documentation requirements e/m codes. targeted codes 99214 : established patient, outpt. visit –...

DOCUMENTATIONDOCUMENTATIONREQUIREMENTSREQUIREMENTS

E/M CodesE/M Codes

Targeted CodesTargeted Codes99214 : established patient, outpt. visit – presenting 99214 : established patient, outpt. visit – presenting problems are usually moderate to high severityproblems are usually moderate to high severity

99212: established patient, outpt. Visit – presenting 99212: established patient, outpt. Visit – presenting problems usually self limited or minorproblems usually self limited or minor

99233: subsequent hospital care – usually patient is 99233: subsequent hospital care – usually patient is unstable, developed a significant complication or unstable, developed a significant complication or a a significant new problemsignificant new problem

99231: subsequent hospital care – usually a stable, 99231: subsequent hospital care – usually a stable, recovering, or improving patientrecovering, or improving patient

Codes accounting for the errorsCodes accounting for the errors What codes should have been usedWhat codes should have been used

Principles of Principles of Documentation:Documentation:

• MR should be complete & legibleMR should be complete & legible• Documentation for each patient encounter should Documentation for each patient encounter should

include:include:– Reason for encounter & relevant historyReason for encounter & relevant history– Physical exam & findingsPhysical exam & findings– Prior diagnostic test resultsPrior diagnostic test results– AssessmentAssessment– Clinical impression or diagnosisClinical impression or diagnosis– Plan for carePlan for care– Date Date – Legible identity of the observerLegible identity of the observer

Principles of Principles of Documentation Cont.Documentation Cont.

• If not documented, the rationale for ordering If not documented, the rationale for ordering diagnostic & ancillary services should be easily diagnostic & ancillary services should be easily inferredinferred

• Past & present diagnosis should be accessible to Past & present diagnosis should be accessible to the treating/consulting physicianthe treating/consulting physician

• Appropriate risk factors should be identifiedAppropriate risk factors should be identified• Pt’s progress, response to & changes in treatment Pt’s progress, response to & changes in treatment

& diagnosis revision should be documented& diagnosis revision should be documented• CPT & ICD-9 codes on claim must be supported CPT & ICD-9 codes on claim must be supported

by MR documentationby MR documentation

Evaluation and Evaluation and Management CodesManagement Codes

--Developed jointly by HCFA & the AMADeveloped jointly by HCFA & the AMA

How to stay on the good side of HCFAHow to stay on the good side of HCFA

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MEDICAL NECESSITYMEDICAL NECESSITY

– InpatientInpatient : Does the diagnosis code : Does the diagnosis code support the medical need for the support the medical need for the service performed? service performed?

If not,If not, does the documentation in does the documentation in the record support the necessity?the record support the necessity?

– OutpatientOutpatient : Level of Visit Codes : Level of Visit Codes

The 7 Components:The 7 Components:

1) History1) History

2) Examination2) Examination

3) Medical Decision Making3) Medical Decision Making

4) Counseling4) Counseling

5) Coordination of Care5) Coordination of Care

6) Nature of Presenting Problem6) Nature of Presenting Problem

7) Time7) Time

KEYKEY

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E & M Determination E & M Determination

LevelLevel HistoryHistory ExaminationExamination

Med. Decision Med. Decision MakingMaking

II Prob. FocusedProb. Focused Problem FocusedProblem Focused StraightforwardStraightforward

IIII Expanded Prob. Expanded Prob. FocusedFocused

Expanded Problem Expanded Problem FocusedFocused

StraightforwardStraightforward

IIIIII DetailedDetailed DetailedDetailed Low ComplexityLow Complexity

IVIV ComprehensiveComprehensive ComprehensiveComprehensive Moderate Moderate ComplexityComplexity

VV ComprehensiveComprehensive ComprehensiveComprehensive High ComplexityHigh Complexity








7) Time7) Time

KEYKEY

Documentation of History:Documentation of History:

Level of service is based on 4 types:Level of service is based on 4 types:

1) problem focused1) problem focused

2) expanded problem focused2) expanded problem focused

3) detailed3) detailed

4) comprehensive4) comprehensive

History elements (some or all):History elements (some or all):

chief complaint, CCchief complaint, CC history of present illness, history of present illness, HPIHPI

review of systems, ROS review of systems, ROS past, family and/or social past, family and/or social history, PFSH history, PFSH

ROS & PFSH obtained Earlier ROS & PFSH obtained Earlier w/o any change:w/o any change:

• Do not have to re-record if there is Do not have to re-record if there is evidence that a physician had evidence that a physician had reviewed & updated the previous onereviewed & updated the previous one

• How to documented the review:How to documented the review:– Describe any new information,Describe any new information,– not that there has been no change, ornot that there has been no change, or– note the date & location of the earlier note the date & location of the earlier

entryentryDG 1

• If not able to obtain information - note in chart If not able to obtain information - note in chart the patient’s condition & the circumstances the patient’s condition & the circumstances

that preclude obtaining a historythat preclude obtaining a history

DG 2 & 3

•ROS & PFSH may be recorded by ancillary ROS & PFSH may be recorded by ancillary staff or by the patient - physician must staff or by the patient - physician must supplement or confirm the information supplement or confirm the information

received for documentation received for documentation

HPI ElementsHPI Elements

1) location1) location

2) quality2) quality

3) severity3) severity

4) duration4) duration

5) timing5) timing

6) context6) context

7) modifying factors7) modifying factors

8) associated signs & symptoms8) associated signs & symptoms

Brief:Brief: 1-31-3

Extended:Extended: at least 4at least 4 oror the status the status of at least 3 chronic or of at least 3 chronic or

inactive conditions inactive conditions

DG 4 & 5

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ROS ElementsROS Elements

• constitutional symptomsconstitutional symptoms• eyeseyes• ears, nose, mouth, throatears, nose, mouth, throat• cardiovascularcardiovascular• respiratoryrespiratory• gastrointestinalgastrointestinal• genitourinarygenitourinary

• musculoskeletalmusculoskeletal• integumentaryintegumentary• neurologicalneurological• psychiatricpsychiatric• endocrineendocrine• hematologic/lymphatichematologic/lymphatic• allergic/immunologicallergic/immunologic

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ROS DefinitionsROS Definitions

• PROBLEM PERTINENTPROBLEM PERTINENT - inquires about the - inquires about the system directly related to the problem in HPIsystem directly related to the problem in HPI

• EXTENDED EXTENDED - directly related system + - directly related system + 2 - 92 - 9 systems documentedsystems documented

• COMPLETECOMPLETE - directly related system + - directly related system + allall additional body systemsadditional body systems

DG 6, 7 & 8

PFSH - PFSH - • PertinentPertinent - - review of history areas directly review of history areas directly

related to problem in HPIrelated to problem in HPI

• CompleteComplete - review of 2 or all 3, depending - review of 2 or all 3, depending on the category on E&M code (required for on the category on E&M code (required for comprehensive assessments)comprehensive assessments)

DG 9

PFSH requirements for: PFSH requirements for: Initial PatientsInitial Patients

• requires 1 item from requires 1 item from the 3 areasthe 3 areas

• applies to outpt/office, applies to outpt/office, consults, observation consults, observation

pts, nursing home pts, nursing home assessments, domiciliary assessments, domiciliary

care, home carecare, home care

Est. PatientsEst. Patients• requires 1 item requires 1 item

from the 2 areasfrom the 2 areas• applies to outpt/office, applies to outpt/office,

ER services, ER services, domiciliary care, home domiciliary care, home

carecare

DG 10 & 11

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Level of Service Determination Level of Service Determination

* Must have all 3 in column or choose lowest* Must have all 3 in column or choose lowest

HistoryHistoryProblem Problem FocusedFocused

Expanded Expanded

Prob. Prob. FocusedFocused

DetailedDetailed ComprehensiveComprehensive

HPIHPI BriefBrief BriefBrief ExtendedExtended ExtendedExtended

ROSROS N/AN/A Problem Problem PertinentPertinent

ExtendedExtended CompleteComplete

PFSHPFSH N/AN/A DetailedDetailed PertinentPertinent CompleteComplete








7) Time7) Time

KEYKEY

Documentation of Examination:Documentation of Examination:


1) problem focused1) problem focused

2) expanded problem focused2) expanded problem focused

3) detailed3) detailed

4) comprehensive4) comprehensive

Exam Types:Exam Types:

cardiovascular, ENT & mouth, eyes, male & female cardiovascular, ENT & mouth, eyes, male & female genitourinary, hematological/lymphatic/immunologic, genitourinary, hematological/lymphatic/immunologic, musculoskeletal, neurological, psychiatric, respiratory, skinmusculoskeletal, neurological, psychiatric, respiratory, skin

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Documentation Guidelines:Documentation Guidelines:• Elements w/ mult. components require Elements w/ mult. components require

documentation of at least 1 componentdocumentation of at least 1 component

• ““abnormal” can be used for exams of the abnormal” can be used for exams of the affected or symptomatic body areaaffected or symptomatic body area

• abnormal/unexpected finding in abnormal/unexpected finding in asymptomatic areas should be describedasymptomatic areas should be described

• ““negative” or “normal” is sufficient for negative” or “normal” is sufficient for unaffected or asymptomatic areasunaffected or asymptomatic areas

General Multi-System Exams:General Multi-System Exams:

PROBLEM FOCUSED:PROBLEM FOCUSED: 1-51-5 elements in elements in 11 body areas/systems body areas/systems

EXPANDED PROBLEM FOCUSED:EXPANDED PROBLEM FOCUSED: 66 elements in elements in 11 body body areas/systemsareas/systems

DETAILED:DETAILED: 22 elements in elements in 66 ore ore more body areas/systems more body areas/systems (or (or 12 12 elements in elements in 2 areas) 2 areas)

COMPREHENSIVE:COMPREHENSIVE: allallelements in elements in selected areas, selected areas, 99 body areas/systems body areas/systems

Single Organ Exams:Single Organ Exams:

PROBLEM FOCUSED:PROBLEM FOCUSED: 1-51-5 elements in any boxelements in any box

EXPANDED PROBLEM FOCUSED:EXPANDED PROBLEM FOCUSED: 66 elements in any boxelements in any box

DETAILED:DETAILED: 1212 elements in any box elements in any box (eye & (eye & psychiatric psychiatric 9 elements) 9 elements)

COMPREHENSIVE:COMPREHENSIVE: allallelements ( document every elements ( document every element in bold boxes & at least 1 in normal boxes)element in bold boxes & at least 1 in normal boxes)








7) Time7) Time

KEYKEY

Documentation of Medical Documentation of Medical Decision Making:Decision Making:


1) straight - forward1) straight - forward

2) low complexity2) low complexity

3) moderate complexity3) moderate complexity

4) high complexity4) high complexity

-complexity of establishing a diagnosis and/or -complexity of establishing a diagnosis and/or selecting a management optionselecting a management option

Complexity factors….Complexity factors….• Pt’s # of diagnosesPt’s # of diagnoses

• the amount and/or complexity of MR, the amount and/or complexity of MR, tests, & other information that must be tests, & other information that must be obtained, reviewed, & analyzedobtained, reviewed, & analyzed

• risk of significant complications, risk of significant complications, morbidity/mortality as well as co-morbidity/mortality as well as co-morbidities morbidities associated with the presenting associated with the presenting problem(s)problem(s)

DG for # of Diagnoses DG for # of Diagnoses or Mgmt. Options….or Mgmt. Options….

• Established dx. - state if improved/well Established dx. - state if improved/well controlled/ resolving or worsening/failing to controlled/ resolving or worsening/failing to change as expectedchange as expected

• new diagnosis - stated in form of differential dx. new diagnosis - stated in form of differential dx. possible/probable/rule outpossible/probable/rule out

• initiation or changes in treatmentinitiation or changes in treatment

• to whom or where referrals or consults are made to whom or where referrals or consults are made or from whom the advice is requestedor from whom the advice is requested

DG for amount & complexity DG for amount & complexity of data to review….of data to review….

• Types of service ordered at the time of encounterTypes of service ordered at the time of encounter

• reviewed results, initial & date report w/ the resultsreviewed results, initial & date report w/ the results

• any further history or information obtained from any further history or information obtained from MR, patient, etc.MR, patient, etc.

• relevant findings from aboverelevant findings from above

• results of discussions w/ physicians results of discussions w/ physicians

associated w/ reviewed resultsassociated w/ reviewed results

• direct visualization or independent interpretation of direct visualization or independent interpretation of tests/films interpreted by another physiciantests/films interpreted by another physician

Risk DG...Risk DG...• Any factor that would increase the risk of Any factor that would increase the risk of

complications, morbidity, mortalitycomplications, morbidity, mortality

• procedures planned at that timeprocedures planned at that time

• specific procedure performed at time of specific procedure performed at time of encounterencounter

• need for an urgent procedure to be doneneed for an urgent procedure to be done

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Table of Risk Table of Risk Level of Level of

RiskRiskPresenting Presenting ProblemProblem

Diagnostic Procedure Diagnostic Procedure OrderedOrdered

Management Options Management Options SelectedSelected

minimalminimal • one self limited one self limited or minor problemor minor problem

•Lab tests w/ venipunctureLab tests w/ venipuncture

•Chest x-raysChest x-rays

•EKG/EEGEKG/EEG

•UrinalysisUrinalysis

•UltrasoundUltrasound

•KOH PrepKOH Prep

• restrest

•GarglesGargles

•Elastic bandagesElastic bandages

•Superficial dressingsSuperficial dressings

lowlow • 2 or more self 2 or more self limited problemslimited problems

• 1 stable chronic 1 stable chronic illnessillness

•Acute Acute complicated complicated illnessillness

•Physiologic tests not Physiologic tests not under stressunder stress

•Non-cardiovascular Non-cardiovascular imaging studies w/ imaging studies w/ contrastcontrast

•Superficial needle Superficial needle biopsiesbiopsies

•Clinical lab testClinical lab test

•Skin biopsiesSkin biopsies

• over the counter over the counter drugsdrugs

•Minor surgery w/ no Minor surgery w/ no identified risk factorsidentified risk factors

•PT or OTPT or OT

•IV fluids w/o IV fluids w/o additivesadditives

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RiskRiskPresenting ProblemPresenting Problem Diagnostic Procedure Diagnostic Procedure

OrderedOrderedManagement Options Management Options

SelectedSelected

ModerateModerate • one or more one or more chronic illness w/ chronic illness w/ mild exacerbationmild exacerbation

• 2 or more stable 2 or more stable chronic illnesseschronic illnesses

• undiagnosed new undiagnosed new problem w/ problem w/ uncertain uncertain prognosisprognosis

•Acute illness w/ Acute illness w/ systemic systemic symptomssymptoms

•Acute Acute complicated injurycomplicated injury

•Physiologic test under Physiologic test under stressstress

•Diagnostic endoscopies Diagnostic endoscopies w/ no identified risk w/ no identified risk factorsfactors

•Deep needle or Deep needle or incisional biopsyincisional biopsy

•Cardiovascular Cardiovascular imaging studies w/ imaging studies w/ contrast & no identified contrast & no identified risk factorsrisk factors

•Obtain fluid from body Obtain fluid from body cavitycavity

• minor surgery w/ minor surgery w/ identified risk factorsidentified risk factors

•Elective major Elective major surgery w/ no surgery w/ no identified risk factorsidentified risk factors

•Prescription drug Prescription drug managementmanagement

• Therapeutic Nuclear Therapeutic Nuclear Med.Med.

•IV fluids w/ additivesIV fluids w/ additives

•Closed treatment of Closed treatment of fracture or dislocation fracture or dislocation w/o manipulationw/o manipulation

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RiskRiskPresenting ProblemPresenting Problem Diagnostic Procedure Diagnostic Procedure

OrderedOrderedManagement Options Management Options

SelectedSelected

HighHigh • one or more one or more chronic illness w/ chronic illness w/ severe severe exacerbationexacerbation

• acute/chronic acute/chronic illness/injury that illness/injury that pose a threat to life pose a threat to life or bodily functionor bodily function

• Diagnostic Diagnostic endoscopies w/ endoscopies w/ identified risk factorsidentified risk factors

•Cardiovascular Cardiovascular imaging studies w/ imaging studies w/ contrast & identified contrast & identified risk factorsrisk factors

•Cardiac Cardiac electrophysiological electrophysiological teststests

•DiscographyDiscography

• Emergency major Emergency major surgery surgery

•Elective major Elective major surgery w/ identified surgery w/ identified risk factorsrisk factors

•Parental controlled Parental controlled substancessubstances

•Drug therapy Drug therapy requiring intensive requiring intensive monitoring for monitoring for toxicitytoxicity

•Decision not to Decision not to resuscitateresuscitate

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Medical Decision Making Medical Decision Making Determination Determination

* 2 of 3 elements must be met or exceeded* 2 of 3 elements must be met or exceeded

Type of Type of Decision Decision MakingMaking

Straight Straight ForwardForward

LowLow ModerateModerate HighHigh

# of dx. or # of dx. or mgmt mgmt

optionsoptionsMinimalMinimal LimitedLimited MultipleMultiple ExtensiveExtensive

Data Data ReviewedReviewed MinimalMinimal LimitedLimited ModerateModerate ExtensiveExtensive

RisksRisks MinimalMinimal LowLow extensiveextensive HighHigh

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E & M Determination E & M Determination Initial PatientsInitial Patients must have 3 of 3 must have 3 of 3



II

9920199201

Prob. FocusedProb. Focused Problem FocusedProblem Focused StraightforwardStraightforward

IIII

9920299202

Expanded Prob. Expanded Prob. FocusedFocused



IIIIII

9920399203

DetailedDetailed DetailedDetailed Low ComplexityLow Complexity

IVIV

9920499204

ComprehensiveComprehensive ComprehensiveComprehensive Moderate Moderate ComplexityComplexity

VV

9920599205

ComprehensiveComprehensive ComprehensiveComprehensive High ComplexityHigh Complexity

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E & M Determination E & M Determination Initial PatientsInitial Patients must have 3 of 3 must have 3 of 3



II

9920199201


IIII

9920299202




IIIIII

9920399203


IVIV

9920499204


VV

9920599205


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NEW PATIENTSNEW PATIENTS99201-9920599201-99205

One who has NOT received any One who has NOT received any professional services from the professional services from the

physician or any other physician of physician or any other physician of the same specialty who belongs to the same specialty who belongs to the same group practice within the the same group practice within the

past 3 years.past 3 years.

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E & M Determination E & M Determination Established PatientsEstablished Patients must have 2 of 3 must have 2 of 3



II

9921199211


IIII

9921299212




IIIIII

9921399213


IVIV

9921499214


VV

9921599215


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ESTABLISHED PATIENTSESTABLISHED PATIENTS99211-9921599211-99215

One who One who HASHAS received professional received professional services from the physician of the services from the physician of the same specilaity who belongs to the same specilaity who belongs to the same group practice within the last same group practice within the last

3 years.3 years.

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EST. PT Billing - 99211EST. PT Billing - 99211

Can be billed by the nursing staff when a Can be billed by the nursing staff when a chief complaint exists.chief complaint exists.

Normally Required Care:Normally Required Care:Blood pressure, weight, reactions to current meds, additional Blood pressure, weight, reactions to current meds, additional

services not usually provided by a physicianservices not usually provided by a physician

NOT: finger sticks & injectionsNOT: finger sticks & injections

*physician must be on the premises*physician must be on the premises

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Observation CareObservation Care99218-9922099218-99220

Report encounters by the supervising MDReport encounters by the supervising MD

Characteristics of Observation Pts:Characteristics of Observation Pts:• not been admitted as an inpatientnot been admitted as an inpatient

• may be physically detained in ERmay be physically detained in ER

• clinical condition is being observedclinical condition is being observed

• additional time needed to clarify conditionadditional time needed to clarify condition

• to determine if hospitalization is neededto determine if hospitalization is needed

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Observation to Inpatient-Observation to Inpatient-

• MD admits pt to both w/in 24 hours – bill MD admits pt to both w/in 24 hours – bill as initial hospital visitas initial hospital visit

• Do NOT bill for an initial hospital visit & Do NOT bill for an initial hospital visit & initial obs. code initial obs. code

• Can NOT bill for an obs. discharge Can NOT bill for an obs. discharge mgmt when admitting to inpt.mgmt when admitting to inpt.

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Global Surgical PeriodGlobal Surgical Period

• Fee includes obs paymentFee includes obs payment• Must use modifiers with the CPT code to Must use modifiers with the CPT code to

receive payment receive payment • – –57 indicates that the decision for surgery was 57 indicates that the decision for surgery was

made while the patient was in obs.made while the patient was in obs.• -24 denotes observation services are unrelated -24 denotes observation services are unrelated

to the surgeryto the surgery• -79 subsequent surgical procedure-79 subsequent surgical procedure• -25 separately identifiable service-25 separately identifiable service

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MODIFIER -25MODIFIER -25

Indicates that E/M Indicates that E/M codes reported on the codes reported on the

same bill are for same bill are for significant and significant and

separately identifiable separately identifiable servicesservices

One last thing…One last thing…

If using a template to dictate your If using a template to dictate your note DON’T FORGET to state note DON’T FORGET to state

that it was “normal” or that it was “normal” or “negative”“negative”

documentation requirements e/m codes. targeted codes 99214 : established patient, outpt. visit –...

Documents

documentation of history

mr documentation slide

pfsh slide

hcfa slide

principles of documentation

time key slide

patient codes accounting

targeted codes