profile, urinalysis, electrocardiogram, and chest x-ray are ordered. Impression: 1. Diabetes-controlled. 2. Hypertensionuncontrolled. Atenolol 50 mg prescribed. The patient is to return in one week for recheck. • 1 or more chronic illnesses with mild exacerbation, progression or side effects of treatment

• Lab test requiring venipuncture / CXRs / ECG • Prescription Drugs

102

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TIME • If the physician elects to report the level of service based on counseling and/or coordination of care, the total time of the encounter (face-to-face time) should be documented.

Time determines level if 50% of encounter is Counseling and Coordination of Care.

103

103

Documentation Requirements for Reporting Time

• Total Counseling Time • Who was present • Diagnosis/prognosis

• Risk/Benefits of Treatment

• Informed consent for Procedure

• Instructions for treatment • Importance of Compliance

• Additional workup needed 104

104

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USING TEMPLATES /FORMS FOR DOCUMENTATION

• A Template for History Portion can be filled by the

patient with a notation by the physician “I have reviewed the questionnaire with the patient” signed and date • The Template can be used as a Grid for dictation. • Increased accuracy in capturing required data for documentation requirements. • Economics- Another way to increase profit is to cut costs. It will allow you to more easily transition to an EMR and cut down all of your transcription costs. 105

105

E&M Exercise

106

106

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Poll Questions

107

Poll Questions

108

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Poll Questions

109

Poll Questions

110

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Poll Questions

111

This Week’s Homework Call or Email me if you have questions!!

Fax or Email To Me 112

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