E/M Auditing. Today s Session

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5 E/M Auditing Shannon O. Smith, CPC, CPC-I, CEMC, CMSCS, CPMA DoctorsManagement/NAMAS 1 Today s Session Auditing Basics Teaching the Provider E&M Documentation Guidelines Documentation Components Difference Between 1995 & 1997 Guidelines 2 1

6 Auditing Basics Why are you performing the audit? Compliance Risk Management Reimbursement Combo Should it matter? 3 The Well-Rounded Audit Random dates Don t pull all of your charts from one date of service Random services Provider specialty specific Don t forget IP services Make sure you obtain all forms referred to Initial history forms Consult letters Services other than E/M 4 2

7 The Well-Rounded Audit Review of what to look at: Patient encounter Any forms the provider refers to Encounter form CMS-1500 claim form EOB Productivity 5 The Well-Rounded Audit Remember to audit for the HOT issues Provider signatures Incident-to services Providers legibly identified name Date documentation produced (dictated/emr) Diagnosis Orders 6 3

8 NOT TO ASSUME! The Auditor s Job Give credit were credit is due, but don t put your back against the fence. Do NOT second guess the providers medical care. Educate. Educate. Educate. Cover yourself. 7 The Report Contents Findings Grids Productivity Comparisons Educational Resources What about the Compliance Plan? 8 4

9 Be specific in your findings to the provider. Do not be afraid to tell them what they did not do correctly

10 Grade each provider you audit. Show them approximately how much they are costing themselves annually. 11 Show the provider what level of service the documentation is and the medical necessity supported. Also show the financial impact- AGAIN! 12 6

11 Show the provider specifics regarding their documentation. For specialty providers, show that you scored the documentation under 95 and 97 guidelines. 13 Chief Complaint E/M Components In the patient s own words Documented on all encounters Make sure to educate the nursing staff The driving force of the medical complexity of the service 14 7

12 E/M Components History of Present Illness Symptoms the patient is having caused by the chief complaint 4 is the maximum number needed Mommy Questions How hard is it to get 4 elements on every patient, every encounter 15 E/M Components History of Present Illness Location Quality Severity Duration Timing Context Modifying Factors Associated Signs and Symptoms 16 8

13 cc: Diabetes E/M Components The patient has a 20-year history of diabetes. He has been on Glucophage and currently his diabetes is stable although he does note shifts in sugar levels first thing in the morning. 17 cc: Diabetes E/M Components The patient has a 20 year history of diabetes. He has been on Glucophage and currently his diabetes is stable although he does note shifts in sugar levels first thing in the morning. 18 9

14 E/M Components History of Present Illness These guidelines are pertinent to 1995 & 1997 Documentation Guidelines 1997 Guidelines do allow for documenting the HPI in another manner STATUS of the 3 chronic or inactive conditions 19 E/M Components History of Present Illness Key to the documentation is the inclusion of the status of each Can be documented anywhere in the medical record May be used in lieu of 4 HPI elements 20 10

15 E/M Components Mr. Brown has been a longtime patient of our clinic and returns today for evaluation of his chronic problems: Diabetes: Stable on the Glucophage Depression: Mood swings noted especially at work- he continues to take Prozac Eczema: Flares have been occurring since the onset of the winter months. 21 E/M Components Mr. Brown has been a longtime patient of our clinic and returns today for evaluation of his chronic problems: Diabetes: Stable on the Glucophage Depression: Mood swings noted especially at work- he continues to take Prozac Eczema: Flares have been occurring since the onset of the winter months

16 E/M Components Review of Systems The review of systems is a required portion of the documentation because it tells what other systems have been affected by the chief complaint. Simply asking the patient if they are having any other problems today will satisfy that all ROS have been reviewed. (LCDs may override) Guidelines are the same regardless of 1995 or 1997 Documentation Guidelines 23 E/M Components Constitutional Eyes ENT Card/Vasc Resp GI GU Musculo Endo Integumentary Neuro Hem/lymph All/Immuno Psych 24 12

17 E/M Components Past Family Social History PFSH should be reviewed with every patient on every visit because items in their history may help explain the reasons for the patient s chief complaint. A key point to remember is that you may refer to any form in the patient s chart, as long as this referred to documentation is also reviewed. We recommend that each time you refer to this sheet that you initial and date it to prove that you did review this information. 25 E/M Components After reviewing the documentation you may now, within the current days documentation incorporate a statement of, PFSH has been reviewed as per the intake form, at this time there are no changes to note, or PFSH has been reviewed as per the intake sheet and the pertinent changes/updates are as follows Documenting in this way will support a comprehensive level of service in this portion of the documentation. No rule regarding content volume PFSH is the same for 1995 and 1997 Guidelines 26 13

18 27 E/M Components Mr. Brown has been a longtime patient of our clinic and returns today for evaluation of his chronic problems: Diabetes: Stable on the Glucophage Depression: Mood swings noted especially at work- he continues to take Prozac Eczema: Flares have been occurring since the onset of the winter months. ROS: - for N/V/D, fever, headaches, coughs, and muscle aches. PFSH: Family history- (+) Diabetes Social history- Smoker Past history- (-) Skin cancer 28 E/M Components Mr. Brown has been a longtime patient of our clinic and returns today for evaluation of his chronic problems: Diabetes: Stable on the Glucophage Depression: Mood swings noted especially at work- he continues to take Prozac Eczema: Flares have been occurring since the onset of the winter months. ROS: - for N/V/D, fever, headaches, coughs, and muscle aches. PFSH: Family history- (+) Diabetes Social history- Smoker Past history- (-) Skin cancer 14

19 E/M Components Exam 1995 vs Documentation Guidelines 1995 body systems 1997 bullets 29 E/M Components 1995 Documentation Guidelines will have an exam which falls into one of these categories: Problem Focused: Exam of the affected system Expanded Problem Focused: Exam of the affected system and other related systems Detailed: Detailed exam of the affected body system and other related systems (some carriers allow 5-7 systems instead) Comprehensive: 8 or more systems 30 15

20 E/M Components Under 1995 Documentation Guidelines, qualifying body systems are: Cardiovascular ENT Eyes Genitourinary Lymph/immunologic Musculoskeletal Neurological Psychiatric Respiratory Skin 31 E/M Components On exam, Mr. King is mildly agitated by his pain, alert and oriented 3. His back has good range of motion

21 E/M Components On exam, Mr. King is mildly agitated by his pain, alert and oriented 3. His back has good range of motion. Based on 1995 Documentation Guidelines 33 E/M Components 1997 Exam Documentation Guidelines will have exams that fall into one of the following categories: Problem Focused: 1-5 bullets Expanded Focused: 6 bullets Detailed: 12 bullets Comprehensive: 18 bullets 34 17

22 E/M Components Mr. Star is in no apparent distress today, alert and oriented 3. Patient s gait appears good, with good range of motion. On palpation, no tenderness was noted over the L3-L4 area. No swelling was noted in the feet, and the skin appears normal in nature. 35 E/M Components Mr. Star is in no apparent distress today, alert and oriented 3. Patient s gait appears good, with good range of motion. On palpation, no tenderness was noted over the L3-L4 area. No swelling was noted in the feet, and the skin appears normal in nature

23 E/M Components Medical Decision Making Same for 1995 and 1997 Guidelines 3 sections to Medical Decision Making Number and treatment level of diagnoses Tests ordered, records interpreted or reviewed Level of risk 37 E/M Components Number and treatment level of diagnoses Improved Worsening New Patient w/o additional work up New Patient w/ additional work up 38 19

24 E/M Components Test Reviewed/Ordered, Summarization Ordering Labs/-rays/Medicine Tests: 1 point per test Summarization/Decision to obtain Records: You must give an overview of records for the summarization and you must document you are requesting for decision: 2 points Independent Reading of Films: Interpreting -ray films will give you 2 points. Discussion with another provider 39 Table of Risk Risk of Complications and/or Morbidity or Mortality Levels of Level of Risk Presenting Problem(s) Diagnostic Procedure(s) Ordered Management Options Service Minimal O One self-limited or minor problem, e.g. cold, insect bite, Tinea Corporis O Laboratory tests requiring venipuncture O Chest x-rays O EKG/EEG O Urinalysis O Ultrasound, e.g., echo O KOH prep O Rest O Gargles O Elastic bandages O Superficial dressings Low O Over-the-counter drugs O Two or more self-limited or minor problems O Physiologic tests not under stress, e.g., pulmonary function tests. O Minor surgery with no identified risk factors O One stable chronic illness, e.g. well controlled O Non-cardiovascular imaging studies with contrast, e.g., barium O Physical therapy hypertension or non-insulin dependent diabetes, cataract, enema O Occupational therapy BPH O Superficial needle biopsies O IV fluids O Acute uncomplicated illness or injury, e.g. cystitis, O Clinical laboratory tests requiring arterial puncture allergic rhinitis, simple sprain O Skin biopsies Moderate O One or more chronic illnesses with mild exacerbation, O Physiologic tests not under stress, e.g. cardiac stress test, fetal O Minor surgery with identified risk factors progression, or side effects of treatment contraction stress test O Major surgery (open, percutaneous or endoscopic) O Two or more stable chronic illnesses O Diagnostic endoscopies with no identified factors with no identified risk factors O Undiagnosed new problem with uncertain prognosis, O Deep needle or incisional biopsy O Prescription drug management e.g., lump in breast O Cardiovascular imaging studies with contrast and no identified O Therapeutic nuclear medicine O Acute illness with systematic symptoms, risk factors, e.g. arteriogram cardiac cath O IV fluids with additives e.g.pyelonephritis, pneumonitis, colitis. O Obtain fluid from body cavity, e.g. lumbar puncture, thoracentesis, O Closed treatment of fracture or dislocation without O Acute complicated injury, e.g., head injury with brief culdecentisis manipulation loss of consciousness High O One or more chronic illnesses with severe O Cardiovascular imaging studies with contrast with identified risk O Elective major surgery (open, percutaneousor exacerbation, progression, or side effects of treatment factors endoscopic with identified risk factors). O Acute or chronic illnesses or injuries that may pose a O Cardiac electrophysiological tests O Emergency major surgery (open, percutaneous or threat to life or bodily function, e.g. multiple trauma, acute O Diagnostic endoscopies with identified risk factors endoscopic) MI, pulmonary embolus, severe respiratory distress, O Discography O Parenteral controlled substances progressive severe rheumatoid arthritis, psychiatric illness O Drug therapy requiring intensive monitoring for with potential threat to self or others, peritonitis, acute toxicity renal failure O Decision not to resuscitate or de-escalate care O An abrupt change in neurologic status, e.g., seizure, because of poor prognosis TIA, weakness or sensory loss 40 20

25 Impression: E/M Components Low Back Pain Plan: Patient should continue on current treatment of Oxycontin 10 mg b.i.d. and return to our clinic in 2 weeks. 41 Let s Put It All Together Start with Case #

26 Case #1 CHIEF COMPLAINT: Knee pain Valid chief complaint? May I use this as location as well? 43 Case #1 HISTORY OF PRESENT ILLNESS: This 42 year-old female presents today complaining of knee pain. This is an initial visit with me. She comes in for pain in her left knee. She was wearing a wedge heel and stepped on some uneven ground and she is not sure if her knee went into varus or valgus stress. She had acute increase in severe pain in the knee and had swelling and warmth in the knee. She has had increased pain on weight bearing. She had pain in the posterior of the knee throughout the knee as well as the medial aspect anteriorly and the posterior aspect laterally. She denies any giving out or locking of the knee

27 Case #1 HISTORY OF PRESENT ILLNESS: This 42 year-old female presents today complaining of knee pain. This is an initial visit with me. She comes in for pain in her left knee. She was wearing a wedge heel and stepped on some uneven ground and she is not sure if her knee went into varus or valgus stress. She had acute increase in severe pain in the knee and had swelling and warmth in the knee. She has had increased pain on weight bearing. She had pain in the posterior of the knee throughout the knee as well as the medial aspect anteriorly and the posterior aspect laterally. She denies any giving out or locking of the knee. 45 Case #1 HISTORY OF PRESENT ILLNESS: This 42 year-old female presents today complaining of knee pain. This is an initial visit with me. She comes in for pain in her left knee. She was wearing a wedge heel and stepped on some uneven ground and she is not sure if her knee went into varus or valgus stress. She had acute increase in severe pain in the knee and had swelling and warmth in the knee. She has had increased pain on weight bearing. She had pain in the posterior of the knee throughout the knee as well as the medial aspect anteriorly and the posterior aspect laterally. She denies any giving out or locking of the knee

28 Case #1 HISTORY OF PRESENT ILLNESS: This 42 year-old female presents today complaining of knee pain. This is an initial visit with me. She comes in for pain in her left knee. She was wearing a wedge heel and stepped on some uneven ground and she is not sure if her knee went into varus or valgus stress. She had acute increase in severe pain in the knee and had swelling and warmth in the knee. She has had increased pain on weight bearing. She had pain in the posterior of the knee throughout the knee as well as the medial aspect anteriorly and the posterior aspect laterally. She denies any giving out or locking of the knee. 47 Case #1 HISTORY OF PRESENT ILLNESS: This 42 year-old female presents today complaining of knee pain. This is an initial visit with me. She comes in for pain in her left knee. She was wearing a wedge heel and stepped on some uneven ground and she is not sure if her knee went into varus or valgus stress. She had acute increase in severe pain in the knee and had swelling and warmth in the knee. She has had increased pain on weight bearing. She had pain in the posterior of the knee throughout the knee as well as the medial aspect anteriorly and the posterior aspect laterally. She denies any giving out or locking of the knee

29 Case #1 REVIEW OF SYSTEMS: She complains of knee joint pain and headaches. She denies any allergy symptoms, chest pain, chills, nasal congestion, blurred vision, diarrhea/constipation, nausea/vomiting, painful urination, easy bruising, new skin lesions, or shortness of breath. 49 Case #1 REVIEW OF SYSTEMS: She complains of knee joint pain and headaches. She denies any allergy symptoms, chest pain, chills, nasal congestion, blurred vision, diarrhea/constipation, nausea/vomiting, painful urination, easy bruising, new skin lesions, or shortness of breath

30 Case #1 ALLERGIES: No known medical allergies MEDICATIONS: Midrin capsules, Motrin 800 mg every 6 hours PAST MEDICAL HISTORY: Positive for migraines and skin cancer on her forehead PAST SURGICAL HISTORY: 1. Left knee ACL repair 2. Left knee PCL repair 3. Appendectomy 4. Left knee arthroscopy FAMILY HISTORY: Mother had uterine cancer. Father has prostate cancer. Heart attack and stroke is associated with her maternal grandfather. SOCIAL HISTORY: Patient is employed as a hairstylist. She is divorced and currently single. She admits to alcohol consumption of 0-2 beverages per week. She denies illegal drug use and denies tobacco use. 51 Score It Up! 1995 HPI Guidelines O O O Location O Severity O Timing O Assoc. signs Brief (1-3) Extended O Quality O Duration O Context O Modifying Factors (4 or more) ROS (review of Systems): O O O O O Constitutional O All/Immuno O Ears, nose, mouth throat O Integumentary O Eyes O Musculo O Neuro O Hem/lymph O Cardiac/ vasc O GU O Resp O GI O Psych O Endo N/A PFSH (Past, Family, Social History): O O O O O Past history (the patient's past experiences w ith illnesses, operations, injuries and treatments) O Family history ( a review of medical events in the patient's family, including diseases that may be hereditary or place the patient at risk) O Social history (an age appropriate review of past and current activities) * Complete PFSH 2 history areas: a) established patients- office (outpatient) care, domiciliary care, home care; b) emergency department; c) subsequent nursing facility care; and, d) subsequent hospital care. 3 history areas: a) new patients-office ( N/A PROBLEM FOCUSED Pertinent to problem (1 system) EP. N/A PROBLEM FOCUSED Extended (pert & others) (2-9 syst.) Pertinent 1 history item DETAILED Complete (pert & all others) (10 *Complete 2-3 history areas COMPREHEN SIVE 99204/ Final History requires all 3 components above met or exceeded 52 26

31 Score It Up! 1995 HPI Guidelines O O O Location O Severity O Timing O Assoc. signs Brief (1-3) Extended O Quality O Duration O Context O Modifying Factors (4 or more) ROS (review of Systems): O O O O O Constitutional O All/Immuno O Ears, nose, mouth throat O Integumentary Extended Complete Pertinent to (pert & (pert & all O Eyes O Musculo O Neuro O Hem/lymph O Cardiac/ vasc problem others) others) O GU O Resp O GI O Psych O Endo N/A (1 system) (2-9 syst.) (10 PFSH (Past, Family, Social History): O O O O O Past history (the patient's past experiences w ith illnesses, operations, injuries and treatments) O Family history ( a review of medical events in the patient's family, including diseases that may be hereditary or place the patient at risk) O Social history (an age appropriate review of past and current activities) * Complete PFSH 2 history areas: a) established patients- office (outpatient) care, domiciliary care, home care; b) emergency department; c) subsequent nursing facility care; and, d) subsequent hospital care. 3 history areas: a) new patients-office ( N/A PROBLEM FOCUSED EP. N/A PROBLEM FOCUSED Pertinent 1 history item DETAILED *Complete 2-3 history areas COMPREHEN SIVE 99204/ Final History requires all 3 components above met or exceeded 53 Score It Up! 1995 HPI Guidelines O O O Location O Severity O Timing O Assoc. signs Brief (1-3) Extended O Quality O Duration O Context O Modifying Factors (4 or more) ROS (review of Systems): O O O O O Constitutional O All/Immuno O Ears, nose, mouth throat O Integumentary Extended Complete Pertinent to (pert & (pert & all O Eyes O Musculo O Neuro O Hem/lymph O Cardiac/ vasc problem others) others) O GU O Resp O GI O Psych O Endo N/A (1 system) (2-9 syst.) (10 PFSH (Past, Family, Social History): O O O O O Past history (the patient's past experiences w ith illnesses, operations, injuries and treatments) O Family history ( a review of medical events in the patient's family, including diseases that may be hereditary or place the patient at risk) O Social history (an age appropriate review of past and current activities) * Complete PFSH 2 history areas: a) established patients- office (outpatient) care, domiciliary care, home care; b) emergency department; c) subsequent nursing facility care; and, d) subsequent hospital care. 3 history areas: a) new patients-office ( N/A PROBLEM FOCUSED EP. N/A PROBLEM FOCUSED Pertinent 1 history item DETAILED *Complete 2-3 history areas COMPREHEN SIVE 99204/ Final History requires all 3 components above met or exceeded 54 27

32 Score It Up! 1995 HPI Guidelines O O O Location O Severity O Timing O Assoc. signs Brief (1-3) Extended O Quality O Duration O Context O Modifying Factors (4 or more) ROS (review of Systems): O O O O O Constitutional O All/Immuno O Ears, nose, mouth throat O Integumentary Extended Complete Pertinent to (pert & (pert & all O Eyes O Musculo O Neuro O Hem/lymph O Cardiac/ vasc problem others) others) O GU O Resp O GI O Psych O Endo N/A (1 system) (2-9 syst.) (10 PFSH (Past, Family, Social History): O O O O O Past history (the patient's past experiences w ith illnesses, operations, injuries and treatments) O Family history ( a review of medical events in the patient's family, including diseases that may be hereditary or place the patient at risk) O Social history (an age appropriate review of past and current activities) * Complete PFSH 2 history areas: a) established patients- office (outpatient) care, domiciliary care, home care; b) emergency department; c) subsequent nursing facility care; and, d) subsequent hospital care. 3 history areas: a) new patients-office ( N/A PROBLEM FOCUSED EP. N/A PROBLEM FOCUSED Pertinent 1 history item DETAILED *Complete 2-3 history areas COMPREHEN SIVE 99204/ Final History requires all 3 components above met or exceeded 55 PHYSICAL EAM: Case #1 VITALS: BP sitting 96/70, Temp 97.9, Weight 129 lbs., SPO2: 96%. Patient is a pleasant, 42 year-old female in no apparent distress who looks her given age, is well-developed and nourished with good attention to hygiene and body habitus

33 Case #1 PSYCHIATRIC: Psychiatric exam reveals orientation x 3 with mood and affect appropriate to situation. HEAD AND FACE: Examination of head and face is unremarkable. ETREMITIES: Nail of finger and toes do not demonstrate pitting or any other changes. There is no clubbing, cyanosis or edema noted at either the legs or arms. Her left knee does show some mild bony exuberance. There are medical and lateral longitudinal scars from prior surgeries. There is warmth and mild effusion. She has no significant laxity on provocative tests of the ACL, PCL, MCL or LCL. McMurray s is negative. She has mild tenderness over the posterior aspect of the lateral meniscus. 57 Case #1 HEART: Regular rate and rhythm LUNGS: Clear to auscultation 58 29

34 PHYSICAL EAM: Case #1 VITALS: BP sitting 96/70, Temp 97.9, Weight 129 lbs., SPO2: 96%. Patient is a pleasant, 42 year-old female in no apparent distress who looks her given age, is well-developed and nourished with good attention to hygiene and body habitus. 59 PHYSICAL EAM: Case #1 VITALS: BP sitting 96/70, Temp 97.9, Weight 129 lbs., SPO2: 96%. Patient is a pleasant, 42 year-old female in no apparent distress who looks her given age, is well-developed and nourished with good attention to hygiene and body habitus

35 Case #1 PSYCHIATRIC: Psychiatric exam reveals orientation x 3 with mood and affect appropriate to situation. HEAD AND FACE: Examination of head and face is unremarkable. ETREMITIES: Nail of finger and toes do not demonstrate pitting or any other changes. There is no clubbing, cyanosis or edema noted at either the legs or arms. Her left knee does show some mild bony exuberance. There are medical and lateral longitudinal scars from prior surgeries. There is warmth and mild effusion. She has no significant laxity on provocative tests of the ACL, PCL, MCL or LCL. McMurray s is negative. She has mild tenderness over the posterior aspect of the lateral meniscus. 61 Case #1 HEART: Regular rate and rhythm LUNGS: Clear to auscultation 62 31

36 Case #1 HEART: Regular rate and rhythm LUNGS: Clear to auscultation 63 Score It Up Baby! 2. Examination Refer to data section (table below) in order to quantify. After referring to data, identify the type of examination. Circle the type of examination within the appropriate grid in section 5. CPT Type of Exam 95 Guidelines 97 Guidelines Exam Equals Problem Focused Exam (PF) Expanded Problem Focused Exam (EPF) One body area or organ system 2-7 Body Systems- No Detail of any system required 1-5 bulleted elements 6-11 bulleted elements Detailed Exam (D) Comprehensive Exam (C) Comprehensive Exam (C) 2-7 body systems w/affected system in detail 8 or more body systems Not Applicable to 1995 Guidelines Not Applicable to 1995 Guidelines bulleted elements for 2 or more systems Not Applicable for 1997 Guidelines 18 or more bulleted elements for 9 or more systems. See requirements for individual single system exams 64 32

37 1997 Guidelines Guidelines 66 33

38 1997 Guidelines Guidelines 68 34

39 1997 Guidelines Guidelines 70 35

40 1997 Guidelines Guidelines 72 36

41 Score It Up Baby! 2. Examination Refer to data section (table below) in order to quantify. After referring to data, identify the type of examination. Circle the type of examination within the appropriate grid in section 5. CPT Type of Exam 95 Guidelines 97 Guidelines Exam Equals Problem Focused Exam (PF) Expanded Problem Focused Exam (EPF) One body area or organ system 2-7 Body Systems- No Detail of any system required 1-5 bulleted elements 6-11 bulleted elements Detailed Exam (D) 2-7 body systems w/affected system in detail bulleted elements for 2 or more systems Comprehensive Exam (C) Comprehensive Exam (C) 8 or more body systems Not Applicable to 1995 Guidelines Not Applicable to 1995 Guidelines Not Applicable for 1997 Guidelines 18 or more bulleted elements for 9 or more systems. See requirements for individual single system exams 73 Case #1 No tests to report at this time. IMPRESSION: 1. Initial visit 2. Left knee sprain/strain PLAN: At this point I feel physical therapy and continued conservative care is appropriate. Should she not continue to improve with PT or should she find that her pain is getting worse, she is to follow-up for re-evaluation and possible MRI. Referral was written for PT at ABC Physical Therapy to evaluate/treat 2-3 treatments per week for 4-6 weeks. SIGNED: Patrick Wise, MD 74 37

42 Case #1 No tests to report at this time. IMPRESSION: 1. Initial visit 2. Left knee sprain/strain New Problem no added workup PLAN: At this point I feel physical therapy and continued conservative care is appropriate. Should she not continue to improve with PT or should she find that her pain is getting worse, she is to follow-up for re-evaluation and possible MRI. Referral was written for PT at ABC Physical Therapy to evaluate/treat 2-3 treatments per week for 4-6 weeks. SIGNED: Patrick Wise, MD 75 Case #1 No tests to report at this time. IMPRESSION: 1. Initial visit 2. Left knee sprain/strain New Problem no added workup PLAN: At this point I feel physical therapy and continued conservative care is appropriate. Should she not continue to improve with PT or should she find that her pain is getting worse, she is to follow-up for re-evaluation and possible MRI. Referral was written for PT at ABC Physical Therapy to evaluate/treat 2-3 treatments per week for 4-6 weeks. SIGNED: Patrick Wise, MD 76 38

43 Score It Up Baby! Number of Diagnosis or Treatment Options A Problem(s) Status Self-Limited or minor (stable, improved, or w orsening) Est. problem (to examiner); stable, improved Est. problem (to examiner); w orsening New problem (to examiner); no add'l w orkup planned New problem (to examiner); add'l w orkup planned B x C= D Number Points Result Max= Max=1 3 4 Total: 3 77 Score It Up Baby! Amount and/or Complexity of Data Reviewed Reviewed Data Points Review and/or order of clinical lab tests 1 Review and/or order tests in the radiology section of CPT Review and/or order of tests in the medicine section of CPT Discussion of test results w ith performing physician Decision to obtain old records and/or obtain history from someone other than patient Review and summarization of old records and/or obtaining history fro someone other than patient and or discussion of case w ith another health care provider Independent visualization of image, tracing or specimen itself (not simply review of Total:

44 Risk of Complications and/or Morbidity or Mortality Level of Risk Minimal Low Moderate Presenting Problem(s) O Laboratory tests requiring O One self-limited or minor venipuncture problem, e.g. cold, insect bite, Tinea O Chest x-rays Corporis O EKG/EEG O Urinalysis O Two or more self-limited or minor problems O One stable chronic illness, e.g. w ell controlled hypertension or noninsulin dependent diabetes, cataract, BPH O Acute uncomplicated illness or injury, e.g. cystitis, allergic rhinitis, O One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment O Two or more stable chronic illnesses O Undiagnosed new problem with uncertain prognosis, e.g., lump in breast O Acute illness with systematic symptoms, Diagnostic Procedure(s) Ordered Ultrasound, e.g., echo O Physiologic tests not under stress, e.g., pulmonary function tests. O Non-cardiovascular imaging studies w ith contrast, e.g., barium enema O Superficial needle biopsies O Clinical laboratory tests requiring arterial puncture O Skin biopsies O Physiologic tests not under stress, e.g. cardiac stress test, fetal contraction stress test O Diagnostic endoscopies w ith no identified factors O Deep needle or incisional biopsy O Cardiovascular imaging studies w ith contrast and no identified risk Management Options O Rest O Gargles O Elastic bandages O Superficial dressings O Over-the-counter drugs O Minor surgery w ith no identified risk factors O Physical therapy O Occupational therapy O IV fluids x O Minor surgery w ith identified risk factors O Major surgery (open, percutaneous or endoscopic) w ith no identified risk factors O Prescription drug management O Therapeutic nuclear medicine O IV fluids w ith additives O Closed treatment of fracture o High O One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment O Acute or chronic illnesses or injuries that may pose a threat to life or bodily function, e.g. multiple trauma, acute MI, pulmonary embolus, severe r O Cardiovascular imaging studies w ith contrast w ith identified risk factors O Cardiac electrophysiological tests O Diagnostic endoscopies w ith identified risk factors O Discography O Major surgery (open, percutaneousor endoscopic w ith identified risk factors). O Emergency major surgery (open, percutaneous or endoscopic) O Parenteral controlled substances O Drug therapy requiring intensive monitoring for toxicity O Decision not 79 Score It Up Baby! 5. Level of Service OUTPATIENT, CONSULTS (OUTPATIENT, INPATIENT & CONFIRMATORY), AND ER New Office/ Consults/ ER *Established Office requires 3 components within shaded area requires 2 components within D C History PF EPF ER:EPF ER:D C PF EPF D C D C Examination PF EPF ER:EPF ER:D C PF EPF D C Complexity of Medical decision SF SF ER: L L ER:M M H SF L M H Average time (minutes) (Confirmatory consults & ER have no average time) NEW OUTPT CONS IP CONS ER NEW OUTPT CONS IP CONS ER NEW OUTPT CONS IP CONS ER NEW OUTPT CONS IP CONS ER NEW OUTPT CONS IP CONS ER MIN MIN MIN. LEVEL I II III IV V II III IV V MIN

45 Score It Up Baby! 5. Level of Service OUTPATIENT, CONSULTS (OUTPATIENT, INPATIENT & CONFIRMATORY), AND ER New Office/ Consults/ ER *Established Office requires 3 components within shaded area requires 2 components within D C History PF EPF ER:EPF ER:D C PF EPF D C D C Examination PF EPF ER:EPF ER:D C PF EPF D C Complexity of Medical SF L decision SF ER: L ER:M M H SF L M H Average time (minutes) (Confirmatory consults & ER have no average time) NEW OUTPT CONS IP CONS ER NEW OUTPT CONS IP CONS ER NEW OUTPT CONS IP CONS ER NEW OUTPT CONS IP CONS ER NEW OUTPT CONS IP CONS ER MIN MIN MIN. LEVEL I II III IV V II III IV V MIN. 81 Score It Up Baby! 5. Level of Service OUTPATIENT, CONSULTS (OUTPATIENT, INPATIENT & CONFIRMATORY), AND ER New Office/ Consults/ ER *Established Office requires 3 components within shaded area requires 2 components within D C History PF EPF ER:EPF ER:D C PF EPF D C D C Examination PF EPF ER:EPF ER:D C PF EPF D C Complexity of Medical SF L decision SF ER: L ER:M M H SF L M H Average time (minutes) (Confirmatory consults & ER have no average time) NEW OUTPT CONS IP CONS ER NEW OUTPT CONS IP CONS ER NEW OUTPT CONS IP CONS ER NEW OUTPT CONS IP CONS ER NEW OUTPT CONS IP CONS ER MIN MIN MIN. LEVEL I II III IV V II III IV V MIN

46 Score It Up Baby! 5. Level of Service OUTPATIENT, CONSULTS (OUTPATIENT, INPATIENT & CONFIRMATORY), AND ER New Office/ Consults/ ER *Established Office requires 3 components within shaded area requires 2 components within D C History PF EPF ER:EPF ER:D C PF EPF D C D C Examination PF EPF ER:EPF ER:D C PF EPF D C Complexity of Medical SF L decision SF ER: L ER:M M H SF L M H Average time (minutes) (Confirmatory consults & ER have no average time) NEW OUTPT CONS IP CONS ER NEW OUTPT CONS IP CONS ER NEW OUTPT CONS IP CONS ER NEW OUTPT CONS IP CONS ER NEW OUTPT CONS IP CONS ER MIN MIN MIN. LEVEL I II III IV V II III IV V MIN. 83 Wait just a minute! Medical Necessity! 84 42

47 Risk of Complications and/or Morbidity or Mortality Levels of Service Level of Risk Presenting Problem(s) Minimal O One self-limited or minor problem, e.g. cold, insect bite, Tinea Corporis Low O Two or more self-limited or minor problems O One stable chronic illness, e.g. well controlled hypertension or non-insulin dependent diabetes, cataract, BPH O Acute uncomplicated illness or injury, e.g. cystitis, allergic rhinitis, simple sprain Moderate O One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment O Two or more stable chronic illnesses O Undiagnosed new problem with uncertain prognosis, e.g., lump in breast O Acute illness with systematic symptoms, High O One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment O Acute or chronic illnesses or injuries that may pose a threat to life or bodily function, e.g. multiple trauma, acute MI, pulmonary embolus, severe r 85 Risk of Complications and/or Morbidity or Mortality Levels of Service Level of Risk Presenting Problem(s) Minimal O One self-limited or minor problem, e.g. cold, insect bite, Tinea Corporis Low O Two or more self-limited or minor problems O One stable chronic illness, e.g. well controlled hypertension or non-insulin dependent diabetes, cataract, BPH O Acute uncomplicated illness or injury, e.g. cystitis, allergic rhinitis, simple sprain Moderate O One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment O Two or more stable chronic illnesses O Undiagnosed new problem with uncertain prognosis, e.g., lump in breast O Acute illness with systematic symptoms, High O One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment O Acute or chronic illnesses or injuries that may pose a threat to life or bodily function, e.g. multiple trauma, acute MI, pulmonary embolus, severe r 86 43

48 Overall Documentation supports Medical Necessity supports billable level of service 87 Questions? 88 44

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