Evaluation and Management (E/M) Training. Module 4

Transcription

1 Evaluation and Management (E/M) Training Module 4

2 AMA Disclaimer CPT copyright 0 American Medical Association. All rights reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association. 0 AAPC 480 South 3850 West, Suite B, Salt Lake City, Utah CODE (633), Fax , All rights reserved. CPC, CPC-H, CPC-P, CIRCC, CPMA, CPCO, and CPPM are trademarks of AAPC. CPT copyright 0 AMA. All rights reserved. Page ii E/M Training

3 Module M o d u l e 4 Determining the Medical Decision Making (MDM) The most subjective component to E/M code selection is the Medical Decision Making (MDM). MDM is perhaps the most important of the three primary components of E/M code selection as it often guides medical necessity for the visit. Whether you use the 995 or 997 E/M Documentation Guidelines, the nature of the presenting problem and medical necessity of the encounter are the best MDM indicators. The nature of presenting problem, as defined by the CPT codebook is, a disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for the encounter, with or without a diagnosis being established at the time of the encounter. There are five types of presenting problems defined in your CPT codebook. You will choose an overall MDM level based on three factors: The number of diagnoses or management options; The amount and/or complexity of data to be reviewed; and The risk of complications and morbidity or mortality. Diagnoses or Management Options The number of diagnoses or management options is based on the relative difficulty level in making a diagnosis and the status of the problem. Documentation should reflect the decision making of the provider. Complete documentation will include when a problem is established and stable or resolving or when it is inadequately controlled, worsening, or failing to change as expected. A new problem may be listed as possible, probable, or rule out diagnosis if a diagnosis has not yet been determined. Although these diagnoses are not coded with ICD-9-CM codes for physician services, they are taken into consideration when determining the level of MDM. Initiation of new treatment or changes in treatment may indicate an established diagnosis is not responding as expected, or could identify when a problem is resolving requiring less treatment. Ordering additional workup such as diagnostic tests to confirm or to rule out the suspected diagnosis and/or differential diagnosis to be performed after the current visit also adds additional value to the calculation of the MDM level. Workup is defined as anything that the physician plans to do to make or confirm a diagnosis. For example, if the physician suspects a particular diagnosis and sends the patient for a diagnostic test to confirm that suspicion, that diagnostic test would count as workup. If the patient is scheduled for routine blood work to monitor side effects of medication, this would not be considered additional workup. Although audit tools vary, the number of diagnosis and management options typically is determined using a points system. Under this system, points are assigned according to how sick a patient is, and the amount of physician work involved. CPT copyright 0 AMA. All rights reserved. Page E/M Training

4 Table C: Medical Decision Making or Management Options Number of diagnosis or treatment options Problem Number Points Total Self limited or minor (max points) Max = points Established problem to provider (stable or improved) Established problem to provider (worsening) New problem to provider with no additional work up planned New problem to provider with additional work up planned. Max = 3 points 3 4 (Number x Points) Total Determining when a problem is self-limited or minor is one of the grey areas in the point system. According to the CPT codebook, a self limited or minor problem is, a problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health OR has a good prognosis with management/compliance. Examples of a self-limited or minor problem can be found in the Table of Risk in the Evaluation and Management Documentation Guidelines. They include a cold, insect bite, and tinea corporis. Example Assessment/ Differential Diagnosis: ) pelvic pain; ) pelvic inflammatory disease; 3) rule out ectopic; 4) rule out appendicitis Plan: ) Admit for observation, begin IV antibiotics; ) IV fluids & NPO, bed rest; 3) pain control; 4) labs ordered: CBC with diff tonight and in am, pregnancy test STAT; 3) ultrasound in am; 4) cultures from office pending; blood cultures tonight before IV antibiotics begun; 5) Prozac qd with sip In this example, although there are two listed diagnoses, there are also two rule out diagnoses indicating there is not a complete determination of the diagnosis. There is additional work-up planned with observation and lab tests. Example A: Moderate PID. Has received doses of IV antibiotics. P: Continue IV antibiotics Check cultures & gram stain Continue NPO and modified bed rest Ultrasound at 9:30am Increase Demerol to q3h In this example, the definitive diagnosis is listed; however, it is difficult to determine from this portion of the documentation whether the condition is improving, stable, or worsening. Looking further into the documentation for this visit, there is a note stating, Exam unchanged from yesterday on admission, indicating no improvement. Data Amount and Complexity The amount and complexity of data for review is measured by the need to order and review tests, and the need to gather information and data. Planning, scheduling, and performing clinical labs and tests from the medicine and CPT copyright 0 AMA. All rights reserved. Page E/M Training

5 radiology portions of CPT are indications of complexity, as is the need to request old records, or to obtain additional history from someone other than the patient (such as a family member, caregiver, teacher, etc.). Documented discussions with the performing physician about unusual or unexpected patient results also may result in credit. If a physician makes an independent visualization and interpretation, for example, with an MRI or a Gram stain and he or she is not billing separately for the service it would be credited in this component of code selection. A points system is very effective for measuring the amount and complexity of data for review: Table D: Data Amount and Complexity Reviewed/Ordered Data Points Review and/or order lab test(s) Review and/or order test(s) in the radiology section of CPT Review and/or order test(s) in the medicine section of CPT Discussion of test results with performing physician Decision to obtain old records and/ or obtain history from someone other than the patient Review and summarization of old records and/or obtaining history from someone other than the patient and/ or discussion of case with another health care provider. Independent visualization of image, specimen or tracing (NOT simply a review of report, do not use if billing for the interpretation) The review of a test is only counted in the data amount and complexity of an E/M if it is not separately billed with another CPT code. For example, an orthopedist reviews an X-ray of a patient s arm. If the orthopedist interprets the X-ray and is billing for the professional component of the X-ray, it is not included in the level of the E/M code. When counting for points in the data amount and complexity, you do not count two points for independent visualization since the interpretation of the X-ray is separately billed, you will only count one point for the orthopedist ordering the X-ray. However, if the orthopedist is reviewing the X-ray to make a determination in treatment, and the X-ray will be read, interpreted, and billed by the radiologist, the orthopedist can count one point for the review in this section of medical decision making. A physician can count two points for the independent visualization when he or she interprets a lab, medicine, or radiology test, but does not separately bill for the service. Example Documentation for review when another provider provides the interpretation and report and bills for it (professional component): I personally reviewed, on the PAC system, a MRI of the brain which was completely normal, except for very mild subcortical ischemic changes, appropriate for age. There is no evidence for any type of stroke, transient ischemic attack, etc. MRI of the cervical spine revealed disk protrusions at C3-C4, causing moderate right foraminal narrowing and C5-C6, causing moderate spinal stenosis at this level. There was no cord compromise nor demyelinating lesion noted in the cord, nor in the brain. The ventricular systems were normal in size in the brain. The fourth ventricle was fully visualized. The circle of Willis was normal, without aneurismal dilation. The brainstem and the pituitary regions were normal. Old records may be reviewed for clarity on the patient s past. To receive credit towards the level of E/M, the provider is required to document a summary of the old records. Simply stating old records reviewed without further documentation of the pertinent information found in the old records is not sufficient. CPT copyright 0 AMA. All rights reserved. Page 3 E/M Training

6 Example Plan: ) Admit for observation, begin IV antibiotics; ) IV fluids & NPO, bed rest; 3) pain control; 4) labs ordered: CBC with diff tonight and in am, pregnancy test STAT; 3) ultrasound in am; 4) cultures from office pending; blood cultures tonight before IV antibiotics begun; 5) Prozac qd with sip. In this example, labs were ordered, and an ultrasound was ordered, allowing for two points in this section of MDM. Note: Clinical labs that are ordered or reviewed would be worth one point, whether it is one lab test or five lab tests, they all are worth just a combined total of one point. The same rule is applied for ordering/reviewing tests from the medicine section and radiology section. ECG: A -lead electrocardiogram obtained today in clinic reveals sinus rhythm with a rate of 40. There is normal P wave morphology with a PR interval of 90. There are no pathologic Q waves or evidence of ventricular preexcitation noted. There are no significant ST-T wave changes. The adjusted QT interval is 439 msec. IMPRESSION/RECOMMENDATION:. Paroxysmal atrial flutter: The patient has documented atrial flutter from /0. I suspect that he had an additional episode very recently after stopping his Multaq. His previous EKG is suggestive to me of a right atrial flutter. P waves are negative in the inferior leads and positive in VI. There is a somewhat atypical appearance of this which may suggest that it is a clockwise atrial flutter. Furthermore, we ve discussed stroke prevention. He has a CHADS risk score of one considering his hypertension. After discussion of the risks and benefits, he is interested in anticoagulation with Pradaxa. I do think this is reasonable for the most optimal stroke prevention in him. At this point therapeutic options include continuing current medical therapy versus considering an ablation procedure. The advantage of him having an ablation procedure would be that in the long term he might not need antiarrhythmic medication and might not need anticoagulation. Regardless, prior to consideration of an ablation procedure, I would like to make sure that he is not having any atrial fibrillation, -check a one month CardioNet monitor -hold Multaq in anticipation of diagnosis of atrial flutter versus atrial fibrillation -with another episode he will try to immediately come to our office for an EKG -re-start Multaq vs. start flecainide at the time of recurrent atrial flutter or a fib -start Pradaxa 50mg bid and stop ASA. Hypertension: He will continue his current lisinopril. 3. Hyperlipidemia: He is currently taking simvastatin. If his Multaq is restarted then we will need to decrease his simvastatin dose to 0 mg p.o. q.h.s. 4. Sinus bradycardia: The patient reports that he chronically has a heart rate in the 40s. He does not appear to have any significant symptoms from this. RETURN VISIT: 6 weeks. In this example, an EKG (ECG) was performed and interpreted. If the provider is billing for the interpretation, the provider will only count one point for ordering the EKG, but will not count two points for the independent visualization. A one month CardioNet monitor has been ordered, which will also count towards the MDM for this service. The Table of Risk Risk is measured based on the physician s determination of the patient s probability of becoming ill or diseased, having complications, or dying between this encounter and the next planned encounter. Risk indications include the nature of the presenting problem, the urgency of the visit, co-morbid conditions, and the need for diagnostic tests or surgery. Documentation Guidelines determine the risk level using the Table of Risk (Table E). The Table of Risk is divided into three columns; each column correlates with an overall risk level. The three columns list presenting problems, diagnostic procedures ordered, and management options selected. It is important to keep in mind medical necessity also plays a very important role in the level of risk. Identifying one bullet within a level of risk is sufficient for determining the level of risk. CPT copyright 0 AMA. All rights reserved. Page 4 E/M Training

7 Table E: Table of Risk Level of Risk Presenting Problem(s) Diagnostic Procedure(s) Ordered Management Options Selected One self-limited or minor problem, eg, cold, insect bite, tinea corporis Laboratory tests requiring: venipuncture Chest X-rays Rest Gargles Elastic bandages Minimal EKG/EEG Urinalysis Superficial dressings Ultrasound, eg, echocardiography KOH prep Low Two or more self-limited or minor problems One stable chronic illness, eg, well controlled hypertension, non-insulin dependent diabetes, cataract, BPH Acute uncomplicated illness or injury, eg, cystitis, allergic rhinitis, simple sprain Physiologic tests not under stress, eg, pulmonary function tests Non-cardiovascular imaging studies with contrast, eg, barium enema Superficial needle biopsies Clinical laboratory tests requiring arterial puncture Skin biopsies Over-the-counter drugs Minor surgery with no identified risk factors Physical therapy Occupational therapy IV fluids without additives Moderate One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment Two or more stable chronic illnesses Undiagnosed new problem with uncertain prognosis, eg, lump in breast Acute illness with systemic symptoms, eg, pyelonephritis, pneumonitis, colitis Acute complicated injury, eg, head injury with brief loss of consciousness Physiologic tests under stress, eg, cardiac stress test, fetal contraction stress test Diagnostic endoscopies with no identified risk factors Deep needle or incisional biopsy Cardiovascular imaging studies with contrast and no identified risk factors, eg, arteriogram, cardiac catheterization Obtain fluid from body cavity, eg lumbar puncture, thoracentesis, culdocentesis Minor surgery with identified risk factors Elective major surgery (open, percutaneous or endoscopic) with no identified risk factors Prescription drug management Therapeutic nuclear medicine IV fluids with additives Closed treatment of fracture or dislocation without manipulation CPT copyright 0 AMA. All rights reserved. Page 5 E/M Training

8 High One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment Acute or chronic illnesses or injuries that pose a threat to life or bodily function, eg, multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure Cardiovascular imaging studies with contrast with identified risk factors Cardiac electrophysiological tests Diagnostic Endoscopies with identified risk factors Discography Elective major surgery (open, percutaneous or endoscopic) with identified risk factors Emergency major surgery (open, percutaneous or endoscopic) Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Decision not to resuscitate or to de-escalate care because of poor prognosis An abrupt change in neurologic status, eg, seizure, TIA, weakness, sensory loss Source: CMS: Evaluation & Management Services Guide Documentation should indicate comorbidities and/or underlying diseases that increase the level of risk. Conditions that increase the level of risk should also be coded with ICD-9-CM codes to support medical necessity. In the column for management options selected, there are options for minor and major surgeries with identified risk factors. Understanding that all surgeries have inherent risk factors, for the level of risk table, the risk factor is based on the current patient and current condition. If the surgery for this particular patient increases the risk above the normal risk for that surgery, it would be considered with identified risk factors. If the risk involved in the surgery is the normal risk involved with that particular surgery, with no additional factors for this patient increasing that risk, it would be considered without identified risk factors. Another grey area in the table of risk is prescription drug management. To count the prescriptions toward a moderate risk, there should be some evidence the medication was evaluated to start, continue as prescribed, dosage modified, or a change in medication. Some carriers may vary in their interpretations of this. Often, you will find, if you are unsure of one item in the table of risk, it can be confirmed with information from another column. Keep in mind, the nature of the presenting problem (column one in the table of risk) is useful in determining medical necessity. Examples A: PID; pelvic pain; r/o ectopic, r/o appendicitis P: Admit for IV antibiotics, pain control & lab w/u. NPO, possible surgery Send by wheel chair to hospital. In this example, the patient is admitted to the hospital for IV antibiotics. In the table of risk, there is an option for IV without additives and IV with CPT copyright 0 AMA. All rights reserved. Page 6 E/M Training

9 additives. An additive is medication or vitamins added to the saline solution to fulfill a purpose. In this case, it is an antibiotic so the selection for IV with additives is selected making this a moderate level of risk. IMPRESSION: Elbow sprain. PLAN: Given a prescription for Naprosyn, Vicodin, two weeks off work. Told to wear the sling for the next 5 7 days as needed for comfort. Return to the ED with any new concerns. Follow up with her doctor this week. In this example, prescription drugs were prescribed to the patient to control the pain. Prescription drug management falls under a Moderate level of risk. Totaling the MDM Component To select an overall MDM level, at least two of three elements (number of diagnoses or management options; amount and/or complexity of data to be reviewed; risk of complications and/ or morbidity or mortality) for that level must be met. Table F: Medical Decision Making (MDM) Final Result of Tables C, D, E = Level of Medical Decision Making (MDM) Table C Table D Table E Number of diagnosis/ treatment options Amount of data reviewed/ ordered Level of risk Minimal Low Moderate High MDM Level Straight forward Low Moderate High CPT copyright 0 AMA. All rights reserved. Page 7 E/M Training

10 Documentation Dissection: Hospital Admit Assessment/Differential Diagnosis: ) pelvic pain; ) pelvic inflammatory disease; 3) rule out ectopic; 4) rule out appendicitis Plan: ) Admit for observation, begin IV antibiotics; ) IV fluids & NPO, bed rest; 3) pain control; 4) labs ordered: CBC with diff tonight and in am, pregnancy test STAT; 3) ultrasound in am; 4) cultures from office pending; blood cultures tonight before IV antibiotics begun; 5) Prozac qd with sip Table C: Medical Decision Making or Management Options Number of diagnosis or treatment options Problem Number Points Total Self limited or minor (max points) Max = points Established problem to provider (stable or improved) Established problem to provider (worsening) New problem to provider with no additional work up planned New problem to provider with additional work up planned. Max = 3 points Total 4 (Number x Points) This is a new problem to the examiner with additional work up planned (lab tests, ultrasound). Table D: Data Amount and Complexity Reviewed/Ordered Data Points Review and/or order lab test(s) Review and/or order test(s) in the radiology section of CPT Review and/or order test(s) in the medicine section of CPT Discussion of test results with performing physician Decision to obtain old records and/or obtain history from someone other than the patient Review and summarization of old records and/or obtaining history from someone other than the patient and/or discussion of case with another health care provider. Independent visualization of image, specimen or tracing (NOT simply a review of report, do not use if billing for the interpretation) Data ordered includes the lab tests and ultrasound. CPT copyright 0 AMA. All rights reserved. Page 8 E/M Training

11 Table E: Level of Risk - Moderate The risk level is determined to be moderate based IV antibiotics being used to treat the infection. Table F: Medical Decision Making (MDM) Because two out of three levels must be met in order to reach the level of MDM, this example is considered moderate MDM. Final Result of Tables C, D, E = Level of Medical Decision Making (MDM) Table C Number of diagnosis/treatment options 3 4 Table D Amount of data reviewed/ordered 3 4 Table E Level of risk Minimal Low Moderate High MDM Level Straightforward Low Moderate High CPT copyright 0 AMA. All rights reserved. Page 9 E/M Training

12 Documentation Dissection: Consultation ECG: A -lead electrocardiogram obtained today in clinic reveals sinus rhythm with a rate of 40. There is normal P wave morphology with a PR interval of 90. There are no pathologic Q waves or evidence of ventricular preexcitation noted. There are no significant ST-T wave changes. The adjusted QT interval is 439 msec. IMPRESSION/RECOMMENDATION:. Paroxysmal atrial flutter: The patient has documented atrial flutter from /0. I suspect that he had an additional episode very recently after stopping his Multaq. His previous EKG is suggestive to me of a right atrial flutter. P waves are negative in the inferior leads and positive in VI. There is a somewhat atypical appearance of this which may suggest that it is a clockwise atrial flutter. Furthermore, we ve discussed stroke prevention. He has a CHADS risk score of one considering his hypertension. After discussion of the risks and benefits, he is interested in anticoagulation with Pradaxa. I do think this is reasonable for the most optimal stroke prevention in him. At this point therapeutic options include continuing current medical therapy versus considering an ablation procedure. The advantage of him having an ablation procedure would be that in the long term he might not need antiarrhythmic medication and might not need anticoagulation. Regardless, prior to consideration of an ablation procedure, I would like to make sure that he is not having any atrial fibrillation, -check a one month CardioNet monitor -hold Multaq in anticipation of diagnosis of atrial flutter versus atrial fibrillation -with another episode he will try to immediately come to our office for an EKG -re-start Multaq vs. start flecainide at the time of recurrent atrial flutter or a fib -start Pradaxa 50mg bid and stop ASA. Hypertension: He will continue his current lisinopril. 3. Hyperlipidemia: He is currently taking simvastatin. If his Multaq is restarted then we will need to decrease his simvastatin dose to 0 mg p.o. q.h.s. 4. Sinus bradycardia: The patient reports that he chronically has a heart rate in the 40s. He does not appear to have any significant symptoms from this. RETURN VISIT: 6 weeks. Notes: An EKG was performed in the office. For this case, we are going to say the professional component was billed for by this office. This will allow for one point for the ordering of the EKG. Credit is not given for the independent visualization because this provider is already billing for the professional component. In the event the professional component is not billed by this provider, the provider would also get points for the independent visualization. CPT copyright 0 AMA. All rights reserved. Page 0 E/M Training

13 Table C: Medical Decision Making or Management Options Number of diagnosis or treatment options Problem Number Points Total Self limited or minor (max points) Max = points Established problem to provider (stable or improved) Established problem to provider (worsening) New problem to provider with no additional work up planned New problem to provider with additional work up planned. Max = 3 points Total 4 (Number x Points) The patient has four diagnoses. Whether they are new or established, worsening or improved, the most points you can use for the number of diagnosis or management options is four. Table D: Data Amount and Complexity Reviewed/Ordered Data Points Review and/or order lab test(s) Review and/or order test(s) in the radiology section of CPT Review and/or order test(s) in the medicine section of CPT Discussion of test results with performing physician Decision to obtain old records and/or obtain history from someone other than the patient Review and summarization of old records and/or obtaining history from someone other than the patient and/or discussion of case with another health care provider. Independent visualization of image, specimen or tracing (NOT simply a review of report, do not use if billing for the interpretation) The provider has ordered a repeat EKG and a one month CardioNet monitor. These are both coded from the medicine section, only one point is given. CPT copyright 0 AMA. All rights reserved. Page E/M Training

14 Table E: Level of Risk - Moderate All four diagnoses are managed by prescription drugs, with all prescriptions addressed in the assessment. This note also indicates one or more chronic illnesses with mild exacerbation. Both options indicate a moderate level of risk. Table F: Medical Decision Making (MDM) Final Result of Tables C, D, E = Level of Medical Decision Making (MDM) Table C Table D Number of diagnosis/ treatment options Amount of data reviewed/ordered Table E Level of risk Minimal Low Moderate High MDM Level Straightforward Low Moderate High Two of the three columns must be met or exceeded to determine the level of MDM. This level of MDM is moderate. CPT copyright 0 AMA. All rights reserved. Page E/M Training

15 Documentation Dissection: Emergency Department In the emergency room, X-rays were done of the elbow showing no acute abnormalities, no fractures noted. She already has a sling. She is going to be discharged. IMPRESSION: Elbow sprain. PLAN: Given a prescription for Naprosyn, Vicodin, two weeks off work. Told to wear the sling for the next 5-7 days as needed for comfort. Return to the ED with any new concerns. Follow up with her doctor this week. Table C: Medical Decision Making or Management Options Number of diagnosis or treatment options Problem Number Points Total Self limited or minor (max points) Max = points Established problem to provider (stable or improved) Established problem to provider (worsening) New problem to provider with no additional work up planned New problem to provider with additional work up planned. Max = 3 points 3 3 Total 3 This is a new problem to the examiner. There is no additional work-up planned. 4 (Number x Points) CPT copyright 0 AMA. All rights reserved. Page 3 E/M Training

16 Table D: Data Amount and Complexity Reviewed/Ordered Data Points Review and/or order lab test(s) Review and/or order test(s) in the radiology section of CPT Review and/or order test(s) in the medicine section of CPT Discussion of test results with performing physician Decision to obtain old records and/or obtain history from someone other than the patient Review and summarization of old records and/or obtaining history from someone other than the patient and/or discussion of case with another health care provider. Independent visualization of image, specimen or tracing (NOT simply a review of report, do not use if billing for the interpretation) X-rays of the elbow were completed in the emergency department. When X-rays are performed in a hospital, typically, they have a radiologist to interpret and provide a report for the X-ray. In this case, the ED physician will receive credit towards the MDM for review of the X-ray because the radiologist will bill for the professional component of the X-ray. If the X-ray (or any test result) is interpreted by the ED physician documentation will be made by the ED physician that the test was interpreted by me. Table E: Level of Risk - Moderate In this example, prescription drugs were prescribed to the patient to control the pain. Prescription drug management falls under a Moderate level of risk. Table F: Medical Decision Making (MDM) Final Result of Tables C, D, E = Level of Medical Decision Making (MDM) Table C Table D Number of diagnosis/ treatment options Amount of data reviewed/ordered Table E Level of risk Minimal Low Moderate High MDM Level Straightforward Low Moderate High Two of the three columns must be met or exceeded to determine the level of MDM. This level of MDM is moderate. CPT copyright 0 AMA. All rights reserved. Page 4 E/M Training