1 Evaluation & Management Services. 2 E/M Coding Key components History Physical examination Medical Decision making Contributory factors Nature of the.

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Evaluation & Management Services

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E/M CodingKey components

History Physical examination Medical Decision making

Contributory factors Nature of the presenting problem

•Medical Necessity drives code selection Extent of counseling Coordination of care Time

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E/M GuidelinesMedicare and Commercial Insurance

CMS 1995 and 1997 E/M guidelines• Use either set• 1997 approved by AMA

Medicaid Does not use ‘95 or ‘97 guidelines Uses AMA guidelines found in the CPT

book• E/M Service Guidelines section in

“Instructions for selecting a Level of E/M Service”

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Medical Necessity

A service that is reasonable and necessary for the diagnosis and treatment of illness or injury, or to improve the functioning of a malformed body member

Government definition

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History

Definitions Chief complaint (CC)(CC)

• Reason for the visit History of present illness (HPI)(HPI)

• Chronological review of condition/complaint

Review of systems (ROS)(ROS)• Inventory of systems through questions

Past, Family, Social, History (PFSH)(PFSH)

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HistoryProblem Focused Detailed

Chief Complaint Chief Complaint Brief HPI (1-3) Extended HPI (4 or status of No ROS 3 chronic/inactive) No PFSH Extended ROS (2-9)

Expanded Problem Pertinent PFSH (1)

Focused Comprehensive Chief Complaint Chief Complaint Brief HPI (1-3) Extended HPI (4 or status of Problem pertinent ROS (1) 3 chronic/inactive) No PFSH Complete ROS (10)

ALL 3 elements must be Complete PFSH (2 or 3

met: HPI,ROS,PFSH based on category of E/M)

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CPT History Guidelines(Medicaid)

Problem focused: CC; brief HPI Expanded problem focused: CC; brief HPI,

problem pertinent ROS Detailed: CC; extended HPI, problem pertinent

ROS extended to include a review of limited number of additional systems; pertinent PFSH directly related to the patient’s problems

Comprehensive: CC; extended HPI, ROS which is directly related to the problem(s) identified in the HPI plus a review of all additional body systems; complete PFSH

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History ExampleCC - Vaginal dischargeHPI - New patient is complaining of a white

vaginal (location) discharge for the past 2 days (duration) with a heavier flow in the morning (timing). There is no change with Monistat (modifying factor).

ROS - Patient denies itching (integumentary), burning with urination (genitourinary) or fever (constitutional).

PFSH - Patient has had 2 sexual partners in the past 60 days (social)

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History Example

History Level = Detailed (3 of 3) CCCC HPIHPI = Extended (4+ elements) ROSROS = Extended (3 elements) PFSHPFSH = Pertinent (1 element)

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Physical ExamProblem

Focused (95)<1 body area/ organ system (97) 1-5 elements

Expanded Problem Focused

(95) 2-4 body areas/ organ systems

(97) 6 - 11 elements

Detailed (95) 5-7 body areas/organ systems

(97) 12 elements in 2+areas/systems

Comprehensive (95) 8 organ systems

(97) General exam: Perform all elements document at least 2 elements in each of 9 areas/systems

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CPT Physical Exam Guidelines(Medicaid)

Problem focused: limited exam of the affected body area or organ system

Expanded problem focused: limited exam of the affected body area or organ system and other symptomatic or related organ system(s)

Detailed: extended exam of the affected body area(s) and other symptomatic or related organ system(s)

Comprehensive: general multi-system exam or a complete exam of a single organ system

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Physical Exam ExampleVaginal Discharge Exam

Constitutional• BP, temp, pulse

Genitourinary• Examination of external genitalia• Examination of cervix

Physical Exam level = Expanded Problem Focused At least two body areas/organ

systems

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Decision MakingStraightforward

#Diagnostic/treatment options (0 -1)(0 -1)

Amt./complexity of data (0 -1)(0 -1)

Risk (minimal)

Low Complexity #Diagnostic/treatment

options (2) (2) Amt./complexity

of data (2) (2)

Risk (low)

Moderate Complexity

#Diagnostic/treatmentoptions (3)(3)

Amt./complexity of data (3)(3) Risk (moderate)

High Complexity #Diagnoses/mgmt options

(4)(4) Amt./complexity of data (4)(4) Risk (high)

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CPT MDM Guidelines(Medicaid)

Complexity measured by: # of possible diagnoses and/or the number the number

of management optionsof management options that must be considered.

Amount/complexity of records, tests, other tests, other informationinformation that must be obtained, reviewed, and analyzed.

Risk of significant complications, morbidity, morbidity, mortality, as well as co-morbidities, mortality, as well as co-morbidities, associated with the patient’s presenting associated with the patient’s presenting problem(s),problem(s), the diagnostic procedure(s) the diagnostic procedure(s) and/or the possible management options.and/or the possible management options.

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Decision Making ExampleVaginal Discharge Exam

New problem, additional workup planned• Lab is ordered (4)(4)

Review/order tests in 8xxxx series (1)(1) Moderate decision making

• Undiagnosed new problem with uncertain prognosis• Prescription drug management

– Prescription written

Decision Making level = Moderate (2 0f 3)(2 0f 3) Extensive # Diagnosis/treatment options Minimal amount of data to be reviewed Table of risk - Moderate

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Level Assignment ExampleHistory = DetailedPhysical exam = Expanded Problem

Focused Decision Making = Moderate

Level = 99202, new patient If established patient = 99214

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Contributing FactorsPresenting Problem

Minimal Self-Limited/Minor Low Severity Moderate Severity High Severity

Time FACE-TO-FACE Time is a key factor ONLY when:

• Counseling or coordination of care takes up OVER 50% of the total visit time

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Counseling/Coordination of Care

Main factor determining code when takes up MORE than 50% of the total visit time Documentation:

• Total visit time• Time spent in Counseling/Coordination of Care

– Face to face

• Subject/ content

Code level is based on the total visit time not just the time spent in counseling

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Counseling ExamplesEstablished patient, 20 minute visit to

follow-up on oral contraceptive use NP 99213 RN 99211 (MA 99213)

15 minutes of a 20 minute visit spent counseling the patient on alcohol and cigarette use during pregnancy

NP 99213 RN 99211 (MA 99213)

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Definitions

New patient Has not received face-to-face

services from • ANY provider in the agency • Within past 3 years (AMA)

Established patient Has received face-to-face services

from • ANY provider in the agency • Within past 3 years (AMA)

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Selecting a Level of E/MIdentify

Place of service (POS)(POS) = where (office) Type of service (TOS) (TOS) = what

(Problem/Preventive) Status of Patient = who (New/Established)

Determine the extent of history - history - physical exam - decision making - physical exam - decision making - counselingcounseling Must consider all factors, and make sure

adequate DOCUMENTATIONDOCUMENTATION in chart to justify code.

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Office99201-99215

Report Problem visit (vs. Preventive visit)99201-99205, 99212-99215 performed by

MD,DO,NP,PA,CNS 99211 - Ancillary staff i.e. RN, LPN, CNA

MD/NP must be in the clinic

Report only 1 E/M per dayReport diagnostic tests, studies,

procedures separately

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Office99201-99215

(Medicaid) 99201-99205, 99212-9921599201-99205, 99212-99215 may be

performed by any staff of a “certified family planning clinic”. Staff may be MD, NP, PA, RN, CMA or unlicensed personnel acting in a coordinated manner to provide the service(s).

Other reporting requirements are the same as other providers

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Preventive Medicine Services

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Preventive Medicine 99381-99397

Routine management of patients without presenting problems, i.e. annual, routine, well child exams

Performed by MD, DO,NP,PA,CNS Includes other clinic staff if Medicaid

Codes New/established patients Age

Not used for scheduled follow-up visits for specified problems