Evaluation and Management Services April 2013

Evaluation and Management Services

April 2013

INPATIENT AND OUTPATIENT SERVICES

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What is E&M Coding? Evaluation and

Management Codes (E&M) Three to 5 levels of codes for

each type/location of visit Reimbursement dependent on

level Can document using:

Documentation Guidelines Time spent in counseling and

coordination of care 1997 guidelines best for

psychiatry as includes a single system exam.

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Understanding Billing Codes and Their Requirements

Evaluation and Management Codes (E&M) Work Based Coding Decision

based on: the type and comprehensiveness of

the history; extensiveness of the examination; complexity of the medical decision-

making

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Understanding Billing Codes and Their Requirements Evaluation and Management Codes (E&M)

New or established client groupings New: client who has not received any

professional services from the physician/non-physician practitioner or another physician of the same specialty or sub-specialty in the same group within the past 3 years. OMH consider the clinic the group.

On-call: original physician’s relationship to client rules if a part of the group

No distinction of new/established in an emergency room

Also for payers other than Medicare, consultations may be available codes

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Understanding Billing Codes and Their Requirements

Evaluation and Management Codes (E&M) Time is defined differently depending

on location: Office and OP:

Face to face time Non face to face time is not included but included in

work value for the service

Inpatient Face to face time plus work on floor or unit –

reviewing charts, talking to family or other treatment staff, etc.

Counseling and coordination of care MUST take place at bedside or on floor unit

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The Three Key Components

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History: counting elements and components

Examination: counting elements

Medical Decision Making (MDM): presenting

problems, additional information reviewed to

determine diagnoses and management options and

risk associated with management options.

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History

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Documentation of History will include some or all of the following elements:• Chief Complaint (CC)

• History of Present Illness (HPI): must be taken by prescriber

• Review of Systems (ROS): can be documented by pati

• Past Medical, Family, and/or Social History (PFSH)

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Elements of HPI

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Timing: onset of illness; description of onset – rapid, slow, intermittent

Severity: intensity; in pain management would use a 1-10 scale;

Quality: how does it feel? What is the quality of the symptom

Location: where is it felt? Duration: if episodic, how long last? Felt intensely for how

long? Context: risk factors present or absent; when is it worse

and when better – night, morning, in public, at work, etc. Modifying Factors: what makes it better – any self-help,

symptoms management; what makes it worse – symptoms are relieved by or symptoms are made worse by

Associated Signs and Symptoms – complains of and/or denies

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Review of Systems (ROS)

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Constitutional Eyes Ears/Nose/Mouth/

Throat Cardiovascular Respiratory Gastrointestinal Genitourinary

Musculoskeletal Integumentary Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergic/Immunologic

A ROS is an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced. The following systems are recognized:

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Review of Systems - ROS

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An earlier ROS does not need to be re-recorded. Instead, correlate to the previous ROS by noting the date and location of the earlier ROS.

A review of systems may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.

For a Complete ROS, you may document all positive or pertinent negative responses and then state “all other systems reviewed and negative”. At least 2 positive or pertinent negative must be documented and then can do the round-up of all others.

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Behavioral Health Treatment,Medications

Hospitalizations, AllergiesChronic Diseases

General Medical Hx, developmental Hx, if appropriate

Parents, Siblings, Etc.Specific Diseases Related to CC, e.g.

substances, MHHereditary/Congenital Diseases

Marital Status/Family StructureEmployment and Military Hx

Legal HxSexual History

EducationHobbies

Family History

Social history

Past, Family, & Social History - PFSH

Past Medical/Psych

History

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History - Special Exception

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If the physician is unable to obtain a history from the patient or other source, the record should describe the patient’s condition or other circumstance that precludes obtaining a history.

History will be considered comprehensive

Example: “Unable to obtain history - patient unconscious”

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Documentation of History Summary: 3 of 3 required

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History of Present Illness

(HPI)

Review of Systems

(ROS)

Past, Family, and/or Social

History

(PFSH)

Type of History

Brief 1-3 elements

N/A N/A Problem-Focused

Brief 1-3 elements

Problem-Pertinent 1 system

N/A Expanded Problem-Focused

Extended 4+ elements

Extended 2-9 systems

Pertinent 1 area

Detailed

Extended 4+ elements

Complete >9 systems

Complete 3 areas

Comprehensive

* Lowest level of the 3 components determines level of history

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1997 Documentation of Psych Examination

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Problem Focused One to five elements identified by a bullet.

Expanded Problem Focused At least six elements identified by a bullet.

Detailed At least nine elements identified by a bullet.

Comprehensive Perform all elements identified by a bullet from constitutional and psyc section and at least one element from the Muculoskeletal section.

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Medical Decision Making - MDM

Remember, two of the three elements must be met or exceeded.

Number of Diagnoses or Management

Options

Amount and/or Complexity of Data

to be Reviewed

Risk of Complications and/or

Morbidity or Mortality

Type of Decision Making

Minimal Minimal or none Minimal Straightforward

Limited Limited Low Low Complexity

Multiple Moderate Moderate Moderate Complexity

Extensive Extensive High High Complexity

Medical Decision Making - MDM

Remember, two of the three elements must be met or exceeded.

Number of Diagnoses or Management

Options

Amount and/or Complexity of Data

to be Reviewed

Risk of Complications and/or

Morbidity or Mortality

Type of Decision Making

Minimal Minimal or none Minimal Straightforward

Limited Limited Low Low Complexity

Multiple Moderate Moderate Moderate Complexity

Extensive Extensive High High Complexity

Coding E&M Outpatient: often the MD must code the

service themselves May have nursing or other billing back-up Templates have to be helpful in assisting with the

coding

Inpatient: professional coders will code the service based only on your documentation Templates: dictation or EMR provide guidance and

reminders Paper records: take your cheat sheets with you

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Example: Documentation Outpatient The client is a 23 year old female who needs a

refill of their prescription for Lithium and Klonopin. Client moved to area 2 months ago from Florida. Diagnosed with bi-polar disorder at age of 17 years. States she is well-controlled on current medications. States she is compliant with meds and uses Klonopin only 2-3 times a week for sleep, usually after stressful work days or fights with boyfriend.

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Example: Documentation ( CC: The client is a 23 year old female who needs a refill of

their prescription for Lithium and Klonopin.) (PFSH 1: Client moved to area 2 months ago from Florida.) (HPI 1: Diagnosed with bi-polar disorder at age of 17 years. HPI 2: States she is well-controlled on current medications. HPI 3: States she is compliant with meds and HPI 4: uses Klonopin only 2-3 times a week for sleep, usually after (PFSH 2:

stressful work ) days or (PFSH 3: fights with boyfriend. ) CC: yes PFSH: 1 count –only social history, no past medical or

family hx ROS: none HPI: Brief to extended problem pertinentEquals: Problem Focused History

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HPI Factors Timing: yes onset described Severity: yes well controlled Quality: Location: Duration: Context: yes – use of Klonopin Modifying Factors: yes - compliant with

medication Associated Signs and Symptoms:

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Example: New Client PX: WDWN female in no acute distress; temp 98.6, pulse 68,

BP 120/70, respirations 20. HEENT within normal limits; MSE normal, oriented x 3. 1995 Guidelines: 3 systems = Expanded problem focused –

vitals, HEENT, MSE 1 element 1997 Guidelines: one system for psych – depends on

completeness of MSE – need more detail in documentation or cannot be counted – vitals and only 1 element of MSE

Impression: Bi-polar disorder, stable on present medications. Client stable with known illness; even though med management

brings it to moderate level risk all other elements are for “straightforward”.

Plan: Prescription for 60 days; Lithium level now; client to check back sooner if any problems; client referred to Health Center for annual check-up. No case management or other MH needs at this time. RTC in 60 days.

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Example: Documentation Problem-focused history Problem to Expanded problem focused exam Straightforward medical decision-making Equals: 99201

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How Codes Chosen Outpatient Services chart Inpatient Services chart

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Special Coding Considerations

Time-based, Consultations, and Prolonged Services

Understanding Billing Codes and Their Requirements

Evaluation and Management Codes (E&M) If counseling and coordination of care

are 50% or more of the time spent in the encounter: E&M become time-based codes Counseling and coordination of care must

be documented Time spent in C&CofC and total time must

be documented

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Level of Service Based on Time TEACHING PHYSICIANS: teaching physician

may not add time spent by the resident in the absence of teaching physician to face-to-face time spent with the patient by the teaching physician with or without the resident present .

Example: “30 of 45 minutes on the floor concerned the

coordination of ____________ care and in discussion with patient and family about treatment options. Will follow-up with them tomorrow after they have had time to discuss.

“30 of 40 minutes spent at __________ bedside discussing medications and plans to ………”

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Consultation Services Documentation required: The service is provided by a physician/NPP whose opinion/advice

regarding the evaluation and management of a specific issue is being sought and has been requested by a provider.

The request is recognition of the consultant’s expertise in a specific medical area beyond the requesting provider’s knowledge;

The request must be documented in the medical record including why and from who the consult is being sought.

A written report of the consultant’s findings, opinions, and recommendations is documented in the inpatient record.

Intent is to return the patient to requesting provider for ongoing care of the problem.

The consultant may: Perform or order diagnostic tests, or Initiate a treatment plan, including performing emergent

procedures.

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Prolonged Services Only count the duration of direct face-to-face contact between the

physician and the patient (whether the service was continuous or not) beyond the typical/average time of the E/M visit code billed for the same date of service.

Must be 30 minutes or more beyond the typical time assigned to the E/M level coded Example: Average time for 99232 = 25 minutes, so a minimum of 55

minutes would be required to also bill 99356. Cannot bill prolonged services:

Based on time spent reviewing charts or discussing a patient with house medical staff without direct face-to-face contact with the patient.

These are add-on codes must have an underlying inpatient E/M service on the same date of service

If the total duration of direct face-to-face time does not equal or exceed the threshold time for the level of E/M service the provider is billing

When the E/M service is selected based on time, prolonged services may only be reported as the companion code with the highest code level in that family of codes (i.e., 99223, 99233, or 99255).

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Split Visits This is a shared visit between a physician and an

NPP (within scope of practice) from the SAME practice.

Can occur in hospital inpatient, outpatient (incident to) or ED

Each perform a part of the E&M service Physician MUST provide a face to face portion of

the E&M (clearly documented) Same patient and same DOS There is NO supervision requirement Each documents their portion Signatures and credentials of both

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Split Visits This is not simply a review of the work of the

NPP – physician must clearly perform a face to face portion of the E&M

NO: Seen and agree Discussed and agree Pt. seen and evaluated

Code is chosen using combined work and documentation

Billed at 100% of physician schedule

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Split Visits CNS makes a morning round and sees patient

for subsequent hospital visit Interval history and exam

Psychiatrist comes later in pm and sees patient, reviews earlier note, does brief exam and writes orders for labs, makes medication changes.

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Thank You!

For additional information: Mary Thornton

[email protected]

617-730-5800

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