Evaluation and Management Services

Transcription

1 Advanced E/M Auditing Evaluation and Management Services Disclaimer area Evaluation and Management Services History Exam Medical Decision Making Select the E/M Code Subjective portion of the visit where the provider gains information from the patient about the symptoms. Hands-on portion of the visit where the provider objectively assesses the patient. Symptoms, diagnoses, tests, and severity of the condition are all taken into consideration for the MDM. Key components are combined to determine the level of visit along with additional contributing factors. 1

2 History Components Chief complaint History of Present Illness (HPI) Review of Systems (ROS) Past, Family, Social History (PFSH) History Chief Complaint Audit Concerns The reason for the visit should be clearly stated or easily inferred All visits must have a chief complaint Patient presents for follow up on medications Patient returns for lab 4 2

3 History Example Does this record have documentation to support a chief complaint? HISTORY No chief complaint on file. HPI Comments: 81 yo M with one month history of left back to left lower pain, that shoot down to left knee, also reports weakness of left leg. The pain is always there and moving makes it worse. He complaints of left leg weakness for one month also. He initially report incontinence of bowel movements and urinary incontinence, but since abx was taken 1 month ago, the incontinence have stopped. 5 History History of Present Illness (HPI) Location Quality Severity Duration Timing Context Modifying factors Associated Signs & Symptoms DG: The CC, ROS, and PFSH may be listed as separate elements of history, or they may be included in the description of the history of present illness. DG: The CC, ROS, and PFSH may be listed as separate elements of history, or they may be included in the description of the history of present illness. 6 3

4 History History of Present Illness (HPI) Cahaba GBA: It is expected that the HPI will be performed by the provider billing the service, and not by ancillary personnel. First Coast: Q: Do I get credit for negative HPI elements, e.g., if I ask the patient about modifying factors and say no modifying factors are present would I get credit for this HPI element? A: No, credit is not given for negative responses regarding HPI elements. 7 Evaluation and Management (E/M) Services 1995 & 1997 E/M Documentation Guidelines CMS states 1995 or 1997 documentation guidelines may be used, not a combination. 8 4

5 History History of Present Illness (HPI) 1997 Guidelines Status of three chronic or inactive conditions Common Sufficient documentation: concern: The Diabetes: status of He the is chronic a Type II conditions diabetic under is not good stated. control and is very diligent with managing his sugars. Compared to last visit the diabetes remains Chronic controlled Conditions: by improved diet and increased exercise. Hypertension: Compared to last visit the hypertension is improved and Diabetes remains controlled by the patient increasing daily activity and taking ACE Hypertension inhibitors. Hypercholesterolemia: Compared to last visit the cholesterol is stable. The patient is maintaining goals of total cholesterol < 200, LDL <100, HDL >4O. 9 History Chief Complaint: follow up on medications, anxiety and general health Common Status of documentation Chronic conditions: concern: The Hypertension, problem list Benign in EHR - does stablenot include the current status for HPI Anxiety, NOS stable on medications Status Mixed of urinary Chronic incontinence conditions: worsening, Hypertension, more urination Benign at night Anxiety, NOS Warts Viral, Unspecified Back Pain, Lower Urge Incontinence 10 5

6 History HPI Example Chief Complaint: follow up on medications, anxiety and general health Status of Chronic conditions: Hypertension, Benign Anxiety, NOS Warts Viral, Unspecified Back Pain, Lower Urge Incontinence HPI: Urge/stress incont getting worse More urination at night No dysuria No flank pain 11 History Review of Systems (ROS) Constitutional Eyes Ears, nose, throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergic/Immunologic 12 6

7 History Review of Systems (ROS) Documentation Concern: Results documented are not for the system directly related to the chief complaint Chief Complaint: follow up on medications, anxiety and general health Review of Systems: Constitutional: No complaints Cardiovascular: No complaints Chief Complaint: HTN, colon issues Review of Systems: Constitutional: No complaints Cardiovascular: No complaints Chief Complaint: recheck HPI: Loose stools x 2-3 days, will see cardiologist this week, Nephro in spring. Review of Systems: Cardiovascular: No complaints Respiratory: No complaints 13 History ROS Documentation Requirements Results documented for the system directly related to the chief complaint Remaining systems all others reviewed and negative is acceptable Important to include pertinent positives and negatives Can be documented by patient, ancillary staff if noted as reviewed by provider Can use ROS from a previous visit Can document unobtainable 14 7

8 History ROS Audit Concerns Documentation Concern: ROS and HPI documentation is contradictory HPI: Patient continues to have chronic constipation, moving her bowels every 2-3 days. ROS: General: Appetite fair; weight stable Skin: Dry skin Cardiovascular: Hypertension; Atrial Fibrillation, Dyslipidemia Gastrointestinal: No complaints Genitourinary: Status post UTI 15 History Past, Family, Social History (PFSH) Past history childhood diseases, illnesses, operations, injuries, treatments, and medications. Family history review of medical events in the patient s family, including the age of death and diseases that may be hereditary, or place the patient at an increased risk. Social history review of the past and current activities that the patient is undergoing. 16 8

9 History Documentation Guidelines The CC, ROS and PFSH may be listed as separate elements of history, or they may be included in the description of the history of the present illness. 17 History Example: Past Medical History Reviewed Documentation Guidelines A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. Example: ROS and PFSH from 12/12/2013 reviewed. Patient states since her last visit she has stopped smoking. All other information remains the same. The ROS and/or PFSH 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. 18 9

10 History Documentation Guidelines 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. Example: I was unable to obtain history because patient arrived unconscious. The paramedic states the patient was found on a park bench, unresponsive. 19 History PFSH Concerns No Family history documented for Hospital, Consults, and or New patient visits Social history documentation inappropriately includes alcohol and tobacco use for infants and young children Provider does not reference previous forms or provide the date of the last update EHR system defaults to history components as not on file and giving full credit for the statement Non-contributory PFSH: None 20 10

11 Coding Requirements Interval History Some categories only require an interval history: Subsequent hospital care Follow-up inpatient consultations Subsequent nursing facility care Not necessary to record information about the PFSH. Example 1: Subjective: Pt. stated that it is difficult to accept the news, pt is feeling bad all over. Example 2: Subjective: Feels much better. Pt. Stated that she coughed up a bunch of stuff yesterday and now feels much better. Still c/o of L shoulder pain. 21 History Patient A Chief Complaint: follow up on medications, anxiety and general health Status of Chronic conditions: Hypertension, Benign Anxiety, NOS Warts Viral, Unspecified Back Pain, Lower Urge Incontinence Past medical history reviewed HPI: Urge/stress incont getting worse More urination at night No dysuria No flank pain ROS: Constitutional: No complaints Cardiovascular: No complaints 22 11

12 Exam 1995 E/M Documentation Guidelines Expanded Problem Focused -- a limited examination of the affected body area or organ system and other symptomatic or related organ system(s). Detailed -- an extended examination of the affected body area(s) and other symptomatic or related organ system(s). 23 Exam 1995 E/M Documentation Guidelines Novitas: By providing a tool we call 4X4 (4 elements examined in 4 body areas or 4 organ systems satisfies a detailed examination; however, less than such can be a detailed exam based on the reviewers clinical judgment) our reviewers and physicians have a clinically derived tool to assist in implementing the E/M guidelines and decreasing one area of ambiguity. Novitas Solutions nurse reviewers follow the guidelines for auditing E/M services that are provided by the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA). This includes consideration of both the 1995 and 1997 guidelines, with the utilization of the guidelines that are most beneficial to the physician. We also instruct our nurse reviewers to use their clinical knowledge while reviewing the medical record documentation to determine the correct and appropriate level of care. Clinical inference overrides the 4 x 4 tool

13 Exam 1997 E/M Documentation Guidelines Expanded Problem Focused Examination should include performance and documentation of at least six elements identified by a bullet ( ), whether in a box with a shaded or unshaded border. Detailed Examination examinations other than the eye and psychiatric examinations should include performance and documentation of at least twelve elements identified by a bullet ( ), whether in a box with a shaded or unshaded border. 25 Example 1: PHYSICAL EXAMINATION: Const: Well developed, well nourished female, appears stated age in NAD. Nose: No external lesions, mucosa non-inflamed, septum and turbinates normal, nares patent. Oropharynx: No abnormalities or lesions to the oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx. Mucous membranes moist. Neck: Appearance and symmetry is normal, trachea is midline, no masses nor crepitus. Supple, no nuchal rigidity. Respiratory: Lungs clear to auscultation bilaterally with normal respiratory effort. Cardiovascular: Regular rate and rhythm without murmur or abnormal heart sounds, gallops or rubs Skin: No rashes, lesions, ulcers, or palpable abnormalities. Psych: Mood/affect anxious Extremities: No clubbing, cyanosis or edema 26 13

14 Example 2: Patient A PHYSICAL EXAMINATION: Constitutional: Well developed, well nourished female, appears stated age in NAD. Respiratory: Lungs clear to auscultation bilaterally with normal respiratory effort. Cardiovascular: Regular rate and rhythm without murmur or abnormal heart sounds, gallops or rubs Psych: Mood/affect anxious Extremities: No clubbing, cyanosis or edema 27 Exam Documentation concerns Documentation lacks all required elements/bullets required for the level of E/M reported General Multi-System comprehensive exams require 2 elements from at least 9 body areas or organ systems for 18 bullets. Single organ specialty exams require all bullets in the shaded boxes and at least one bullet from each unshaded box

15 Exam Documentation concerns Missing one of the required elements for constitutional system The 97 Documentation guidelines for Constitutional contain 2 bullets 1 for vital signs and 1 for general appearance of the patient. Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff) 29 Exam Documentation Concerns negative or normal A notation of abnormal without elaboration is insufficient Negative or normal is sufficient when documenting findings to an unaffected body area/organ systems 30 15

16 Exam Documentation Concerns EMR and Paper Templates Appearance of cloning Over-documenting due to one-click exams Exams being pulled forward from previous visits 31 Medical Decision Making (MDM) Complexity of Medical Decision Making Diagnoses or management options Amount and/or complexity of data to be reviewed Risk of complications and/or morbidity or mortality 32 16

17 Medical Decision Making (MDM) Diagnoses or Management Options (Table A) Categories for Problems/New Symptoms Number Points Results Self limited or minor problem: stable, improved, or 1 Max=2 worsening Established problem: stable or improved 1 Established problem: Worsening 2 New problem: no additional work-up planned 3 Max=1 New problem: additional work-up planned 4 33 Medical Decision Making (MDM) Diagnoses or Management Options (Table A) Categories for Problems/New Symptoms Number Points Results Self limited or minor problem: stable, improved, or 1 Max=2 worsening Workup is defined as anything that the physician plans to do to make or confirm a diagnosis. For example, if the physician Established problem: suspects stable a or particular improveddiagnosis and sends the patient 1 on for a diagnostic test to confirm that suspicion, that diagnostic test Established problem: would Worsening count as workup. If the patient is scheduled 2for routine blood work to monitor side effects of medication, this would not New problem: no additional work-up be considered planned additional workup. 3 Max=1 New problem: additional work-up planned

18 Medical Decision Making (MDM) Diagnoses or Management Options What conditions is the patient being treated for? Conditions currently being treated Differential diagnoses Chronic conditions affecting treatment New Problem: additional work up New Problem: no additional work up planned Established Problem: worsening Established Problem: stable or improved 35 Medical Decision Making (MDM) Diagnoses or Management Options New Problem: Additional Work-up Planned New patient - Diabetes mellitus I do not see that she has had any diabetic lab work for some time and cannot find a recent A1C nor TSH. She does not check her home blood sugars. She requires all her medications refilled. Plan: Basic Metabolic Panel, Lipid Panel, Fasting, Microalbumin, Urine, metformin 1000 MG OR tablet, Hemoglobin A1C Panel

19 Medical Decision Making (MDM) Diagnoses or Management Options New Problem: No Additional Work-up Planned New patient - Diabetes Reviewed recent labs done, A1C remains below 8, goal to get under 7.5. Discussed improved focus on dietary and exercise. No change in meds at this time. 37 Medical Decision Making (MDM) Diagnoses or Management Options Established Problem: Worsening Established patient - Diabetes follow up A1C 1/14/ /25/ /29/ /12/ A1C is 9.2. This is higher than it should be. Since patient couldn't tolerate metformin because of the side effects, we will change to metformin ER. Follow-up again in 3 months. Plan: Metformin 500MG OR 24 hr tablet, Basic Metabolic Panel, check sugars daily, bring them to DM RN ED visit

20 Medical Decision Making (MDM) Diagnoses or Management Options Established Problem: Stable or Improved Established patient - Diabetes follow up She has diabetes. Had recent labs, A1C improvement. Has been improving diet, more active, taking meds as instructed. Overall says she is feeling better and working on wt loss, has more energy. Plan: Diabetes improving - continue current meds and lifestyle improvements. 39 Medical Decision Making (MDM) Amount and/or complexity of data to be reviewed (Table B) Categories of Data to be Reviewed Points Review and/or order of clinical lab tests 1 Review and/or order of tests in the radiology section of CPT 1 Review and/or order of tests in the medicine section of CPT 1 Discussion of test results with performing physician 1 Decision to obtain old records and/or obtain history from someone other than patient 1 Review and summarization of old records and/or obtaining history from someone other than 2 patient and/or discussion of case with another health care Provider Independent visualization of image, tracing or specimen itself (not simply review of report)

21 Medical Decision Making (MDM) Amount and/or complexity of data to be reviewed (Table B) What tests and/or records did you review? Labs Radiology Medicine (EKG, PFT, etc.) Documentation examples: I reviewed A1C and TSH. Review of MRI shows stable osseous structures. Radiographs are reviewed from March 28, XXXX that she brought with her that were done at another facility. AP and lateral views show She has tricompartmental degenerative changes with pronounced degenerative wear laterally, where she has spurs, loss of contour of the lateral tibial plateau. 41 Medical Decision Making (MDM) Amount and/or complexity of data to be reviewed (Table B) Independent visualization of image, specimen or tracing Not simply a review of the report Do not use if billing for the interpretation Documentation examples: My review of the film shows a fracture of the distal end of the ulna. X-Ray will be interpreted by radiology 42 21

22 Medical Decision Making (MDM) Level of Risk Presenting Problem(s) Diagnostic Procedure(s) Ordered Management Options Selected Table of Risk (Table C) Minimal Low Moderate High One self-limited or minor problem Two or more self-limited or minor problems, One stable chronic illness, Acute uncomp. illness or injury One or more chronic illness with mild exacerbation, two or more chronic illnesses, undiagnosed new problem with uncertain prognosis One or more chronic illnesses with severe exacerbation, acute or chronic illnesses or injuries that pose a threat to life. Lab test, simple X-rays, EKG, Echo, KPH prep PFT, non-cardiovascular imaging studies with contrast, superficial needle biopsies, Lab test requiring arterial puncture, skin biopsies Cardiac stress test, diagnostic endoscopies, cardiovascular imaging with contrast and no identified risk factors, obtain fluid from a body cavity Cardiovascular imaging with contrast and identified risk factors, diagnostic endo with identified risk factors, discography. Rest, gargles, elastic bandages, superficial dressings OTC meds, minor surgery with no identified risk factors, PT, PT, IV fluids without additives Minor surgery w/identified risk factors, Elective major surgery, Prescription drug management, IV fluids w/additives Elective major surgery w/identified risk factors, ER major surgery, Drug therapy requiring intensive monitoring for toxicity. 43 Medical Decision Making (MDM) Table of Risk Minor and major surgeries with identified risk factors vs major and minor surgeries with no identified risk factors. Prescription drug management Example documentation: Depression with anxiety. Increase clonazepam q.h.s. Discussed the significance of tolerance and dependence and dose escalation. Discussed concern for cognitive function and the long-term. Suggest once the Zoloft titrated to effective dose that clonazepam be weaned in preference for alternative sleep aid

23 Medical Decision Making (MDM) Patient A Assessment: Diagnosis: Hypertension, benign Depressive Disorder, NEC Chronic: Mixed Urinary Incontinence Plan: Continue current medication(s) at dose, continue regular exercise regimen 4-5 times a week for 30 minutes, continue prayer, continue getting out. Urogynecology/pelvic surgery referral to Gyn. 45 Medical Decision Making (MDM) Overall MDM Level Final Result of Tables A, B, C = Level of Medical Decision Making (MDM) Table A Number of diagnosis/treatment options Table B Amount of data reviewed/ordered Table C Level of risk Minimal Low Moderate High MDM Level Straightforward Low Moderate High 46 23

24 Select the E/M Code Level the E/M Code Code History Exam MDM Nurse Visit Problem Focused Problem Focused Straightforward Expanded Problem Focused Expanded Problem Focused Detailed Detailed Moderate Low Comprehensive Comprehensive High 47 Contributing Factors Time Counseling or Coordination of Care More than 50% of the visit. Example: I had an extremely extensive 60+ minute examination, and series of discussions, with the patient and her family members. Over half of the time was spent on counseling the patient and family members. At great length, with the patient and her daughter, and later with her son-in-law who arrived secondarily, and later again with her husband, who arrived at the end of my visit, I discussed how with diabetic injury, especially with neuropathy, she would be at risk, over time, of valvular dysfunction in the leg veins. I discussed the anatomy and physiology of orthostatic hypotension, and how this can be very pronounced, especially in long-term diabetics, and this would be made even worse with respect to her gait and balance, with her underlying peripheral neuropathy. Superimposing orthostatic hypotension on top of the neuropathy could certainly make her at risk for falling, to greater degree

25 Contributing Factors Time Total time must be documented Some payers require a start and stop time Documentation should include a description of topics discussed CPT states that the time spent in counseling and coordination of care should be greater than 50% of the total time spent with the patient 49 Medical Necessity Diagnosis Diagnosis codes support medical necessity Reported codes must be supported in the body of the note Diagnosis for associated conditions or risk factors should be reported Monitoring Evaluating Addressing/ Assessing Treatment 50 25

26 Medical Necessity Example: CC: HTN INTERVAL HISTORY: No new complaints. EXAM: NAD. 130/80, 84, 22. Lungs are clear. Heart RRR, no MRGs. Abdomen is soft, non-tender. No peripheral edema. IMPRESSION: Stable HTN on current meds. He also has mild OA. Hypertension only Osteoarthritis only Hypertension and Osteoarthritis PLAN: No changes needed. RTC in six months with labs. 51 Medical Necessity Steps to demonstrate medical necessity 1. List the principle diagnosis, condition, problem, or other reason for the medical service or procedure. 2. Assign the code to the highest level of specificity. 3. For office and/or outpatient services, never use a rule-out statement. If no definitive diagnosis is yet determined, code symptoms and/or signs instead of using rule-out statements. 4. Be specific in describing the patient s condition, illness, or disease. 5. Distinguish between acute and chronic conditions when appropriate. 6. Identify the acute condition of an emergency situation. 7. Identify chronic complaints or secondary diagnoses, only when treatment is provided or when they affect the overall management of the patient s care. 8. Identify how injuries occur

27 Medical Necessity CMS Internet Only Manual (IOM) , Medicare Claims Processing Manual, Chapter 12, Section 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 evaluation and management service when a lower level of service is warranted. The amount of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as possible after it is provided to maintain an accurate medical record. 53 Questions? 54 27

28 CEU# Katherine Abel, CPC, CPMA, CPPM, CPB, CPC-I. CMRS Director of Curriculum AAPC 55 28