Evaluation & Management (E/M)

Normal Distribution

Presented by: Katie Roemer, HSA, CPC

Objectives

• CMS bell curves for multiple Evaluation & Management (E&M) codes.

• Case study of distributions under the bell curve for established patient office visit codes (99211 – 99215).

• Overview of documentation requirements for established patient office visit codes (99211 – 99215).

What is Normal Distribution?

Webster’s Dictionary says: “A theoretical frequency distribution represented by a normal curve.” (2010)

CMS says it’s a peer comparison. Where, under the bell curve, do you fall in comparison to your peers?

CMS E/M Normal Distribution

CMS E/M Normal Distribution

CMS E/M Normal Distribution

CMS E/M Normal Distribution

CMS E/M Normal Distribution

CMS E/M Normal Distribution

Case Study

• Per routine audit, CMS identifies 60 midlevel providers who have continually submitted, for payment, a year’s worth of established patient office visits.

• The audit consists of an even amount of Nurse Practitioner and Physician Assistant charges.

• The auditor identifies 14 providers whose records will be requested to verify support of the codes billed.

• Pass rate for this audit: 77%

CMS Specialty Bell Curve: Established Patient Visits

Specialty 99211 99212 99213 99214 99215

NP 3.37% 10.02% 49.84% 33.47% 3.30%

PA 1.84% 12.83% 54.80% 28.25% 2.28%

Audit Results

Outliers

Don’t forget medical necessity!

99211 99212 99213 99214 99215

History N/A Problem Focused

Expanded Problem Focused

Detailed Comprehensive

Exam N/A Problem Focused

Expanded Problem Focused

Detailed Comprehensive

MDM N/A Straight-forward Low Moderate High

Time (minutes) 5 10 15 25 40

99212 Components

3/3 ∙ HPI: 1-3 Elements ∙ ROS: 0 Systems ∙ PFSH: 0 Histories

∙ 1995 DG: 1 organ system/body area

or ∙ 1997 DG: 1-5 bullets

2/3 ≤ ∙ 1 Diagnosis ∙ Minimal Risk ≤ ∙ 1 Data Element

MDM: 99212

Presenting Problem(s)

Diagnostic Procedure(s) Ordered

Management Option(s) Selected

Minimal

One self-limiting or minor :• Problem • Illness• Injury• Condition• Diagnosis

• Lab tests requiring venipuncture• Urinalysis• Ultrasound• X-rays• EKG/EEG• KOH prep

• Rest• Gargles• Elastic bandages• Superficial dressings

99213 Components

3/3 ∙ HPI: 1-3 Elements ∙ ROS: 1 System ∙ PFSH: 0 Histories

∙ 1995 DG: 2-7 organ system/body area

(limited)or

∙ 1997 DG: 6-11 bullets

2/3 ∙ 2 Diagnoses ∙ Low Risk ∙ 2 Data Elements

MDM: 99213

Presenting Problem(s)

Diagnostic Procedure(s) Ordered

Management Option(s) Selected

Low

• 2+ self limiting or minor problems.• 1 stable, chronic illness, diagnosis, condition.• Acute uncomplicated illness or injury.

• Physiologic tests not under stress. • Non-cardiovascular imaging studies with contrast.• Superficial needle biopsies. • Clinical lab tests requiring arterial puncture.•Skin biopsies.

• OTC drugs.•Minor surgery (10-day) with no patient-specific risk factors identified.• PT/OT• IV fluids without additives.

99214 Components

3/3 ∙ HPI: ≥ 4 Elements ∙ ROS: 2-9 Systems ∙ PFSH: 1 History

∙ 1995 DG: 2-7 organ system/body area

(extended)or

∙ 1997 DG: 12+ bullets

2/3 ∙ 3+ Diagnosis ∙ Moderate Risk ∙ 3 Data Elements

MDM: 99214

Presenting Problem(s) Diagnostic Procedure(s) Ordered

Management Option(s) Selected

Moderate

• 1+ chronic condition with mild exacerbation, progression or side effect of treatment.• 2+ stable, chronic conditions. • Undiagnosed new problem with uncertain prognosis.• Acute illness with systemic symptoms.• Acute complicated injury.

• Physiologic tests under stress.• Diagnostic endoscopies with no patient-specific identified risk factors.• Deep needle or incisional biopsy.• Cardiovascular imaging studies with contrast and no patient-specific identified risk factors.• Obtain fluid from body cavity.

• Minor surgery (10-day) with patient-specific identified risk factors.• Elective major surgery (90-day) with no patient-specific identified risk factors. • Rx drug management. •Therapeutic nuclear medicine. • IV fluids with additives.•Closed treatment of fracture or dislocation without manipulation.

99215 Components

3/3 ∙ HPI: ≥ 4 Elements ∙ ROS: 10+ Systems ∙ PFSH: 2-3 Histories

∙ 1995 DG: 8+ organ systems

or ∙ 1997 DG: 18+ bullets

2/3 ≥ ∙ 4 Diagnosis ∙ High Risk ≥ ∙ 4 Data Elements

MDM: 99215Presenting Problem(s)

Diagnostic Procedure(s) Ordered

Management Option(s) Selected

High

• 1+ chronic illness with severe exacerbation, progression, or side effect of treatment. • Acute or chronic illness/injury that poses a threat to life or bodily function. • An abrupt change in neurologic status.

• Cardiovascular imaging studies with contrast with patient-specific identified risk factors. • Cardiac electrophysiological tests.• Diagnostic endoscopies with patient-specific identified risk factors. • Discography

• Elective major surgery (90-day) with patient-specific identified risk factors. • Emergency major surgery (90-day). • Parenteral controlled substances. • Drug therapy requiring intensive monitoring for toxicity. •Decision not to resuscitate, or to de-escalate care because of poor prognosis.

Specialty Distributions

• Report Data: – Provider(s)– Date Range– Procedure Codes– Units

Change numbers to percents

Verify the sum = 100%

Specialty Distributions

Normal Distribution

• http://www.aapcps.com/resources/em_utilization.aspx

Thank you!

Any questions?