Evaluation & Management Coding

8/7/2019 Evaluation & Management Coding

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EVALUATION &MANAGEMENT CODING

Presented by: Sherri Jurysta



Foc us of this Presentati o n

Intro duc tio n to Evaluatio n & Management (E/M)co des ² l oc ated in CPT ManualGuidelines established by CMS

1995 Guidelines1997 Guidelines

Co mpo nents of E/M co ding



E/M Co des

Used fo r no n-surgical/pr oc edural servi ces

E/M co des are divided int o three categ o riesO ff ice visits, Ho spital visits, and C o nsultatio nsMo st categ o ries inc lude sub categ o riesFurther identi f ied by level of service ² identi f ied by co des

Other subse c tio ns of E/M inc lude:Ho spital in patient

Co nsultatio n

Critical

care

Pediatri c and Ne o natal critical care

Emergenc y care

Preventative Medi c ine





E/M Co des

Three ´keyµ co mpo nents to determine level of service ²must besubstantiated in the d oc umentatio n

Histo ry

Physical Exam

Medical De c isio n Making

Time ² o nly when 50% o r mo re of the visit is doc umentedco unseling and/ o r coo rdinati o n of care

Spe c if ied d oc umentatio n is best fo r generating the pr o perlevel of service co de ² ´ if it is not documented, it did not occur.µ



E/M Doc umentatio n Guidelines

Guidelines are pr o vided by CMS1995 and 1997 E/M Doc umentatio n Guidelines

http://www. cms.go v

Pro viders can use either system ² varian ce is in the determinati o n of the

key co mpo nents

PROBLEMFOCUSED

EXPANDEDPROBLEMFOCUSED

DETAILED COMPREHENSIVE

1997 1 -5 bullets 6-12 bullets 12 bullets >/= 2 bullets fo r ea c h of 9 areas/ systems OR ´allµelements in a single system

1995 1 bo dyarea/system

2 -7 bo dy areas/systems( 2 , 3, o r 4 systems)

2 -7 bo dy areas/systems, mo redetail(5 , 6, o r 7 systems)

8 o r mo re systems ORco mplete single system



Co mpo nents of E/M Co des

Histo ryHisto ry of present illness

Review of systems

Past, Family and s oc ial histo ry

Exam1995 o r 1997 standards

Medical De

cisi

on Making

Amo unt of diagn o ses

Amo unt/ co mplexity of data

Risk (determined by pr o vider)

Co unselingDiscussing results, pro gno sis, treatmento ptio ns, ec t. with patient and/ o r f amily

Coo rdinatio n of CareMaking arrangements with o therpro viders

Nature of presenting Pr o blemInc luded with am o unt of diagn o ses in

MDMTime (c learly d oc umented)

Fa ce to f a ceUnit/ f loo r time

´K EYµ COMPONENTS ´ CONTRIBUTORYµ COMPONENTS



Abstra c ting the C o mpo nents

EM_Wo rksheet_Aqua[ 1] .pd f

CMS uses an audit t oo l to co nf irm the co rre c t level of servicewas billed ²

Attac hed t o hand o utE/m wo rksheets are availableChec klists fo r the pr o vider t o use during a visit are help f ulVo lume of doc umentatio n is no t the s o le inf luence fo r the levelof service. The reas o n the patient presented is als o co nsideredwhen determining medi cal ne cessity of the en co unter.



Histo ry Co mpo nents

HPI ² Histo ry of Present Illness

ROS ² Review of SystemsDetermine the am o unt of systems reviewed

PFSH = Past, Family, and S oc ial Histo ryIllnesses, surgeries, injuries, f amily diseases, and current/pasta c tivites

Elements of HPIQ uality Loc ati o n

Duratio n Severity

Timing Co ntext

Mo difying Fa cto rs Assoc iated Signs/Sympt o ms





MDM, Data & Risk Co mpo nents

The extent of info rmatio n doc umented determines thelevel of de c isio n makingNumber of Diagno ses o r treatment o ptio ns

Mino r, established, o r newData

Review/ dis cuss labs, tests, o ld re co rds

RiskRef ers t o level of risk at time of visitCo mplicatio ns, mo rbidity, and/ o r mo rtality



Sele c ting an E/M co de

Determine the categ o ry based o n loc atio nDetermine sub categ o ry ² situati o nalReview re co rd fo r ´keyµ co mpo nents

Take n o te i f there are ´ co ntributo ryµ co mpo nentsAnalyze the in fo rmatio n and assign pr o per co deLevel of service rep o rted MUST ref lec t the medi cal ne cessityof the visit.

Example ² treatment of a skinned knee w o uld no t quali f y fo r aco mprehensive level of service- regardless of doc umentatio n.



Helpful Tips

If yo u can't read it ² neither can CMS

If it is no t d oc umented ² it did n o t happen

If there is n o signature - h o w do yo u pro ve who did it

No

date - when was it do

neNo Chief Co mplaint - why was the servi ce d o ne

Chart sho uld inc lude: who (patient name), what ( c hief co mplaint), when(histo ry), where (exam), h o w (medical de c isio n making)

Read and re-read the d oc umentatio n guidelines

Make sure d oc umentatio n is legible and re co rds are signed and dated



Thank Yo u

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