Rational Physician Coding for E/M Services VA-TX-MD-DE-DC Peter R. Jensen, MD, CPC www.EMuniversity.com Redacted Version
Rational Physician Coding for E/M
Services
VA-TX-MD-DE-DC
Peter R. Jensen, MD, CPC www.EMuniversity.com
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Goals
1) Improve physician E/M compliance 2) Avoid undercoding3) Decrease E/M coding anxiety4) Save time5) Keep the focus on patient care
Peter R. Jensen, MD, CPC
Rational Physician Coding for E/M Services
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A “Routine” Office PatientYou see an established office patient with stable HTN, DM2 and dyslipidemia. There is also a history of CAD, which is well controlled.
You make no changes in medications and schedule return visit in four months.Time spent is 15 minutesWhat is this encounter worth?
1394.6
12412
23 0.8
101 1236
MA/Cr = 28, LDL 77, HgbA1c 6.8
E/M Coding
E/M = Evaluation and ManagementHow patient encounters are translated into 5 digit numbers to facilitate billingWithin each type of encounter there are various levels of care
99211 $20.6099212 $36.8299213 $51.6399214 $80.5399215 $117.21
©2005 Peter R. Jensen, MD, CPC
50%
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E/M = Cognitive Labor
=The E/M Guidelines
The E/M Guidelines
Developed by the AMA and CMSFirst set released in 1995Second set released in 1997Based on three “Key Components”– History– Physical Exam– Medical Decision-Making
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History Physical
Problem FocusedExpanded Problem FocusedDetailedComprehensive
MDM
StraightforwardLow ComplexityModerate ComplexityHigh Complexity
History
PhysicalMDM
We think of the key components as being random, but they’re really not……
This is how auditors look at the E/M guidelines. They view the history, physical exam and medical decision-making in very concrete terms.
MDMHistory Physical
Straightforward
Problem Focused
Expanded Problem Focused
Detailed
Comprehensive
Problem Focused
Expanded Problem Focused
Detailed
Comprehensive
Low Complexity
Moderate Complexity
High Complexity
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Physical
Physical
ROS
HPI
PMHFH
SH
Exam Bullets
Organ Systems
Diagnoses
Data Reviewed
Risk
Our challenge is to find some way to translate our cognitive labor into the abstruse language of the E/M guidelines without wasting time on over-documentation or getting distracted from our real job of taking care of patients.
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MDM
H
RiskDataProblems
Primacy of Medical Decision-Making
MDM =
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Medical Necessity
“Correct” Level of Care
=
The Importance of Medical Necessity
“Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of E/M service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed.”
RiskDataProblems
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MDM Points
High44High
Moderate33Moderate
Low22Low
Minimal11Straight Forward
RiskData Problems MDM Complexity
Need 2 out of 3 to qualify for given level of MDM
Determining the MDM
High Complexity
HighExtensiveExtensive
Moderate Complexity
ModerateModerateMultiple
Low Complexity
LowLimitedLimited
Straight-Forward
MinimalMinimalMinimal
Level of MDM
RiskData Reviewed
Number of Diagnoses
Need 2 out of 3 to qualify for given level of MDM
Given the importance of the MDM, it is essential that we be able to quan-tify this key component in an objective and repeatable manner. Unfortu-nately, the official table of MDM from both the 1995 and 1997 E/M guide-lines (shown above) makes this a very difficult thing to do. The problem is that the terms used to stratify the dimensions of MDM are too vague.
The framers of the E/M guidelines realized that the MDM rules were to vague to be used by auditors, so they came up with a weighted point sys-tem which was eventually released to all Medicare carriers to used on a “voluntary” basis.
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Points for Data Reviewed
1Decision to obtain old records
2Independent review of image, tracing, or specimen
1Review/order clinical lab tests
2Review and summation of old records
1Discussion of test results with performing MD
1Review/order tests in the medicine section (echo, EKG, LHC, PFTs)
1Review/order X-rays
PointsData Reviewed
Problem Points
1Self limited or minor (Max 2)
4New problem, additional work-up planned
3New problem, no additional work-up planned
2Established problem, worsening
1Established problem, stable
PointsProblems/DDx
The problem points are tabulated by referring to this table. You add up all the problems you are addressing during the encounter and come up with the final number of total problem points. “New” problems are defined relative to the physician, not the patient.
The data points are calculated using this table. You only get one data point for reviewing and/or ordering labs and ordering or reviewing X-ray reports. If you personally review any primary data (such as an EKG, an X-ray or a blood smear, etc.), you get two data points, but you must record your findings in the chart.
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Risk Presenting Problem(s) Diagnostic Procedures Management Options Selected
Minimal • One self-limited or minor prob-lem, e.g., cold, insect bite, tinea corporis
• Laboratory tests • Chest X-rays • EKG/EEG • Urinalysis • Ultrasound/
Echocardiogram • KOH prep
• Rest • Gargles • Elastic bandages • Superficial dressings
Low • Two or more self-limited or minor problems
• One stable chronic illness, e.g., well controlled HTN, DM2, cataract
• Acute uncomplicated injury or illness, e.g., cystitis, allergic rhinitis, sprain
• Physiologic tests not under stress, e.g., PFTs
• Non-cardiovascular imag-ing studies with contrast, e.g., barium enema
• Superficial needle biopsy • ABG • Skin biopsies
• Over the counter drugs • Minor surgery, with no identi-
fied risk factors • Physical therapy • Occupational therapy • IV fluids, without additives
Moderate • One or more chronic illness, with mild exacerbation, progres-sion, or side effects of treatment
• Two or more stable chronic ill-nesses
• Undiagnosed new problem, with uncertain prognosis, e.g., lump in breast
• Acute illness, with systemic symptoms, e.g., pyelonephritis, pleuritis, colitis
• Acute complicated injury, e.g., head injury, with brief loss of consciousness
• Physiologic tests under stress, e.g., cardiac stress test, fetal contraction stress test
• Diagnostic endoscopies,
with no identified risk factors
• Deep needle, or incisional biopsies
• Cardiovascular imaging studies, with contrast, with no identified risk factors, e.g., arteriogram, cardiac catheterization
• Obtain fluid from body cavity, (e.g., LP or thora-centesis)
• Minor surgery, with identified risk factors
• Elective major surgery (open, percutaneous, or endoscopic), with no identified risk factors
• Prescription drug manage-ment
• Therapeutic nuclear medicine • IV fluids, with additives • Closed treatment of fracture
or dislocation, without ma-nipulation
High • One or more chronic illness, with severe exacerbation, pro-gression, or side effects of treat-ment
• Acute or chronic illness or in-jury, which poses a threat to life or bodily function, e.g., acute MI, pulmonary embolism, severe respiratory distress, progressive severe rheumatoid arthritis, psy-chiatric illness, with potential threat to self or others, peritoni-tis, ARF
• An abrupt change in neurologi-cal status, e.g., seizure, TIA, weakness, sensory loss
• Cardiovascular imaging, with contrast, with identi-fied risk factors
• Cardiac EP studies • Diagnostic endoscopies,
with identified risk factors • Discography
• Elective major surgery (open, percutaneous, endoscopic), with identified risk factors
• Emergency major surgery (open, percutaneous, endo-scopic)
• Parenteral controlled sub-stances
• Drug therapy requiring inten-sive monitoring for toxicity
• Decision not to resuscitate, or to de-escalate care because of poor prognosis
Table of Risk
This is the official table of risk for both the 1995 and 1997 E/M guidelines. The rules explicitly stat that it only takes one element in any of the catego-ries above to qualify for any given level of risk. Use highest level of risk present to stratify the overall level of risk for any encounter.
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Calculating the Overall MDM
High44High
Moderate33Moderate
Low22Low
Minimal11Straight Forward
RiskData Problems MDM Complexity
Need 2 out of 3 to qualify for given level of MDM
The overall level of MDM is determined by
TrailBlazer Changes the Rules
Unfortunately, if you practice in VA, TX, MD, DE or Washington, D.C., your Medicare carrier (TrailBlazer) recently came up with a completely new medical decision-making point system. The rules are much more complex than the standard MDM rules used by everyone else. In addition, providers have to work harder to qualify for higher levels of medical decision-making.
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TrailBlazer Changes the Rules
TrailBlazer is the Medicare carrier for TX, MD, VA, DE and Washington, D.C.They have unilaterally changed the way that they audit the key component of Medical Decision-Making:– Number of points required is higher– Problem points are added up differently– Different values for data points– Risk is identical to the old rules
TrailBlazer MDM Points
≥High5 Moderate3 Low
≤Straight Forward
RiskData Problem D
MDM Complexity
Need 2 out of 3 to q
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High
ModerateLow
Straight Forward
PMDM Complexity
HighModerate
LowMinimal11Straight ForwardRiskData Pts Problem PtsMDM Complexity
New
Standard MDM Rules
Dx + Tx#Tx#DxNumber of Diagnoses and/or Management Options
Total
New or established problem and E/M is mentioned
New or established problem; no E/M mentioned and problem IS clearly a co-morbid condition
New of established problem; no E/M mentioned and problem IS NOT clearly a co-morbid condition
TrailBlazer Problem Points
?
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1Referral to another physician, consultation
2Hospital admit – other physician(s) contacted
1Hospital admit
1Pt educated on self or home care topics/techniques
1IM injection or other pain management procedure
1Radiation therapy
1Conservative therapy: rest, ice, bandages, diet
2Insulin prescription (sc or combo sc/iv), hyperal, insulin gtt, etc1IV fluids1Closed treatment for fracture/dislocation1Physical, occupational or speech therapy
1Open or percutaneous procedure
1Other – specify
2Drug management (more than 3 Δ’s)
1Drug management (new Rx or Δ dose)
1Continue same treatment and/or monitoring
PointsProblems/Therapeutic Options
1Discuss case with consultant or order consultation or discuss case with other physician managing patient
1Physiologic monitoring
1Order and/or summarize old records
1Review/order clinical lab tests
1Independent review of image, tracing, or specimen
1Discuss test results with performing MD
1Review/order tests in the medicine section (echo, EKG, LHC, PFTs)
1Review/order X-rays
PointsData Reviewed
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Calculating the MDM with the TrailBlazerPoints
High≥ 4≥ 7HighModerate35 - 6Moderate
Low23 - 4Low
Minimal≤ 1≤ 2Straight Forward
RiskData Pts
Problem DDx
MDM Complexity
Need 2 out of 3 to qualify for given level of MDM
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Problem FocusedExpanded Problem FocusedDetailedComprehensive
CCHPIROSPFSH
History
Levels of History
None1BriefEPF1 out of 32 – 9ExtendedDetailed
NoneNoneBriefPF
3 out of 310ExtendedComp
PFSHROSHPIHistory
There are four levels of history based on the documentation of the HPI, ROS and elements of past medical, family and social history.
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HPI
A narrative of the patient’s symptoms or illnesses since onset or since the previous encounterEvery level of history requires and HPI, which may be referred to as an “interval history” for follow-up encountersThe HPI is the only component of history which MUST be personally obtained and documented by the provider
Elements of HPI
• Location • Duration • Timing • Quality
• Severity • Context • Modifying factors • Associated signs or
symptoms
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HPI Elements
LocationQualitySeverityDurationTimingContextModifying FactorsAssociated Signs/Symptoms
Patient complains of stabbing intermittent chest pain which began 8 hours ago while watching TV. The pain is rated as 8/10 in severity, is worse with exertion and is associated with SOB and nausea.
Location
Severity
Quality
Timing
Modifying Factors
Duration
Context Associated Signs or
Symptoms
Example of an extended HPI using all eight of the HPI elements.
Levels of HPI
Brief HPIRequires only one to three HPI elements
Extended HPIRequires four HPI elements or the status of three chronic or inactive problems
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ROSConstitutional EyesEars, nose, mouth, throatCardiovascularRespiratoryGIGU
MusculoskeletalSkinNeurologicalPsychiatricEndocrineHem/LymphaticAllergic/Immunologic
The ROS may be completed by the physician, ancillary staff or by having the patient fill out a questionnaire.
Without a specific somatic complaint, it may be difficult or outright impossible to qualify for any level of HPI using the HPI elements. This problem was addressed in the 1997 E/M guidelines. If there are no somatic complaints, the 1997 E/M guidelines allow you to qualify for extended HPI by commenting on the status of three or more chronic or inactive problems.
What if the patient has no complaints?
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PFSH
Past Medical History– Previously existing illnesses, prior operations,
current medications, allergies, immunizationsFamily History– Health status of parents/siblings/children including
relevant or hereditary diseases Social History– Marital status, employment, DOA, education,
sexual history
The PFSH may be completed by the physician, ancillary staff or by having the patient fill out a questionnaire.
Levels of History
None1BriefEPF1 out of 32 – 9ExtendedDetailed
NoneNoneBriefPF
3 out of 310ExtendedComp
PFSHROSHPIHistory
The documentation requirements for each level of history are very specific. Therefore, the history should be recorded in a purpose-driven manner to ensure compliance while avoiding time-wasting over-documentation.
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History Tips and Shortcuts 1. You need a chief complaint for each and every encounter. It may be a symptom or it may be a state-
ment such as “follow-up HTN.”
setting. These codes are used in addition to the inpatient E/M codes.
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Physical Exam
1997 Physical Exam 15 Organ Systems and 59 bullets
6 - 11EPF12Detailed
1 - 5PF
18Comp
BulletsExam
1997 Physical Exam Organ Systems
• Constitutional • Eyes • Ears, nose, mouth and throat • Neck • Respiratory • Cardiovascular • Chest (breasts) • Gastrointestinal • GU (male, female) • Musculoskeletal • Lymphatic • Skin • Neurologic • Psychiatric
See individual bullets on next page.
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The 1997 Multi-System Exam Bullets Constitutional
• Three vital signs • General appearance
Eyes • Inspection of conjunctiva and lids • Examination of pupils and irises
(PERRLA) • Ophthalmoscopic discs and posterior
segments
Ears, Nose, Mouth, and Throat
• External appearance of the ears and nose
• Otoscopic examination of the exter-nal auditory canals and tympanic membranes
• Assessment of hearing • Inspection of nasal mucosa, septum
and turbinates • Inspection of lips, teeth and gums • Examination of oropharynx: oral
mucosa, salivary glands, hard and soft palates, tongue, tonsils and pos-terior pharynx
Neck
• Examination of neck (e.g., masses, overall appearance, symmetry, tra-cheal position, crepitus)
• Examination of thyroid
Respiratory
• Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic excursions)
• Percussion of chest • Palpation of chest (e.g., tactile fre-
mitus) • Auscultation of the lungs
Cardiovascular
• Palpation of the heart (PMI) • Auscultation of the heart • Assessment of lower extremity
edema • Examination of the carotid arteries • Examination of abdominal aorta • Examination of the femoral pulses • Examination of the pedal pulses
Chest (Breasts)
• Inspection of the breasts • Palpation of the breasts and axillae
Lymphatic Palpation of lymph nodes two or more areas
• Neck • Axillae • Groin • Other
Skin • Inspection of skin and subcutane-
ous tissue (e.g., rashes, lesions, ulcers)
• Palpation of the skin and subcu-taneous tissue (e.g., induration, subcutaneous nodules, tighten-ing)
Neurologic
• Test cranial nerves with notation of any deficits
• Examination of DTRs with nota-tion of any pathologic reflexes (e.g., Babinksi)
• Examination of sensation (e.g., by touch, pin, vibration, proprio-ception)
Psychiatric
• Description of patient’s judgment and insight
Brief assessment of mental status, which may include:
• Orientation to time, place, and person
• Recent and remote memory
• Mood and affect
Gastrointestinal (Abdomen)
• Examination of the abdomen with notation of presence of masses or ten-derness
• Examination of the liver and spleen • Examination for the presence or ab-
sence of hernias • Examination of anus, perineum, and
rectum, including sphincter tone, pres-ence of hemorrhoids, rectal masses
• Obtain stool for occult blood testing
Genitourinary (Male)
• Examination of the scrotal contents (e.g., tenderness of cord)
• Examination of the penis • DRE of the prostate
Genitourinary (Female)
• Examination of the external genitalia • Examination of the urethra • Examination of the bladder (e.g., full-
ness, masses, tenderness) • Examination of the cervix • Examination of the uterus (e.g., size,
contour, position, mobility) • Examination of the adnexa (e.g., masses,
tenderness, nodularity)
Musculoskeletal
• Examination of gait and station • Inspection and/or palpation of digits and
nails (e.g., clubbing, cyanosis, ischemia)
Examination of the joints, bones, and muscles of one or more of the following six areas:
1. Head and neck 2. Spine, ribs, and pelvis 3. Right upper extremity 4. Left upper extremity 5. Right lower extremity 6. Left lower extremity
The examination of a given area includes:
• Inspection and/or palpation with notation of presence of any mis-alignment, asymmetry, crepita-tion, defects, tenderness, masses or effusions
• Assessment of range of motion with notation of any pain, crepi-tation or contracture
• Assessment of stability with notation of any dislocation, sub-luxation, or laxity
• Assessment of muscle strength and tone with notation of any atrophy or abnormal movements
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1995 Exam Rules
♦Head/face ♦Neck ♦Chest/breast/axillae ♦Abdomen ♦Genitalia/groin/buttocks ♦Back/spine ♦Each extremity
♦Constitutional ♦Eyes ♦ENMT ♦Cardiovascular ♦Respiratory ♦GI ♦GU
♦Musculoskeletal ♦Skin ♦Neuro ♦Psychiatric ♦Hematologic-lymphatic
Problem Focused: a limited exam of affected body area or organ system Expanded Problem Focused: a limited exam of the affected body area or organ system and other symptomatic or related organ sys-tems Detailed: an extended exam of the affected body area or organ sys-tem and other symptomatic or related organ systems Comprehensive: a general multi-system exam or complete exam of a single organ system
Organ Systems Body Areas
The 1995 exam rules are included here for the sake of completeness. We recommend using the 1997 physical exam rules because they are
less open to individual interpretation and therefore more likely to stand up against an audit.
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Accounted for $11,155,924,872 in 200439% of E/M spendingFive levels of care99211 $21.0099212 $37.0099213 $52.0099214 $81.0099215 $117.00
Two out of three key components
Established Office Patients
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A “Routine” Office PatientYou see an established office patient with stable HTN, DM2 and dyslipidemia. There is also a history of CAD, which is well controlled.
You make no changes in medications and schedule return visit in four months.Time spent is 15 minutesWhat is this encounter worth?
1394.6
12412
23 0.8
101 1236
MA/Cr = 28, LDL 77, HgbA1c 6.8
Established Office Patients
40HighCompComp9921525ModDetailedDetailed9921415LowEPFEPF9921310SFPFPF992125NoneNoneNone99211
TimeMDMExamHistoryE/M Code
2 out of 3 key components must qualify
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Dx + Tx#Tx#DxNumber of Diagnoses and/or Management Options
Total
0
000New of established problem; no E/M mentioned and problem IS NOT clearly a co-morbid condition
Initial Problem Points
3
1 1
X ?
CAD
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Other – specifyReferral to another physician, consultationHospital admit – other physician(s) contactedHospital admitPt educated on self or home care topics/techniIM injection or other pain management proceduRadiation therapyConservative therapy: rest, ice, bandages, dietInsulin prescription (sc or combo sc/iv), hyperalIV fluidsClosed treatment for fracture/dislocationPhysical, occupational or speech therapyOpen or percutaneous procedureDrug management (more than 3 Δ’s)Drug management (new Rx or Δ dose)Continue same treatment and/or monitoring
Problems/Therapeutic Op
Dx + Tx#Tx#DxNumber of Diagnoses and/or Management Options
New or established problem and E/M is mentioned
0New or established problem; no E/M mentioned and problem IS clearly a co-morbid condition
000New of established problem; no E/M mentioned and problem IS NOT clearly a co-morbid condition
Final Problem Points
1 1
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•Drug therapy requiring intensive monitoring for toxicity•Obtain DNR or de-escalate care
factors•Cardiac EP studies•Diagnostic endoscopies, with identified risk factors
•One orwith sev•Acute or chronic illness or injury, which poses a threat to life or bodily function•An abrupt change in neurological status
High
•One chexacerb•Two st•Undiauncertai
Moderate
•Over the counter drugs•Minor surgery, with no risk factors•PT/OT•IV fluids, without additives
•Physiologic tests not under stress, e.g., PFTs•Non-cardiovascular imaging studies with contrast•ABG•Skin biopsies
•Two or more self-limited or minor problems•One stable chronic illness•Acute uncomplicated injury or illness, e.g., cystitis, allergic rhinitis, sprain
Low
•Rest•Gargles•Superficial dressings
•Laboratory tests •Chest X-rays•EKG/EEG, Echocardiogram
•One self-limited or minor problem, e.g., cold, insect bite, tinea corporis.
Minimal
Management Options
Diagnostic ProceduresPresenting ProblemsRisk
Discuss case with consultant or order consultation or discuss case with other physician managing patient
Physiologic monitoring
Order and/or summarize old records
Review/order clinical lab tests
Independent review of image, tracing, or specimen
Discuss test results with performing MD
Review/order tests in the medicine section (echo, EKLHC, PFTs)
Review/order X-rays
PointsData Reviewed
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Coding Based on Time
Adding Up the TrailBlazer MDM Points
Mo
StFo
MCo
Need
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In tcod
RequiredPresenceMDNo99211
TimeMDMExamHistoryE/M Code
Selecting the Target CodeEstablished Office Patients
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99214
25ModDetDet99214
TimeMDMExamHistoryE/M Code
2 out of 3 key components must qualify
ORNone1BriefEPF
1/32 – 9ExtDet
NoneNoneBriefPF
3/310ExtComp
PFSHROSHPIHx
6 – 11 from any systemsEPF
12 from any systemsDet
1 – 5 from any systemsPF
2 from EACH of NINE systemsComp
BulletsExam
How do you choose which one to do?
ModerateMDMExamHistoryTarget Code
tion
ualify
quires at om ANY
ur HPI of three lus 2 – 9 of PFSH
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99214Detailed HistoryDetailed ExamModerate MDM
2 out of 3 key components must qualify
Purpose-Driven Documentation
ModerateDetailedDetailed99214MDMExamHistoryTarget Code
In this example,
ModerateDetailedDetailed99214MDM
1/32 - 9ExtendedDetailedPFSHROSHPIHistory
CC: F/U HTN and DM2
Interval History: The patient’s HTN remains well controlled on
demia
eview of two ically relevant systems
mponent FSH
Status of Three ProblemsHTN, DM2, Dyslipidemia
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Physical ExaConstit ional Eyes ENMT Neck
Chest/Breasts
V
Skin
Musculoskeletal
Neurologic
1
ModerateDetailedDetailed99214MDMExamHistoryTarget Code
HEENT: No JVD or carotid bruits
Assessment1. Well controlled DM22. Well controlled HTN3. Stable dyslipidemia4. Underlying CAD
Plan1. Continue lisinopril unchanged for HTN2. Renal profile, Urine microalbumin, CBC on return3. Also check LFTs due to ongoing statin therapy4. Return visit in four months
Medical Decision-MakingHGBA1c = 6.8
0.812412
23101
two out of three
Here, only
.
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99214
Target Code History Exam MDM 99214 Detailed Detailed Moderate
Requires two out of three qualifying key components
CC: F/U HTN and DM2
Interval History: The patient’s s
is stable as well, with no sym a
remains stable on statin thera
PFSH is remarkable for CAD,
ROS CV: Negative for Che
Neuro: Negative for p
Vitals: 120/80, 18, 82, 98.6
General: NAD, conversant,
HEENT: No JVD, carotid bruit
Lungs: Clear to auscultation
CV: RRR, no MRG
Ext: No peripheral edema
s
H
OS cal
sed
y edema
iled exam)
Assessment
1. Well controlled DM2
2. Well Controlled HTN
3. Stable dyslipidemia
Plan
1. Continue lisinopril unchang
2. Renal profile, Urine microal
3. Also check LFTs due to ong
4. Return visit in four months
plexity e pres-out of matter
k
n
w
d
h
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Vitals: 120/80, 18, 82, General: NAD, conversLungs: Clear to auscultCV: RRR, no MRGAbd: Soft, non-tenderExt: No peripheral ede
CC: F/U HTN and DM2
Interval History: The patient’s HTN remains well controlled on current medications. Diabetes is stable as well, with nosymptomatic hypoglycemia or severe hyperglycemia. Dyslipidemia remains stable on statin therapy.
PFSH is remarkable for
ROS: CV: NegNeuro: N
Assessment1. Well controlled DM22. Well controlled HTN3. Stable dyslipidemia
Plan1. Continue lisinopril u2. Renal profile, Urine 3. Also check LFTs du4. Return visit in four m
2
Alternative Ending
99214Target Code
For established office patients, only two out of three qualifying key components are needed. In the above example,
The next page shows
how the documentation for this “alternative ending” might look.
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99214
Target 992
CC: F/U HTN
Interval Histor
Vitals: 120/80
General: NAD
HEENT: Anict
Neck: No JVD
Lungs: Clear
CV: RRR, no
Abd: Soft, no
Ext: No perip
Skin: Warm a
Assessment
1. Well contro
2. Well Contro
3. Stable dysli
Plan
1. Continue lis
2. Renal profil
3. Also check
4. Return visit
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MA/Cr =
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Accounted for a total of $4.9 billion in allowed charges in 2005This adds up to 16.5% of E/M spendingThree levels of care99231 $36.0099232 $64.0099233 $91.00
Requires documentation of 2 out of 3 key components
Hospital Progress Notes
35HighDetailedDetailed99233
25ModerateEPFEPF99232
15SF/LowPFPF99231
TimeMDMExamHistoryE/M Code
Only 2 out of 3 key components must qualify
Hospital Progress Notes
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Hospital Progress NoteYou see a patient with CHF exacerbation which had been improving on oral diuretics. CAD has been stable on oral nitrates with no active chest pain.
You notice an empty bag of potato chips on the tray table. BP is 160/90, edema has worsened and patient c/o orthopnea requiring 2 liters NC O2 at rest. Echo report from yesterday shows an EF of 25%.You replete K+, change the patient to a strict 2 gram sodium diet, look at the CXR, order labs and repeat CXR for the a.m. You also change pt to IV Bumex.Total time spent is 25 minutes
©2005 Peter R. Jensen, MD, CPC
1383.1
12410
23 0.8
101 1236
BNP is 1450
Number of Diagnoses a
New or established proble
New or established probleproblem IS clearly a co-m
New of established probleproblem IS NOT clearly a
Initial Problem Points
0
H
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Other – specify
1
Pts #
Referral to another physician, consHospital admit – other physician(s) Hospital admitPt educated on self or home care toIM injection or other pain managemRadiation therapyConservative therapy: rest, ice, banInsulin prescription (sc or combo scIV fluidsClosed treatment for fracture/dislocPhysical, occupational or speech thOpen or percutaneous procedureDrug management (more than 3 Δ’Drug management (new Rx or Δ doContinue same treatment and/or monitoring
Problems/Therapeutic Options1
3
1
1
Dx + Tx#Tx#DxNumber of Diagnoses and/or Management Options
New or established problem and E/M is mentioned
New or established problem; no E/M mentioned and problem IS clearly a co-morbid condition
000New of established problem; no E/M mentioned and problem IS NOT clearly a co-morbid condition
Final Problem Points
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•One or mowith severe •Acute or cinjury, whicor bodily fu•An abrupt neurologica
High
•One chronexacerbatio•Two stable•Undiagnosuncertain pr
Moderate
•Over the counter drugs•Minor surgery, with no risk factors•PT/OT•IV fluids, without additives
•Physiologic tests not under stress, e.g., PFTs•Non-cardiovascular imaging studies with contrast•ABG•Skin biopsies
•Two or more self-limited or minor problems•One stable chronic illness•Acute uncomplicated injury or illness, e.g., cystitis, allergic rhinitis, sprain
Low
•Rest•Gargles•Superficial dressings
•Laboratory tests •Chest X-rays•EKG/EEG, Echocardiogram
•One self-limited or minor problem, e.g., cold, insect bite, tinea corporis.
Minimal
Management Options
Diagnostic ProceduresPresenting ProblemsRisk
Discuss case with consultant or order consultationdiscuss case with other physician managing patie
1Physiologic monitoring
1Order and/or summarize old records
1Review/order clinical lab tests
1Independent review of image, tracing, or specimen
Discuss test results with performing MD
Review/order tests in the medicine section (echo, LHC, PFTs)
Review/order X-rays
PointsData Reviewed
Total 4
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Selecting the Target Code
352515SF/LowPFPF99231
TimeMDMExamHistoryE/M Code
2 out of 3 key components must qualify
Hospital Progress Notes
Adding Up the TrailBlazer MDM Points
High≥ 4≥ 7HighMod35 - 6ModerateLow23 - 4Low
Minimal≤ 1≤ 2Straight Forward
RiskData Pts
Problem DDx
MDM Complexity
Need 2 out of 3 to qualify for given level of MDM
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Least frused cencounReimbuabout $
2 o
Time
99233
99233
TimeMDMExamHistoryE/M Code
2 out of 3 key components must qualify
99233
35HighDetDet99233
TimeMDMExamHistoryE/M Code
6 – 11 from any systemsEPF
12 from any systemsDet
1 – 5 from any systemsPF
2 from EACH of NINE systemsComp
BulletsExam
None1BriefEPF
1/32 – 9ExtDet
NoneNoneBriefPF
3/310ExtComp
PFSHROSHPIHx
OR
In this case, we knAND that we alreadperform and documaddition to our qualhow the documentaof the history.
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HPI: The patient says he fe
CC: F/U CHF
2 out
DetailedHistory
99233Target Code
DeDeHi
Rational Documentation
2 out of
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Plan: 1. D/C PO Lasix 2. Start IV Bumex 2 mg Q 6H3. Strict low Na+ diet4. Replete K+ per protocoll5. Repeat renal profile, BNP in a.m.6. Repeat CXR in a.m.
Me
Assessment: 1. Decompensated CHF 2. Poorly controlled HTN 3. Mild hypokalemia4. Stable CAD
CXR wshowevascul
0.81383.1
12410
28101 12
36
BNP 1450Echo:
DetailedDetailed99233ExamHistoryTarget Code
High
Mod
Low
SF
MDM
Re
Vitals: 160/90, 18, 82, General: NAD, well nouNeck: FROM, supple; nLungs: Bibasilar crackl
CV: RRR, no MRGs; nAbd: Soft, non-tender; Ext: 2+ peripheral ede
Skin: Warm and dry; w
Physical ExamConstitutional Eyes ENMT Neck
hest/Breasts
CV
Skin
sculoskeletal
Neurologic
Psychiatric
GI GULungs1 2 3 4 5 6 7 8 9 10
11
12
Requires AT LEAST12 bullets from ANYorgan systems
igh99233DMTarget Code
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s Risk
Min
Low
Mod
High
99233 Detailed Detailed High
CC:
Interv
HPI, ualify
Vitals
Gene
Neck
Lung
CV:
Abd:
Ext: 2
Skin:
ts:
edema
)
Asse
1. De
2. Po
3. Mil
4. Sta
Plan
1. D/
2. Sta
3. Str
4. Re
5. Re
6. Re
complexity based problem points n though risk is
sions
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CC: CHF
Interval History: TThe patient’ feels generally
Assessment1. Decompensated CHF2. Poorly controlled HTN3. Mild hypokalemia4. Stable CAD
Plan1. D/C PO Lasix2. Start IV Bumex 2 mg Q 6H3. Strict low Na+ diet4. Replete K+ per protocol5. Repeat renal profile and BNP in a.m.6. Repeat CXR in a.m.
t
ets
Echo: RCXR wpulmon
Vitals: 160/90, 18, 82, 98.6 General: NAD, conversant, Neck: FROM, supple; no JVDLungs: Bibasilar crackles; clear to percussioCV: RRR, no MRG; normal PMIAbd: Soft, non-tender; no HSM Ext: 2+ edema; no digital cyanosis Skin: Warm and dry; well perfused A
High
Mod
Low
Min
Risk
Deta99233HisTarget Code
Remember, for hospital progress note, only two out of three qualifying key components must be documented. In the above example,
next page shows how the documentation might look for this “alternative ending.”
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Targ9
CC: F/U HTN
Interval Histor
HTN is poorly
chest pain.
ROS CV: +
Pulmo
Lungs: Bibasil
CV: RRR, no
Ext: 2+ edema
Assessment
1. Decompens
2. Poorly contr
3. Mild hypoka
4. Stable CAD
Plan
1. D/C PO Las
2. Start IV Bu
3. Strict low N
4. Replete K+
5. Repeat ren
6. Repeat CX
sed ts is
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Accounted for $1.3 billion in allowed charges in 2005This adds up to 4.4% of E/M spendingThree levels of care99221 $84.0099222 $118.0099223 $172.00
Requires documentation of 3 out of 3 key components
Admission H&Ps
3 out of 3 key components must qualify
Documentation: Admission H&Ps
70HighCompComp99223
50ModerateCompComp99222
30SF/LowDetailedDetailed99221
TimeMDMExamHistoryE/M Code
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Admission H&P
You are on ER backup and asked to admit a 68 year old diabetic male with HTN and dyslipidemia who presents with chest pain. After reviewing the EKG, CXR and labs, you decide to admit the patient to a monitored bed in the CCU and consult cardiology.The chest pain improves with IV MSO4. You also order ASA, NTP and sliding scale insulin.Total time spent is 50 minutesWhat is the correct code and documentation?
Number of Diagnoses and
New or established problem
New or established problem; problem IS clearly a co-morbi
New of established problem; problem IS NOT clearly a co-
Initia
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Other – specifyReferral to another physician, consultationHospital admit – other physician(s) contactHospital admitPt educated on self or home care topics/teIM injection or other pain management proRadiation therapyConservative therapy: rest, ice, bandages,Insulin prescription (sc or combo sc/iv), hyIV fluidsClosed treatment for fracture/dislocationPhysical, occupational or speech therapyOpen or percutaneous procedureDrug management (more than 3 Δ’s)Drug management (new Rx or Δ dose)Continue same treatment and/or monitorin
Problems/Therapeutic
Number of Diagnoses and/or Managem
New or established problem and E/M is men
New or established problem; no E/M mentioproblem IS clearly a co-morbid condition
New of established problem; no E/M mentioproblem IS NOT clearly a co-morbid conditio
Final Proble
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•One or more chrwith severe exace•Acute or chronicinjury, which poseor bodily function•An abrupt changneurological statu
High
•One chronic illnexacerbation, •Two stable chron•Undiagnosed neuncertain prognos
Moderate
•Two or more selfminor problems•One stable chron•Acute uncomplicillness, e.g., cystitrhinitis, sprain
Low
•One self-limited problem, e.g., coltinea corporis.
Minimal
Presenting Risk
Discuss case with discuss case with o
Physiologic monito
Order and/or summ
Review/order clinic
Independent review
Discuss test results
Review/order tests LHC, PFTs)
Review/order X-ray
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E/
Adding Up the TrailBlazer MDM Points
C
Ne
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Most used encouReimabout
3
Tim
99223
E/M Code
3
99233
E/M Code
BriefEPF
ExtDet
BriefPF
ExtComp
HPIHx
For this type of endocumented. Thisand document BOexam to maintain c
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• Qualifierecorde
• Qualifie
three c • At least
other s
Thi
ROS:
FH: Fatherand has Al
PMH: HTN
HPI: The pas “crushinsometimes
SH: Quit s
CC: Chest
9Targ
CoHis
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se at least two bullets from ormed and documented.
ultation of heart tion of heart
n minal Exam of liver/spleen
ction of skin tion of skin
ssment of affect ssment of orientation
mChest/Breasts
CV
Skin
Musculoskeletal
Neurologic
Psychiatric
GI GUungs
ST 2 H of NINE
10 11 12 13 14
15 16
17 18
19
stated ageERRLApalate
ar line
odules
HighmpMDMm
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Medical Decision-Making
1363.8 2
1
EKG showed LVH by voltage, NCXR was reviewed and showed
Assessment1. USA vs. AMI2. Stable HTN3. Stable DM2
Plan1. F/U enzymes ASAP2. Admit to monitored bed3. Start ASA, PPI, NTP a4. Sliding scale insulin5. Consult cardiology
Com99223HistoTarget Code
This example qualifies as beimaking due to the presence o
• Four or more pro• Four or more dat• High risk
Note: Even if we only had mocomplexity MDM because onlorder to qualify for any given l
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DM High
CC HP escribed as “cr is sometimes assIV
en HPI Elements on, Quality, Severity, Timing, ptoms, Modifying Factors
PM
mplete PFSH from all three components of and social history
FH:Alz
SH
RO
Complete ROS the accepted shortcut, “All other s reviewed and are negative.”
VitaGeEyHENeLunCVAbSkiPsy
Bullets Used onstitutional
Three vital signs General appearance
yes Exam of sclerae/lids Exam of pupils/irises
NT External appearance of ears/nose Exam of oropharynx
eck Exam of neck Exam of thyroid
ungs Auscultation of lungs Assess respiratory effort
V Auscultation of heart Palpation of heart
bdomen Abdominal Exam Exam of liver/spleen
kin Inspection of skin Palpation of skin
syche Assessment of affect Assessment of orientation
ualifies as a comprehensive exam)
Ass1. 2. 3.
Pla1. 2. 3. 4. 5.
M Prob Pts Data Pts Risk
≤ 2 ≤ 1 Min
3 - 4 2 Low
d 5 - 6 3 Mod
h ≥ 7 ≥ 4 High
EK
CX
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Determines the highest ethical level of care Driven by medical necessity Ensures 100% E/M compliance Saves time by avoiding over-documentationIncreases revenue by preventing undercodingFocuses on patient care
Rational Physician Coding
Peter R. Jensen, MD, CPC
Online and On-site Physician-to-Physician E/MCoding Education
1-888-U-EM-CODE
Practical E/M Coding Education
www.EMuniversity.com
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