Fundamental E&M for Primary Care Risk Adjustment 2010

Transcription

1 2-hr Fundamental E&M for Primary Care Risk Adjustment 2010 E/M Relevance to Diagnosis Coding Presented by: Liz Jeremia Market Consultant Toni Toone, CPC, CPMA Sr. Provider Training & Development Consultant

2 Ingenix Clinical Assessment Solutions (CAS) Introduction Ingenix Clinical Assessment Solutions (CAS) collaborates with healthcare professionals and health plans towards improved health outcomes. CAS provides tools and support to help healthcare professionals in the early detection, ongoing assessment and accurate reporting of chronic conditions for Medicare and Medicaid patients. CAS has technology and health intelligence solutions that help healthcare professionals accurately document and code health care services while improving the overall quality of patient care. Ingenix, Inc. 2

3 E/M Relevance in Risk Adjustment

4 E/M Coding Disclaimer This presentation is for informational purposes only and does not guarantee payment or a final prediction of how specific claim(s) will be adjudicated regarding any E/M code listed, as all payments are subject to limits imposed by the member s contract. Due to the complexity of E/M coding guidelines, this presentation is provided "as is" without warranty of any kind, either expressed or implied, and does not necessarily reflect the views and requirements of all Medicare fiscal intermediaries and carrier contracts as well as other commercial contractors. This presentation was current at the time it was created; therefore, it is important to review current E/M updates as Medicare policy changes frequently. Ingenix, Inc. 4

5 E/M Audit Disclaimer Federal law requires that all expenses paid by Medicare, including expenses for Evaluation and Management (E/M) services, are for services that are reasonable and medically necessary. 1 CMS reserves the right to conduct audits on any provider and/or facility to ensure compliance with E&M guidelines according to States and State health care agencies obligated to Medicare fiscal intermediaries and carrier contracts. Therefore, the information provided in this presentation is founded on basic and fundamental E/M code selection only, and is not intended to promote, generate or guarantee successful audit results. Ingenix, Inc Centers for Medicare & Medicaid Services. "Medicare Program Integrity Manual." Centers for Medicare & Medicaid Services. CMS, 30 October Web. 25 May <

6 Evaluation and Management E/M Overview Ingenix, Inc. 6

7 1995 vs Guidelines The guidelines are similar when referencing the history and medical decision making, but differ within the exam component. 1,2 95 guidelines are typically used by primary care providers guidelines are typically used by specialty providers. 2 CMS has instructed auditors to use either the 1995 or 1997 guidelines, whichever is most advantageous to the provider. 3 Ingenix, Inc CMS, (1995) documentation guidelines for evaluation & management services. Retrieved from 2. CMS, (1997) documentation guidelines for evaluation & management services. Retrieved from 3

8 Coding for E/M Services Coding for E/M is not easy for coders. They must rely on provider documentation to determine the level of service for each of the components. Documentation drives the code assignment for each encounter. 1 E/M services include several complex categories and components within each category. 1 This presents compliance risks coders need to watch for when assigning codes. 1. Centers for Medicare & Medicaid Services, (1995) documentation guidelines for evaluation & management services. Retrieved from Ingenix, Inc. 8

9 Documentation Guidelines Medical record documentation is required to record facts, findings, and observations about an individual s health history including past and present illnesses, examination, test, treatments, and outcomes. Information required to validate services: * Site of service * Medical necessity of diagnostic and/or therapeutic services provided * Services provided accurately reported Centers for Medicare & Medicaid Services, (2009, July). Evaluation & management services guide. Retrieved from Ingenix, Inc. 9

10 Medical Record Documentation Guidelines The following applies to E/M documentation 1 The medical record should be complete and legible Each encounter should include: the date, reason for the visit, appropriate history and physical exam the reason for and results of x-rays, lab tests, and ancillary services relevant risk factors patient s progress and response to treatment, any change in treatment or change in diagnosis, and any patient noncompliance plan of treatment, medication change, consultation request complexity of Medical Decision Making the date and authentication CPT/ ICD-9 codes should reflect the documentation in the medical record Ingenix, Inc Centers for Medicare & Medicaid Services, (2009, July). Evaluation & management services guide. Retrieved from

11 Three Factors of E/M Codes Place of service Office Emergency Department Nursing Home,etc Type of service Consultations Admissions Office Visits Patient status New patient Established patient Outpatient Inpatient Ingenix, Inc. 11 Centers for Medicare & Medicaid Services, (2009, July). Evaluation & management services guide. Retrieved from

12 E/M: Key Components Every Face to Face Evaluation and Management Encounter code has three key components: History - Chief Complaint (CC) - History of Present Illness (HPI) - Review of Systems (ROS) - Past, Family and/or Social History (PFSH) Examination (95 or 97 guidelines) Medical Decision Making - # Possible DXs or # of Mgmt Options - Amount and/or Complexity of Data - Risk of Complications and/or Morbidity or Mortality as well as Associated Comorbidities Ingenix, Inc. 12

13 E/M: Contributing Factors Complete documentation is important: Levels of E/M service are based on key components (elements) and their contributing factors: Counseling Provided to patient/family members Discussions of diagnosis, test results, recommendations Documentation must support at least 50% of visit was counseling Coordination of care: Work done on behalf of patient (e.g. admission to hospital or SNF) Nature of the presenting problem(s) Type of problem patient presents with (minimal, self-limited or minor, low severity, moderate severity, high severity) Time A factor in only certain conditions Ingenix, Inc. 13 American Medical Association, (2010). CPT 2010, professional Ed. AMA Press, Chicago, IL

14 E&M (History / Exam / MDM) Evaluation & Management Documentation What elements of documentation validate an Evaluation and Management encounter as required by CMS? Centers for Medicare & Medicaid Services, Initials. (1995) documentation guidelines for evaluation & management services. Retrieved from Ingenix, Inc. 14

15 E&M (History / Exam / MDM) The Evaluation and Management Process First Things to Consider 1. Where did the Service occur? Office? Emergency Department? 2. What type of Service was it? Consultation? Admission? Office Visit? 3. What is the Patient Status? New or Established? Outpatient or Inpatient? Ingenix, Inc. 15

16 E&M (History / Exam / MDM) With E&M Start Counting! The Evaluation and Management Process is, in the end, a calculation based on key elements documented in the chart! This will become more evident as we visit the components of any Evaluation and Management Service. Ingenix, Inc. 16

17 Old Definition New or Established Patient? A New Patient is one that has not been seen by the provider (in a single provider practice) for the past three years or by a group of providers of the same specialty designation in a large group practice. An Established Patient is someone who has been seen by a given provider within the last three years. In multispecialty group practices, the patient is considered established if the provider of the same specialty of the same group practice has seen the patient within the past three years. Ingenix, Inc. 17 American Medical Association, (2010). CPT 2010, professional Ed. AMA Press, Chicago, IL

18 Outpatient / Inpatient Outpatient: One who has not been admitted to a health care facility Example: Patient receives service at clinic or same-day surgery center Inpatient: One who has been formally admitted to a health care facility Example: Hospital, nursing facility, etc. Attending physician dictates:» Admission orders» H & P» Requests consultations Ingenix, Inc. 18

19 E/M Audit Tool (95) New Patient 1,2 To qualify for a given level of service, All Three of the key components (History, Exam, & MDM) must be met or exceeded in documentation. New Patient Office Visit 1 History* A chief complaint is required for all levels. HPI ROS PFSH Exam* (MDM) Medical Decision Making* (Physicians typically spend 10 minutes face-to-face with patient) Brief (1-3 elements or status of 1-2 associated chronic conditions) N/A N/A Problem Focused (1 body area or organ system) Straightforward (Physicians typically spend 20 minutes face-to-face with patient) Brief (1-3 elements or status of 1-2 associated chronic conditions) Problem Pertinent (1 system) N/A Expanded Problem Focused (2-7 body areas and/or organ systems) Straightforward (Physicians typically spend 30 minutes face-to-face with patient) Extended (4+ elements or status of 3+ associated chronic conditions) Extended (2-9 systems) Pertinent (1 of 3) Detailed (2-7 body areas and/or organ systems) Low Complexity (Physicians typically spend 45 minutes face-to-face with patient) Extended (4+ elements or status of 3+ associated chronic conditions) Complete (10+ systems) Complete (3 of 3) Comprehensive (8+ organ systems or complete exam of single system) Moderate Complexity (Physicians typically spend 60 minutes face-to-face with patient) Extended (4+ elements or status of 3+ associated chronic conditions) Complete (10+ systems) Complete (3 of 3) Comprehensive (8+ organ systems or complete exam of single system) High Complexity 1. Current Procedural Terminology CPT Professional ed. Chicago, IL: American Medical Association, Print. 2. Centers for Medicare and Medicaid Services, Trailblazer Health Enterprises, LLC. Evaluation and Management Coding and Documentation Reference Guide. CMS, Trailblazer, Retrieved from: Ingenix, Inc. 19

20 E/M Audit Tool (95) Established Patient 1,2 To qualify for a given level of service, Two of Three of the key components (History, Exam, & MDM) must be met or exceeded in documentation. Established Patient Office Visit 1 History* A chief complaint is required for all levels. HPI ROS PFSH Exam* (MDM) Medical Decision Making* (Providers typically spend 5 minutes face-to-face with patient) May not require an MD to be present. The patient presents with minimal problems. N/A N/A N/A Straightforward (Physicians typically spend 10 minutes face-to-face with patient) Brief (1-3 elements or 1-2 associated chronic conditions) N/A N/A Problem Focused (1 body area or organ system) Straightforward (Physicians typically spend 15 minutes face-to-face with patient) Brief (1-3 elements or 1-2 associated chronic conditions) Problem Pertinent (1 system) N/A Expanded Problem Focused (2-7 body areas and/or organ systems) Low Complexity (Physicians typically spend 25 minutes face-to-face with patient) Extended (4+ elements or status of 3+ associated chronic conditions) Extended (2-9 systems) Pertinent (1 of 3) Detailed (2-7 body areas and/or organ systems) Moderate Complexity (Physicians typically spend 40 minutes face-to-face with patient) Extended (4+ elements or status of 3+ associated chronic conditions) Complete (10+ systems) Complete (2 of 3) Comprehensive (8+ organ systems or complete exam of single system) High Complexity 1. Current Procedural Terminology CPT Professional ed. Chicago, IL: American Medical Association, Print. 2. Centers for Medicare and Medicaid Services, Trailblazer Health Enterprises, LLC. Evaluation and Management Coding and Documentation Reference Guide. CMS, Trailblazer, Retrieved from: Ingenix, Inc. 20

21 E/M Audit Tool Key Elements of HPI* Elements of ROS* Exam: (Organ Systems)* 1. Location 2. Quality 3. Severity 4. Duration 5. Timing 6. Context 7. Modifying Factors 8. Associated SX/sx 1. Constitutional (subjective) 2. Eyes 3. Ears, Nose, Mouth, Throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary Elements of PFSH* 8. Musculoskeletal 9. Integumentary (skin and/or breast) 10. Neurological 11. Psychiatric 12. Endocrine 13. Hematologic/Lymphatic 14. Allergic/Immunologic 1. Past (PH) = Medications, Allergies, Injuries, Illnesses, Surgeries 2. Family (FH) = Family History of Diseases, Medical Events 3. Social (SH) = Marital Status, Living Arrangements, Employment, Drug/Tobacco Use, etc. 1. Constitutional (objective) 2. Eyes 3. Ears, Nose, Mouth, Throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary 8. Musculoskeletal 9. Skin 10. Neurologic 11. Psychiatric 12. Hematologic / Lymphatic / Immunologic Exam: (Body Areas)* 1. Head, including face 2. Neck 3. Chest, incl. breasts & axillae 4. Abdomen 5. Genitalia, groin, buttocks 6. Back, including spine 7. Each extremity MDM (Medical Decision Making)* To qualify for a given type of Medical Decision Making, 2 of the 3 elements in the table below must be met or exceeded. Elements of MDM Straightforward Low Complexity Moderate Complexity High Complexity 1. # Diagnoses or Management Options Minimal 1 DX or Trmt Point Limited 2 DXs or Trmt Points Multiple 3 DXs or Trmt Points Extensive 4 DXs or Trmt Points 2. Amount and/or Complexity of Data to be Reviewed 3. Risk of Complications and/or Morbidity / Mortality* (Select highest bullet item from Table of Risk) Ingenix, Inc. 21 Minimal or None 1 Data Point Limited 2 Data Points Moderate 3 Data Points Extensive 4 Data Points Minimal Low Moderate High If counseling and/or coordination of care = > 50% of physician/patient and/or family encounter, TIME is the key factor. Refer to pink columns. *See: &

22 The 1st Key Component (History) History Component Ingenix, Inc. 22

23 The 1st Key Component (History) The History Overview: Subjective From the patient s perspective or Point of View CC HPI ROS PFSH Chief Complaint (always required) History of Present Illness (8 Elements) Review of Systems (14 Elements) Past, Family, Social History (3 Categories) 1. Past Medical History (PH) 2. Social History (SH) 3. Family History (FH) Ingenix, Inc. 23

24 The 1st Key Component (History) E/M Chief Complaint (CC) Ingenix, Inc. 24

25 History (CC) The Chief Complaint (CC) Simply Stated The CC should express, What are you here for today? The patient provides the reason for the encounter. The chief complaint is required for all levels of history. Ingenix, Inc. 25

26 History (CC) CC: Each entry in the medical record must stand alone Example: Patient follow up, day three for debridement of lower extremity diabetic ulcer. Remember: If the provider sees the patient three days in a row for the same CC, it must still be documented on each entry in the medical record. Ingenix, Inc. 26

27 History (CC) - Physician and Patient Dialogue Development of a CC of chest pain: Started Tuesday night and was mild. During night, it got worse. Wednesday morning I went to work, but had to leave because the pain got so bad. Ingenix, Inc. 27

28 History (CC) - Physician and Patient Dialogue Examples of a definitive CC: This is the first visit for this 62-year-old female patient with a complaint of 1½ days history of cough and fever. Tom, a 75-year-old established patient, returns for follow-up of congestive heart failure. Ingenix, Inc. 28

29 History (CC) - Documentation Pearl Language to avoid: Patient here for follow up Patient here with no complaints The specific reason the patient presents for the current episode of care should be clearly stated. Ingenix, Inc. 29

30 Why is the Patient Here? What is the Chief Complaint? VERY FINE MEDICAL GROUP, INC Real Street, Anytown, CA, Ingenix, Inc. 30

31 Reason for Office Visit Visiting PCP for follow up of what condition? Med Refills can be done over the phone. Is there a reason this patient needed to be seen? There is no Chief Complaint Indicated VERY FINE MEDICAL GROUP, INC Real Street, Anytown, CA, Ingenix, Inc. 31

32 The 1st Key Component (History) Chart Review Working Sample Ingenix, Inc. 32

33 Progress Note Sample Past Medical History DM Type II Controlled, w/ Periph Circulatory Disease & Renal Disease Nephritis & Nephropathy HTN, Hyperlipidemia, Status CABG, Allergic Rhinitis Cardiovascular Disease Angiopathy Nephralgia Family History Father: Diseased with DM complications at 94 yrs of age. Mother: Diseased with cardiovascular complications 90 yrs of age Siblings: 4 brothers, 1 sister. Marital Status: Married, lives with spouse of 40 years. Three children; 1 daughter; 2 sons. Social History Drug abuse: No history of smoking, alcohol or drug abuse. Caffeine: I cup coffee per day. Occupation: Retired Disabled Exercise: Occasionally Allergies Phenergan, Demerol: both cause outbreak of rash Vital Signs T: 98.2; BP 163/92; HR 63; WT 203 lbs; Ht 68; BMI 31.57; RBS 128 CC / HPI: Patient here today complaining of sudden redness and flushing of skin, especially his face, neck, shoulders and arms. Began 2 days ago, with progressive intensity of skin color redness. Claims not to be under stress, but does have hot flashes. Has applied OTC hydrocortisone cream to the area, but not been effective. ROS: No changes in weight. Skin redness and flushing. No ulcers or rest pain. Patient states that finger sticks WNL. Exam: HEENT: Eyes clear, EOMI, PERRLA. Neck-Thyroid: No palpable nodes, no JVD, no thyromegaly, bruits. CHEST: Normal. Lungs: Clear, no rales, no ronchi. HEART: RRR, no murmurs, gallops, rubs, normal S1 S2. ABDOMEN: Soft and non tender, no BS, no organomegaly. EXTREMITIES: PVD, No edema, no cyanosis. NEUROLOGIC: No focal, motor, or sensory deficits. MUSCULOSKELETAL: Reveals appropriate muscle bulk and strength with FROM in joints. INTEGUMENTARY: Erythema noted of skin, no evidence of rash or lesions Assessment 1. Sudden Redness and flushing of skin (primary) 2. Diabetic PVD, Type II, controlled and HTN, Essential Administer Influenza VI vaccine - (G0008) Plan 1. Sudden Redness and flushing of skin: Begin Medrol dose pack, orally. Apply Cortisporin ointment q.i.d. x 7-days, recheck if necessary. 2. Diabetic PVD, Type II, controlled: Continue Januvia tabs, 100 mg orally: disp 30 tabs; one tab once per day. Continue Actos tabs, 15 mg, orally, disp 90 tabs; one tab once per day. Labs: Glucose fingerstick RGS: 128, reported on no necessary changes in current Rx. 3. HTN, Essential, controlled: Continue Normodyne, 100 mg orally: disp 30 tabs: one tab twice daily. no necessary changes in current Rx. Working Sample Progress Note Ingenix, Inc. 33

34 The 1st Key Component (History) E/M History (HPI) Ingenix, Inc. 34

35 History (HPI) Overview: The History of Present Illness (HPI) As defined in CPT, chronological description of the development of the patient s present illness from the first sign and/or symptom to the present. 1 Must be documented by the provider. Patient describes HPI. If patient cannot answer for themselves, a parent, guardian, or other may provide. 1. AMA, (2010). Current Procedural Coding Expert AMA Press: Chicago, Il. p. 411 Ingenix, Inc. 35

36 History (HPI) History of Present Illness (HPI) Using 8 criteria or Elements to describe the current problem: 1. Location Where is the problem? 2. Quality burning, stabbing, sharp 3. Severity A scale of 1 to 10 rating 4. Duration How long has this been going on? Ingenix, Inc. 36 Centers for Medicare & Medicaid Services, (2009, July). Evaluation & management services guide. Retrieved from

37 History (HPI) History of Present Illness (HPI) (continued) Using 8 criteria or Elements to describe the current problem: 5. Timing AM/PM, or pain comes and goes. 6. Context When does it hurt most; when I jog 7. Modifying Factors What the patient has done on their own to correct the problem for example: applied Ben-Gay, or taken aspirin. 8. Assoc. SX/sx Other SX/sx related to this problem - When my knee hurts, I get nauseated! Ingenix, Inc. 37 Centers for Medicare & Medicaid Services, (2009, July). Evaluation & management services guide. Retrieved from

38 History (HPI) The history component of the HPI: Uses 8 criteria to describe the current problem Brief Extended 1-3 elements 4+ elements (or) status of 3+ associated chronic conditions Location Quality Severity Duration Timing Context Modifying Factors Associated SX/sx Ingenix, Inc. 38

39 History (HPI) The history component of the HPI New Patient 1995 Office Visit HISTORY HPI* Est Patient 1995 Office Visit HISTORY HPI* (Physicians typically spend 10 minutes face-to-face with patient) Brief (1-3 elements or status of 1-2 assoc. chronic conditions) (Physicians typically spends 5 minutes face-to-face with patient) May not require an MD present. The patient presents with minimal problems (Physicians typically spend 20 minutes face-to-face with patient) Brief (1-3 elements or status of 1-2 assoc. chronic conditions) (Physicians typically spends 10 minutes face-to-face with patient) Brief (1-3 elements or 1-2 assoc. chronic conditions) (Physicians typically spends 30 minutes face-to-face with patient) Extended (4+ elements or status of 3+ associated chronic conditions) (Physicians typically spends 15 minutes face-to-face with patient) Extended (4+ elements or status of 3+ associated chronic conditions) (Physicians typically spend 45 minutes face-to-face with patient) Extended (4+ elements or status of 3+ associated chronic conditions) (Physicians typically spends 25 minutes face-to-face with patient) Extended (4+ elements or status of 3+ associated chronic conditions) (Physicians typically spend 60 minutes face-to-face with patient) Extended (4+ elements or status of 3+ associated chronic conditions) (Physicians typically spends 40 minutes face-to-face with patient) Extended (4+ elements or status of 3+ associated chronic conditions) * Elements of HPI * Elements of HPI 1. Location 2. Quality 3. Severity 4. Duration 5. Timing 6. Context 7. Modifying Factors 8. Assoc. SX/sx 1. Location 2. Quality 3. Severity 4. Duration 5. Timing 6. Context 7. Modifying Factors 8. Assoc. SX/sx Ingenix, Inc. 39

40 History (HPI): Chart Example Identify any of the (8) HPI statements that apply CC / HPI: Patient returns today complaining of sudden redness and flushing of skin, especially his face, neck, shoulders and arms. Began 2 days ago, with progressive intensity of skin color redness. Claims not to be under stress, but does have hot flashes. Has applied OTC hydrocortisone cream to the area, but not effective. Duration Location Severity Context Quality Modifying Circumstances Timing Associated SX/sx Ingenix, Inc. 40

41 History (HPI): Chart Example Identify any of the (8) HPI elements that apply CC / HPI: Patient returns today complaining of sudden redness and flushing of skin, especially his face, neck, shoulders and arms (Location). Began 2 days ago (Duration), with progressive intensity of skin color redness (Quality). Claims not to be under stress, but does not have hot flashes (Associated SX/sx). Has applied OTC hydrocortisone cream to the area, but not effective (Modifying Circumstances). Duration Location Severity Context Quality Modifying Circumstances Timing Associated SX/sx Ingenix, Inc. 41

42 E/M Audit Tool (95) Established Patient 1,2 To qualify for a given level of service, Two of Three of the key components (History, Exam, & MDM) must be met or exceeded in documentation. Established Patient Office Visit 1 History* A chief complaint is required for all levels. HPI ROS PFSH Exam* (MDM) Medical Decision Making* (Providers typically spend 5 minutes face-toface with patient) May not require an MD to be present. The patient presents with minimal problems. N/A N/A N/A Straightforward (Physicians typically spend 10 minutes face-to-face with patient) Brief (1-3 elements or 1-2 associated chronic conditions) N/A N/A Problem Focused (1 body area or organ system) Straightforward (Physicians typically spend 15 minutes face-to-face with patient) Brief (1-3 elements or 1-2 associated chronic conditions) Problem Pertinent (1 system) N/A Expanded Problem Focused (2-7) body areas +/or organ systems) Low Complexity (Physicians typically spend 25 minutes face-to-face with patient) Extended (4+ elements or status of 3 + associated chronic conditions) Extended (2-9 systems) Pertinent (1 of 3) Detailed (2-7) body areas +/or organ systems) Moderate Complexity (Physicians typically spend 40 minutes face-to-face with patient) Extended (4+ elements or status of 3 + associated chronic conditions) Complete (10+ systems) Complete (2 of 3) Comprehensive (8+ organ systems or complete exam of single system) High Complexity Ingenix, Inc. 42

43 HPI - History Calculation Past Medical History DM Type II Controlled, w/ Periph Circulatory Disease & Renal Disease Nephritis & Nephropathy HTN, Hyperlipidemia, Status CABG, Allergic Rhinitis Cardiovascular Disease Angiopathy Nephralgia Family History Father: Diseased with DM complications at 94 yrs of age. Mother: Diseased with cardiovascular complications 90 yrs of age Siblings: 4 brothers, 1 sister. Marital Status: Married, lives with spouse of 40 years. Three children; 1 daughter; 2 sons. Social History Drug abuse: No history of smoking, alcohol or drug abuse. Caffeine: I cup coffee per day. Occupation: Retired Disabled Exercise: Occasionally Allergies Phenergan, Demerol: both cause outbreak of rash History: Location Duration Quality HPI = Factors Assoc SX/sx 5 ROS = PFSH= Vital Signs T: 98.2; BP 163/92; HR 63; WT 203 lbs; Ht 68; BMI 31.57; RBS 128 CC / HPI: Patient here today Modifying complaining of sudden redness and flushing of skin, especially his face, neck, shoulders and arms. Began 2 days ago, with progressive intensity of skin color redness. Claims not to be under stress, but does have hot flashes. Has applied OTC hydrocortisone cream to the area, but not been effective. ROS: No changes in weight. Skin redness and flushing. No ulcers or rest pain. Patient states that finger sticks WNL. Exam: HEENT: Eyes clear, EOMI, PERRLA. Neck-Thyroid: No palpable nodes, no JVD, no thyromegaly, bruits. CHEST: Normal. Lungs: Clear, no rales, no ronchi. HEART: RRR, no Note: murmurs, gallops, rubs, normal S1 S2. ABDOMEN: Soft and non tender, no BS, no organomegaly. EXTREMITIES: PVD, No edema, no cyanosis. NEUROLOGIC: No focal, motor, or sensory deficits. MUSCULOSKELETAL: Reveals 3+ Chronic appropriate muscle bulk and strength with FROM in joints. INTEGUMENTARY: Erythema noted of skin, no evidence of rash or lesions Assessment 1. Sudden Redness and flushing of skin (primary) 2. Diabetic PVD, Type II, controlled and HTN, Essential Administer Influenza VI vaccine - (G0008) Conditions Plan 1. Sudden Redness and flushing of skin: Begin Medrol dose pack, orally. Apply Cortisporin ointment q.i.d. x 7-days, recheck if necessary.. 2. Diabetic PVD, Type II, controlled: Continue Januvia tabs, 100 mg orally: disp 30 tabs; one tab once per day. Continue Actos tabs, 15 mg, orally, disp 90 tabs; one tab once per day. Labs: Glucose fingerstick RGS: 128, reported on no necessary changes in current Rx. 3. HTN, Essential, controlled: Continue Normodyne, 100 mg orally: disp 30 tabs: one tab twice daily. no necessary changes in current Rx. Ingenix, Inc. 43

44 E/M Audit Tool Key Elements of HPI* Elements of ROS* Exam: (Organ Systems)* 1. Location 2. Quality 3. Severity 4. Duration 5. Timing 6. Context 7. Modifying Factors 8. Associated SX/sx 1. Constitutional (subjective) 2. Eyes 3. Ears, Nose, Mouth, Throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary 8. Musculoskeletal 9. Integumentary (skin and/or breast) 10. Neurological 11. Psychiatric 12. Endocrine 13. Hematologic/Lymphatic 14. Allergic/Immunologic 1. Constitutional (objective) 2. Eyes 3. Ears, Nose, Mouth, Throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary 8. Musculoskeletal 9. Skin 10. Neurologic 11. Psychiatric 12. Hematologic / Lymphatic / Immunologic Elements of PFSH* Exam: (Body Areas)* 1. Past (PH) = Medications, Allergies, Injuries, Illnesses, Surgeries 2. Family (FH) = Family History of Diseases, Medical Events 3. Social (SH) = Marital Status, Living Arrangements, Employment, Drug/Tobacco Use, etc. 1. Head, including face 2. Neck 3. Chest, incl. breasts & axillae 4. Abdomen 5. Genitalia, groin, buttocks 6. Back, including spine 7. Each extremity MDM (Medical Decision Making)* To qualify for a given type of Medical Decision Making, 2 of the 3 elements in the table below must be met or exceeded. Elements of MDM Straightforward Low Complexity Mod Complexity High Complexity 1. # Diagnoses or Management Options Minimal 1 DX or Trmt Point Limited 2 DXsor Trmt Points Multiple 3 DXs or Trmt Points Extensive 4DXs or Trmt Points 2. Amount and/or Complexity of Data to be Reviewed Minimal or None 1 Data point Limited 2 Data points Moderate 3 Data points Extensive 4 Data points 3. Risk of Complications and/or Morbidity / Mortality (Select highest risk bullet item) Ingenix, Inc. 44 Minimal Low Moderate High If counseling and/or coordination of care = > 50% of physician/patient and/or family encounter, TIME is the key factor. Refer to pink columns. *Centers for Medicare & Medicaid Services, CMS. (1995) documentation guidelines for evaluation & management services. Retrieved from

45 E/M Audit Tool Key Elements of HPI* Elements of ROS* Exam: (Organ Systems)* 1. Location 2. Quality 3. Severity 4. Duration 5. Timing 6. Context 7. Modifying Factors 8. Associated SX/sx 1. Constitutional (subjective) 2. Eyes 3. Ears, Nose, Mouth, Throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary 8. Musculoskeletal 9. Integumentary (skin and/or breast) 10. Neurological 11. Psychiatric 12. Endocrine 13. Hematologic/Lymphatic 14. Allergic/Immunologic 1. Constitutional (objective) 2. Eyes 3. Ears, Nose, Mouth, Throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary 8. Musculoskeletal 9. Skin 10. Neurologic 11. Psychiatric 12. Hematologic / Lymphatic / Immunologic Elements of PFSH* Exam: (Body Areas)* 1. Past (PH) = Medications, Allergies, Injuries, Illnesses, Surgeries 2. Family (FH) = Family History of Diseases, Medical Events 3. Social (SH) = Marital Status, Living Arrangements, Employment, Drug/Tobacco Use, etc. 1. Head, including face 2. Neck 3. Chest, incl. breasts & axillae 4. Abdomen 5. Genitalia, groin, buttocks 6. Back, including spine 7. Each extremity MDM (Medical Decision Making)* To qualify for a given type of Medical Decision Making, 2 of the 3 elements in the table below must be met or exceeded. Elements of MDM Straightforward Low Complexity Mod Complexity High Complexity 1. # Diagnoses or Management Options Minimal 1 DX or Trmt Point Limited 2 DXsor Trmt Points Multiple 3 DXs or Trmt Points Extensive 4DXs or Trmt Points 2. Amount and/or Complexity of Data to be Reviewed Minimal or None 1 Data point Limited 2 Data points Moderate 3 Data points Extensive 4 Data points 3. Risk of Complications and/or Morbidity / Mortality (Select highest risk bullet item) Ingenix, Inc. 45 Minimal Low Moderate High If counseling and/or coordination of care = > 50% of physician/patient and/or family encounter, TIME is the key factor. Refer to pink columns. *Centers for Medicare & Medicaid Services, CMS. (1995) documentation guidelines for evaluation & management services. Retrieved from

46 E/M Audit Tool (95) Established Patient 1,2 To qualify for a given level of service, Two of Three of the key components (History, Exam, & MDM) must be met or exceeded in documentation. Established Patient Office Visit 1 History* To qualify for a type, all 3 elements must be met. A chief complaint is required for all levels. HPI ROS PFSH Exam* (MDM) Medical Decision Making* (Providers typically spend 5 minutes face-toface with patient) May not require an MD to be present. The patient presents with minimal problems. N/A N/A N/A Straightforward (Physicians typically spend 10 minutes face-to-face with patient) Brief (1-3 elements or 1-2 associated chronic conditions) N/A N/A Problem Focused (1 body area or organ system) Straightforward (Physicians typically spend 15 minutes face-to-face with patient) Brief (1-3 elements or 1-2 associated chronic conditions) Problem Pertinent (1 system) N/A Expanded Problem Focused (2-7) body areas +/or organ systems) Low Complexity (Physicians typically spend 25 minutes face-to-face with patient) (Physicians typically spend 40 minutes face-to-face with patient) X X Extended (4+ elements or status of 3 + associated chronic conditions) Extended (4+ elements or status of 3 + associated chronic conditions) Extended (2-9 systems) Complete (10+ systems) Pertinent (1 of 3) Complete (2 of 3) Detailed (2-7) body areas +/or organ systems) Comprehensive (8+ organ systems or complete exam of single system) Moderate Complexity High Complexity Ingenix, Inc. 46

47 The 1st Key Component (History) E/M History (ROS) Ingenix, Inc. 47

48 History (ROS) Review of Systems (ROS) Definition The ROS is a systematic approach of asking questions about each of the body systems seeking to identify signs and/or symptoms. May be done in a variety of ways: the physician, a nurse or by means of a questionnaire filled out by the patient or ancillary personnel. Before the information can qualify as a ROS, the physician must review the information and document the review in the medical record. Ingenix, Inc. 48

49 History (ROS) Review of Systems (ROS) Both Positive and Negative Findings are recorded. Constitutional Symptoms do not pertain to any one anatomical body system the physical makeup of the body. These symptoms might indicate a system wide effect of a disease such as a fever or weight gain, hot flashes Ingenix, Inc. 49

50 History (ROS) Examples of Constitutional ROS (Subjective) Chills/sweats Fatigue Fever Weakness Weight change Ingenix, Inc. 50

51 History (ROS) Recognized System Elements of the Review of Systems (ROS) - Constitutional Symptoms - Musculoskeletal - Eyes - Integumentary - Ears, Nose, Mouth, Throat - Neurological - Cardiovascular - Psychiatric - Respiratory - Endocrine - Gastrointestinal - Hematologic/Lymphatic - Genitourinary - Allergic/Immunologic Ingenix, Inc. 51

52 History (ROS) Review of Systems (ROS) The ROS (positive and/or negative) responses must be directly related to the signs and /or symptoms the patient may be experiencing or has experienced as noted in the HPI. A complete review of systems may not be appropriate for all patient encounters. The ROS should be based on Medical Necessity. NOTE: - The exception would be on an annual examination. According to CMS, physicians do not have to document an element twice just so you can use it for both ROS and HPI. Ingenix, Inc. 52 Centers for Medicare & Medicaid Services, (2009, July). Evaluation & management services guide. Retrieved from

53 History (ROS) Guidelines Problem pertinent ROS The patient s positive responses and pertinent negative responses for the system related to the problem should be documented. Extended ROS The patient s positive responses and pertinent negative for two to nine systems should be documented. Complete ROS At least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented. Ingenix, Inc. 53

54 History (ROS) The history component of the ROS: A methodical approach of asking questions about each of the body systems Problem Pertinent Extended Complete 1 system 2-9 systems 10+ systems Constitutional Symptoms Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Integumentary (skin/breast) Neurological Psychiatric Endocrine Hematologic / Lymphatic Allergic / Immunologic Ingenix, Inc. 54

55 History (ROS) The history component of the ROS New Patient 1995 Office Visit HISTORY ROS* Est Patient 1995 Office Visit HISTORY ROS* (Physicians typically spend 10 minutes face-to-face with patient) N/A (Physicians typically spends 5 minutes face-to-face with patient) N/A (Physicians typically spend 20 minutes face-to-face with patient) Problem Pertinent (1 system) (Physicians typically spends 10 minutes face-to-face with patient) N/A (Physicians typically spends 30 minutes face-to-face with patient) Extended (2-9 systems) (Physicians typically spends 15 minutes face-to-face with patient) Problem Pertinent (1 system) (Physicians typically spend 45 minutes face-to-face with patient) Complete (10+ systems) (Physicians typically spends 25 minutes face-to-face with patient) Extended (2-9 systems) (Physicians typically spend 60 minutes face-to-face with patient) Complete (10+ systems) (Physicians typically spends 40 minutes face-to-face with patient) Complete (10+ systems) * Organ Systems for ROS * Organ Systems for ROS 1. Constitutional Symptoms 2. Eyes 3. Ears, Nose, Mouth, Throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary 8. Musculoskeletal 9. Integumentary (skin/breast) 10. Neurological 11. Psychiatric 12. Endocrine 13. Hematologic/Lymphatic 14. Allergic/Immunologic 1. Constitutional Symptoms 2. Eyes 3. Ears, Nose, Mouth, Throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary 8. Musculoskeletal 9. Integumentary (skin/breast) 10. Neurological 11. Psychiatric 12. Endocrine 13. Hematologic/Lymphatic 14. Allergic/Immunologic Ingenix, Inc. 55

56 ROS - History Calculation Past Medical History DM Type II Controlled, w/ Periph Circulatory Disease & Renal Disease Nephritis & Nephropathy HTN, Hyperlipidemia, Constitutional Status CABG, Allergic Rhinitis Cardiovascular Disease Angiopathy Nephralgia Endocrine Family History Father: Diseased with DM complications Integumentary at 94 yrs of age. Mother: Diseased with cardiovascular complications 90 Cardiovascular yrs of age Siblings: (PVD/PAD 4 brothers, L-extrem) 1 sister. Marital Status: Married, lives with spouse of 40 years. Three children; 1 daughter; 2 sons. Social History Drug abuse: No history of smoking, alcohol or drug abuse. Caffeine: I cup coffee per day. Occupation: Retired Disabled Exercise: Occasionally Allergies Phenergan, Demerol: both cause outbreak of rash Vital Signs T: 98.2; BP 163/92; HR 63; WT 203 lbs; Ht 68; BMI 31.57; RBS 128 CC / HPI: Patient here today complaining of sudden redness and flushing of skin, especially his face, neck, shoulders and arms. Began 2 days ago, with progressive intensity of skin color redness. Claims not to be under stress, but does have hot flashes. Has applied OTC hydrocortisone cream to the area, but not been effective. ROS: No changes in weight. Skin redness and flushing. No ulcers or rest pain. Patient states that finger sticks WNL. Exam: HEENT: Eyes clear, EOMI, PERRLA. Neck-Thyroid: No palpable nodes, no JVD, no thyromegaly, bruits. CHEST: Normal. Lungs: Clear, no rales, no ronchi. HEART: RRR, no murmurs, gallops, rubs, normal S1 S2. ABDOMEN: Soft and non tender, no BS, no organomegaly. EXTREMITIES: PVD, No edema, no cyanosis. NEUROLOGIC: No focal, motor, or sensory deficits. MUSCULOSKELETAL: Reveals appropriate muscle bulk and strength with FROM in joints. INTEGUMENTARY: Erythema noted of skin, no evidence of rash or lesions Assessment 1. Sudden Redness and flushing of skin (primary) 2. Diabetic PVD, Type II, controlled and HTN, Essential Administer Influenza VI vaccine - (G0008) Plan 1. Sudden Redness and flushing of skin: Begin Medrol dose pack, orally. Apply Cortisporin ointment q.i.d. x 7-days, recheck if necessary.. 2. Diabetic PVD, Type II, controlled: Continue Januvia tabs, 100 mg orally: disp 30 tabs; one tab once per day. Continue Actos tabs, 15 mg, orally, disp 90 tabs; one tab once per day. Labs: Glucose fingerstick RGS: 128, reported on no necessary changes in current Rx. 3. HTN, Essential, controlled: Continue Normodyne, 100 mg orally: disp 30 tabs: one tab twice daily. no necessary changes in current Rx. History: HPI = ROS = PFSH= 5 4 Ingenix, Inc. 56

57 E/M Audit Tool Key Elements of HPI* Elements of ROS* Exam: (Organ Systems)* 1. Location 2. Quality 3. Severity 4. Duration 5. Timing 6. Context 7. Modifying Factors 8. Associated SX/sx 1. Constitutional (subjective) 2. Eyes 3. Ears, Nose, Mouth, Throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary 8. Musculoskeletal 9. Integumentary (skin and/or breast) 10. Neurological 11. Psychiatric 12. Endocrine 13. Hematologic/Lymphatic 14. Allergic/Immunologic 1. Constitutional (objective) 2. Eyes 3. Ears, Nose, Mouth, Throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary 8. Musculoskeletal 9. Skin 10. Neurologic 11. Psychiatric 12. Hematologic / Lymphatic / Immunologic Elements of PFSH* Exam: (Body Areas)* 1. Past (PH) = Medications, Allergies, Injuries, Illnesses, Surgeries 2. Family (FH) = Family History of Diseases, Medical Events 3. Social (SH) = Marital Status, Living Arrangements, Employment, Drug/Tobacco Use, etc. 1. Head, including face 2. Neck 3. Chest, incl. breasts & axillae 4. Abdomen 5. Genitalia, groin, buttocks 6. Back, including spine 7. Each extremity MDM (Medical Decision Making)* To qualify for a given type of Medical Decision Making, 2 of the 3 elements in the table below must be met or exceeded. Elements of MDM Straightforward Low Complexity Mod Complexity High Complexity 1. # Diagnoses or Management Options Minimal 1 DX or Trmt Point Limited 2 DXsor Trmt Points Multiple 3 DXs or Trmt Points Extensive 4DXs or Trmt Points 2. Amount and/or Complexity of Data to be Reviewed Minimal or None 1 Data point Limited 2 Data points Moderate 3 Data points Extensive 4 Data points 3. Risk of Complications and/or Morbidity / Mortality (Select highest risk bullet item) Ingenix, Inc. 57 Minimal Low Moderate High If counseling and/or coordination of care = > 50% of physician/patient and/or family encounter, TIME is the key factor. Refer to pink columns. *Centers for Medicare & Medicaid Services, CMS. (1995) documentation guidelines for evaluation & management services. Retrieved from

58 E/M Audit Tool Key Elements of HPI* Elements of ROS* Exam: (Organ Systems)* 1. Location 2. Quality 3. Severity 4. Duration 5. Timing 6. Context 7. Modifying Factors 8. Associated SX/sx 1. Constitutional (subjective) 2. Eyes 3. Ears, Nose, Mouth, Throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary 8. Musculoskeletal 9. Integumentary (skin and/or breast) 10. Neurological 11. Psychiatric 12. Endocrine 13. Hematologic/Lymphatic 14. Allergic/Immunologic 1. Constitutional (objective) 2. Eyes 3. Ears, Nose, Mouth, Throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary 8. Musculoskeletal 9. Skin 10. Neurologic 11. Psychiatric 12. Hematologic / Lymphatic / Immunologic Elements of PFSH* Exam: (Body Areas)* 1. Past (PH) = Medications, Allergies, Injuries, Illnesses, Surgeries 2. Family (FH) = Family History of Diseases, Medical Events 3. Social (SH) = Marital Status, Living Arrangements, Employment, Drug/Tobacco Use, etc. 1. Head, including face 2. Neck 3. Chest, incl. breasts & axillae 4. Abdomen 5. Genitalia, groin, buttocks 6. Back, including spine 7. Each extremity MDM (Medical Decision Making)* To qualify for a given type of Medical Decision Making, 2 of the 3 elements in the table below must be met or exceeded. Elements of MDM Straightforward Low Complexity Mod Complexity High Complexity 1. # Diagnoses or Management Options Minimal 1 DX or Trmt Point Limited 2 DXsor Trmt Points Multiple 3 DXs or Trmt Points Extensive 4DXs or Trmt Points 2. Amount and/or Complexity of Data to be Reviewed Minimal or None 1 Data point Limited 2 Data points Moderate 3 Data points Extensive 4 Data points 3. Risk of Complications and/or Morbidity / Mortality (Select highest risk bullet item) Ingenix, Inc. 58 Minimal Low Moderate High If counseling and/or coordination of care = > 50% of physician/patient and/or family encounter, TIME is the key factor. Refer to pink columns. *Centers for Medicare & Medicaid Services, CMS. (1995) documentation guidelines for evaluation & management services. Retrieved from

59 E/M Audit Tool (95) Established Patient 1,2 To qualify for a given level of service, Two of Three of the key components (History, Exam, & MDM) must be met or exceeded in documentation. Established Patient Office Visit 1 History* A chief complaint is required for all levels. HPI ROS PFSH Exam* (MDM) Medical Decision Making* (Providers typically spend 5 minutes face-toface with patient) May not require an MD to be present. The patient presents with minimal problems. N/A N/A N/A Straightforward (Physicians typically spend 10 minutes face-to-face with patient) Brief (1-3 elements or 1-2 associated chronic conditions) N/A N/A Problem Focused (1 body area or organ system) Straightforward (Physicians typically spend 15 minutes face-to-face with patient) Brief (1-3 elements or 1-2 associated chronic conditions) Problem Pertinent (1 system) N/A Expanded Problem Focused (2-7) body areas +/or organ systems) Low Complexity (Physicians typically spend 25 minutes face-to-face with patient) (Physicians typically spend 40 minutes face-to-face with patient) X X Extended (4+ elements or status of 3 + associated chronic conditions) Extended (4+ elements or status of 3 + associated chronic conditions) X Extended (2-9 systems) Complete (10+ systems) Pertinent (1 of 3) Complete (2 of 3) Detailed (2-7) body areas +/or organ systems) Comprehensive (8+ organ systems or complete exam of single system) Moderate Complexity High Complexity Ingenix, Inc. 59

60 The 1st Key Component (History) E/M History (PFSH) Ingenix, Inc. 60

61 History (PFSH) The history component of the PFSH There are 3 categories assigned to the PFSH 1. Past History (PH) Medical Illnesses, Chronic Problems, Injuries, Hospitalizations, Treatments, Prior Operations, current Medications, Allergies, Immunizations, Dietary Status, etc. 2. Family History (FH) Review of the patient s Family History, Hereditary Diseases, Cause of Death. 3. Social History (SH) Marital Status, Education, Occupation, current and previous Use of Drugs, Alcohol, Tobacco, Level of Education, Sexual History, etc. Ingenix, Inc. 61

62 History (PFSH) The history component of the PFSH Levels to the PFSH 1. Problem Focused History No PFSH categories are Required 2. Expanded Problem Focused No PFSH categories are Required 3. Detailed One PFSH category is Required 4. Comprehensive All three categories of the PFSH (PH, FH, SH) are Required Ingenix, Inc. 62

63 PFSH Guidelines A pertinent PFSH is a review of the history area(s) directly related to the problem(s) identified in the HPI. At least one specific item from any of the three history areas must be documented for a pertinent PFSH. A complete PFSH is a review of two or all three of the PFSH history areas, depending on the category of the E/M service. At least one specific item from tow of the three history areas must be documented for a complete PFSH for the established patient seen in the office. At least one specific item from each of the three history areas must be documented for a complete PFSH for the new patient seen in the office. Ingenix, Inc. 63

64 History (PFSH) The history component of the PFSH PFSH is utilized in either of two levels: Pertinent 1 bullet from any of the (3) categories Complete 1 bullet from each of the three categories (3 of 3) (3 of 3) (2 of 3) Ingenix, Inc. 64

65 History (PFSH) The history component of the PFSH New Patient 1995 Office Visit HISTORY PFSH* Est Patient 1995 Office Visit HISTORY PFSH* (Physicians typically spend 10 minutes face-to-face with patient) N/A (Physicians typically spends 5 minutes face-to-face with patient) N/A (Physicians typically spend 20 minutes face-to-face with patient) N/A (Physicians typically spends 10 minutes face-to-face with patient) N/A (Physicians typically spends 30 minutes face-to-face with patient) Pertinent (1 of 3) (Physicians typically spends 15 minutes face-to-face with patient) N/A (Physicians typically spend 45 minutes face-to-face with patient) Complete (3 of 3) (Physicians typically spends 25 minutes face-to-face with patient) Pertinent (1 of 3) (Physicians typically spend 60 minutes face-to-face with patient) Complete (3 of 3) (Physicians typically spends 40 minutes face-to-face with patient) Complete (2 of 3) * Elements of PFSH * Elements of PFSH 1. Past (PH) = Medications, Allergies, Injuries, Illnesses, Surgeries 2. Family (FH) = Family Diseases, Medical Events 3. Social (SH) = Marital Status, Living Arrangements, Employment, Drug/Tobacco Use, etc. 1. Past (PH) = Medications, Allergies, Injuries, Illnesses, Surgeries 2. Family (FH) = Family Diseases, Medical Events 3. Social (SH) = Marital Status, Living Arrangements, Employment, Drug/Tobacco Use, etc. Ingenix, Inc. 65

66 PFSH - History Calculation Past Medical History DM Type II Controlled, w/ Periph Circulatory Disease & Renal Disease Nephritis & Nephropathy HTN, Hyperlipidemia, Status CABG, Allergic Rhinitis Cardiovascular Disease Angiopathy Nephralgia Vital Signs T: 98.2; BP 163/92; HR 63; WT 203 lbs; Ht 68; BMI 31.57; RBS 128 CC / HPI: Patient here today complaining of sudden redness and flushing of skin, especially his face, neck, shoulders and arms. Began 2 days ago, with progressive intensity of skin color redness. Claims not to be under stress, but does have hot flashes. Has applied OTC hydrocortisone cream to the area, but not been effective. ROS: No changes in weight. Skin redness and flushing. No ulcers or rest pain. Patient states that finger sticks WNL. History: HPI = ROS = PFSH= Family History Father: Diseased with DM complications at 94 yrs of age. Mother: Diseased with cardiovascular complications 90 yrs of age Siblings: 4 brothers, 1 sister. Marital Status: Married, lives with spouse of 40 years. Three children; 1 daughter; 2 sons. Social History Drug abuse: No history of smoking, alcohol or drug abuse. Caffeine: I cup coffee per day. Occupation: Retired Disabled Exercise: Occasionally Allergies Phenergan, Demerol: both cause outbreak of rash Exam: HEENT: Eyes clear, EOMI, PERRLA. Neck-Thyroid: No palpable nodes, no JVD, no thyromegaly, bruits. CHEST: Normal. Lungs: Clear, no rales, no ronchi. HEART: RRR, no murmurs, gallops, rubs, normal S1 S2. ABDOMEN: Soft and non tender, no BS, no organomegaly. EXTREMITIES: PVD, No edema, no cyanosis. NEUROLOGIC: No focal, motor, or sensory deficits. MUSCULOSKELETAL: Reveals appropriate muscle bulk and strength with FROM in joints. INTEGUMENTARY: Erythema noted of skin, no evidence of rash or lesions Assessment 1. Sudden Redness and flushing of skin (primary) 2. Diabetic PVD, Type II, controlled and HTN, Essential Administer Influenza VI vaccine - (G0008) Plan 1. Sudden Redness and flushing of skin: Begin Medrol dose pack, orally. Apply Cortisporin ointment q.i.d. x 7-days, recheck if necessary.. 2. Diabetic PVD, Type II, controlled: Continue Januvia tabs, 100 mg orally: disp 30 tabs; one tab once per day. Continue Actos tabs, 15 mg, orally, disp 90 tabs; one tab once per day. Labs: Glucose fingerstick RGS: 128, reported on no necessary changes in current Rx. 3. HTN, Essential, controlled: Continue Normodyne, 100 mg orally: disp 30 tabs: one tab twice daily. no necessary changes in current Rx. Ingenix, Inc. 66

67 E/M Audit Tool Key Elements of HPI* Elements of ROS* Exam: (Organ Systems)* 1. Location 2. Quality 3. Severity 4. Duration 5. Timing 6. Context 7. Modifying Factors 8. Associated SX/sx 1. Constitutional (subjective) 2. Eyes 3. Ears, Nose, Mouth, Throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary 8. Musculoskeletal 9. Integumentary (skin and/or breast) 10. Neurological 11. Psychiatric 12. Endocrine 13. Hematologic/Lymphatic 14. Allergic/Immunologic 1. Constitutional (objective) 2. Eyes 3. Ears, Nose, Mouth, Throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary 8. Musculoskeletal 9. Skin 10. Neurologic 11. Psychiatric 12. Hematologic / Lymphatic / Immunologic Elements of PFSH* Exam: (Body Areas)* 1. Past (PH) = Medications, Allergies, Injuries, Illnesses, Surgeries 2. Family (FH) = Family History of Diseases, Medical Events 3. Social (SH) = Marital Status, Living Arrangements, Employment, Drug/Tobacco Use, etc. 1. Head, including face 2. Neck 3. Chest, incl. breasts & axillae 4. Abdomen 5. Genitalia, groin, buttocks 6. Back, including spine 7. Each extremity MDM (Medical Decision Making)* To qualify for a given type of Medical Decision Making, 2 of the 3 elements in the table below must be met or exceeded. Elements of MDM Straightforward Low Complexity Mod Complexity High Complexity 1. # Diagnoses or Management Options Minimal 1 DX or Trmt Point Limited 2 DXsor Trmt Points Multiple 3 DXs or Trmt Points Extensive 4DXs or Trmt Points 2. Amount and/or Complexity of Data to be Reviewed Minimal or None 1 Data point Limited 2 Data points Moderate 3 Data points Extensive 4 Data points 3. Risk of Complications and/or Morbidity / Mortality (Select highest risk bullet item) Ingenix, Inc. 67 Minimal Low Moderate High If counseling and/or coordination of care = > 50% of physician/patient and/or family encounter, TIME is the key factor. Refer to pink columns. *Centers for Medicare & Medicaid Services, CMS. (1995) documentation guidelines for evaluation & management services. Retrieved from

68 E/M Audit Tool Key Elements of HPI* Elements of ROS* Exam: (Organ Systems)* 1. Location 2. Quality 3. Severity 4. Duration 5. Timing 6. Context 7. Modifying Factors 8. Associated SX/sx 1. Constitutional (subjective) 2. Eyes 3. Ears, Nose, Mouth, Throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary 8. Musculoskeletal 9. Integumentary (skin and/or breast) 10. Neurological 11. Psychiatric 12. Endocrine 13. Hematologic/Lymphatic 14. Allergic/Immunologic 1. Constitutional (objective) 2. Eyes 3. Ears, Nose, Mouth, Throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary 8. Musculoskeletal 9. Skin 10. Neurologic 11. Psychiatric 12. Hematologic / Lymphatic / Immunologic Elements of PFSH* Exam: (Body Areas)* 1. Past (PH) = Medications, Allergies, Injuries, Illnesses, Surgeries 2. Family (FH) = Family History of Diseases, Medical Events 3. Social (SH) = Marital Status, Living Arrangements, Employment, Drug/Tobacco Use, etc. 1. Head, including face 2. Neck 3. Chest, incl. breasts & axillae 4. Abdomen 5. Genitalia, groin, buttocks 6. Back, including spine 7. Each extremity MDM (Medical Decision Making)* To qualify for a given type of Medical Decision Making, 2 of the 3 elements in the table below must be met or exceeded. Elements of MDM Straightforward Low Complexity Mod Complexity High Complexity 1. # Diagnoses or Management Options Minimal 1 DX or Trmt Point Limited 2 DXsor Trmt Points Multiple 3 DXs or Trmt Points Extensive 4DXs or Trmt Points 2. Amount and/or Complexity of Data to be Reviewed Minimal or None 1 Data point Limited 2 Data points Moderate 3 Data points Extensive 4 Data points 3. Risk of Complications and/or Morbidity / Mortality (Select highest risk bullet item) Ingenix, Inc. 68 Minimal Low Moderate High If counseling and/or coordination of care = > 50% of physician/patient and/or family encounter, TIME is the key factor. Refer to pink columns. *Centers for Medicare & Medicaid Services, CMS. (1995) documentation guidelines for evaluation & management services. Retrieved from

69 E/M Audit Tool (95) Established Patient 1,2 To qualify for a given level of service, Two of Three of the key components (History, Exam, & MDM) must be met or exceeded in documentation. Established Patient Office Visit 1 History* A chief complaint is required for all levels. HPI ROS PFSH Exam* (MDM) Medical Decision Making* (Providers typically spend 5 minutes face-toface with patient) May not require an MD to be present. The patient presents with minimal problems. N/A N/A N/A Straightforward (Physicians typically spend 10 minutes face-to-face with patient) Brief (1-3 elements or 1-2 associated chronic conditions) N/A N/A Problem Focused (1 body area or organ system) Straightforward (Physicians typically spend 15 minutes face-to-face with patient) Brief (1-3 elements or 1-2 associated chronic conditions) Problem Pertinent (1 system) N/A Expanded Problem Focused (2-7) body areas +/or organ systems) Low Complexity (Physicians typically spend 25 minutes face-to-face with patient) (Physicians typically spend 40 minutes face-to-face with patient) X X Extended (4+ elements or status of 3 + associated chronic conditions) Extended (4+ elements or status of 3 + associated chronic conditions) X Extended (2-9 systems) Complete (10+ systems) X Pertinent (1 of 3) X Complete (2 of 3) Detailed (2-7) body areas +/or organ systems) Comprehensive (8+ organ systems or complete exam of single system) Moderate Complexity High Complexity Ingenix, Inc. 69

70 History (Summary) History Documentation Guidelines The CC, ROS, and PFSH may be listed as separate elements in the History or may be included in the description for the HPI. If the patient is unable to provide the history information, for example, in the emergency room, the documentation should clearly state why. Ingenix, Inc. 70

71 The 2nd Key Component (Exam) Exam Component Ingenix, Inc. 71

72 The 2nd Key Component (Exam) Examination Objective Data is objective from the Physician s point of view (Based on 1995 E/M Documentation Guidelines) 12 Organ Systems (OSs) - Constitutional - Gastrointestinal - Eyes - Genitourinary - Ears, Nose, Mouth - Musculoskeletal & Throat - Skin - Cardiovascular - Neurologic - Respiratory - Psychiatric - Hematologic/Lymphatic/Immunologic 7 Body Areas (BAs) Ingenix, Inc Head, Including face - Genitalia, Groin, Buttocks - Neck - Back, including spine - Chest, including breasts and axillae - Abdomen - Each extremity

73 The 2nd Key Component (Exam) Constitutional (Objective) Examples: - Blood pressure, sitting - Blood pressure, lying -Pulse - Respiration - Temperature - Height - Weight - General Appearance Ingenix, Inc. 73

74 Exam Documentation The documentation in the exam is often assumed Without thorough documentation, the exam portion of the progress note will not validate Each encounter must include: Abnormal/relevant negative findings Notation of abnormal is insufficient A brief statement indicating negative or normal is sufficient. Ingenix, Inc. 74 CMS-Centers for Medicare & Medicaid Services, "2008 Risk Adjustment Data Technical Assistance For Medicare Advantage Organizations Participant Guide." Leading Through Change, Inc Centers for Medicare & Medicaid Services, (1995) documentation guidelines for evaluation & management services. Retrieved from

75 The 2nd Key Component (Exam) The Component of the Exam 1995 Exam Guidelines are based upon the number of body areas and organ systems examined and documented Expanded Problem Focused Detailed Comprehensive 2-7 BAs +/or OSs 2-7 BAs +/or OSs 8 or more OSs (or) Complete single organ system BAs Head, incl. face Neck Chest, incl. breasts and axillae Abdomen Genitalia, groin, buttocks Back, incl. spine Each extremity OSs Constitutional Eyes Ears, nose, mouth and throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic/lymphatic/immunologic Ingenix, Inc. 75

76 The 2nd Key Component (Exam) New Patient 1995 Office Visit EXAM* Est Patient 1995 Office Visit EXAM* (Physicians typically spend 10 minutes face-to-face with patient) Problem Focused (1 BA or OS) (Physicians typically spends 5 minutes face-to-face with patient) N/A (Physicians typically spend 20 minutes face-to-face with patient) Expanded Problem Focused (2-7 BAs and/or OSs) (Physicians typically spends 10 minutes face-to-face with patient) Problem Focused (1 BA or OS) (Physicians typically spends 30 minutes face-to-face with patient) (Physicians typically spend 45 minutes face-to-face with patient) Detailed (2-7 BAs and/or OSs) Comprehensive (8+ OSs or complete exam of single system) (Physicians typically spends 15 minutes face-to-face with patient) (Physicians typically spends 25 minutes face-to-face with patient) Expanded Problem Focused (2-7 BAs +/or OSs) Detailed (2-7 BAs +/or OSs) (Physicians typically spend 60 minutes face-to-face with patient) Comprehensive (8+ OSs or complete exam of single system) (Physicians typically spends 40 minutes face-to-face with patient) Comprehensive (8+ OSs or complete exam of single system) * Exam: (Organ Systems) * Exam: (Organ Systems) 1. Constitutional (subjective) 2. Eyes 3. Ears, Nose, Mouth, Throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary 8. Musculoskeletal 9. Skin 10. Neurologic 11. Psychiatric 12. Lymphatic/Hem/Imm 1. Constitutional (subjective) 2. Eyes 3. Ears, Nose, Mouth, Throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary 8. Musculoskeletal 9. Skin 10. Neurologic 11. Psychiatric 12. Lymphatic/Hem/Imm * Exam: (Body Areas) * Exam: (Body Areas) 1. Head, including face 2. Neck 3. Chest, incl. breasts & axillae 4. Abdomen 5. Genitalia, groin, buttocks 6. Back, including spine 7. Each Extremity 1. Head, including face 2. Neck 3. Chest, incl. breasts & axillae 4. Abdomen 5. Genitalia, groin, buttocks 6. Back, including spine 7. Each Extremity Ingenix, Inc. 76

77 E/M Audit Tool (95) Established Patient 1,2 To qualify for a given level of service, Two of Three of the key components (History, Exam, & MDM) must be met or exceeded in documentation. Established Patient Office Visit 1 History*. A chief complaint is required for all levels. HPI ROS PFSH Exam* (MDM) Medical Decision Making* (Providers typically spend 5 minutes face-toface with patient) May not require an MD to be present. The patient presents with minimal problems. N/A N/A N/A Straightforward (Physicians typically spend 10 minutes face-to-face with patient) Brief (1-3 elements or 1-2 associated chronic conditions) N/A N/A Problem Focused (1 body area or organ system) Straightforward (Physicians typically spend 15 minutes face-to-face with patient) Brief (1-3 elements or 1-2 associated chronic conditions) Problem Pertinent (1 system) N/A Expanded Problem Focused (2-7) body areas +/or organ systems) Low Complexity (Physicians typically spend 25 minutes face-to-face with patient) (Physicians typically spend 40 minutes face-to-face with patient) X X Extended (4+ elements or status of 3 + associated chronic conditions) Extended (4+ elements or status of 3 + associated chronic conditions) X Extended (2-9 systems) Complete (10+ systems) X Pertinent (1 of 3) X Complete (2 of 3) Detailed (2-7) body areas +/or organ systems) Comprehensive (8+ organ systems or complete exam of single system) Moderate Complexity High Complexity Ingenix, Inc. 77

78 E/M Audit Tool Key Elements of HPI* Elements of ROS* Exam: (Organ Systems)* 1. Location 2. Quality 3. Severity 4. Duration 5. Timing 6. Context 7. Modifying Factors 8. Associated SX/sx 1. Constitutional (subjective) 2. Eyes 3. Ears, Nose, Mouth, Throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary Elements of PFSH* 8. Musculoskeletal 9. Integumentary (skin and/or breast) 10. Neurological 11. Psychiatric 12. Endocrine 13. Hematologic/Lymphatic 14. Allergic/Immunologic 1. Past (PH) = Medications, Allergies, Injuries, Illnesses, Surgeries 2. Family (FH) = Family History of Diseases, Medical Events 3. Social (SH) = Marital Status, Living Arrangements, Employment, Drug/Tobacco Use, etc. 1. Constitutional (objective) 2. Eyes 3. Ears, Nose, Mouth, Throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary 1. Head, including face 2. Neck 3. Chest, incl. breasts & axillae 4. Abdomen Exam: (Body Areas)* 8. Musculoskeletal 9. Skin 10. Neurologic 11. Psychiatric 12. Hematologic / Lymphatic / Immunologic 5. Genitalia, groin, buttocks 6. Back, including spine 7. Each extremity MDM (Medical Decision Making)* To qualify for a given type of Medical Decision Making, 2 of the 3 elements in the table below must be met or exceeded. Elements of MDM Straightforward Low Complexity Mod Complexity High Complexity 1. # Diagnoses or Management Options Minimal 1 DX or Trmt Point Limited 2 DXsor Trmt Points Multiple 3 DXs or Trmt Points Extensive 4DXs or Trmt Points 2. Amount and/or Complexity of Data to be Reviewed Minimal or None 1 Data point Limited 2 Data points Moderate 3 Data points Extensive 4 Data points 3. Risk of Complications and/or Morbidity / Mortality (Select highest risk bullet item) Ingenix, Inc. 78 Minimal Low Moderate High If counseling and/or coordination of care = > 50% of physician/patient and/or family encounter, TIME is the key factor. Refer to pink columns. *Centers for Medicare & Medicaid Services, CMS. (1995) documentation guidelines for evaluation & management services. Retrieved from

79 Exam Calculation Past Medical History DM Type II Controlled, w/ Periph Circulatory Disease & Renal Disease Nephritis & Nephropathy HTN, Hyperlipidemia, Constitutional Status CABG, Allergic Rhinitis Cardiovascular OS: Ears, Disease Nose, Angiopathy Throat Nephralgia Family History Father: Diseased with DM complications at 94 yrs of age. Mother: OS: Diseased with cardiovascular Respiratory complications 90 yrs of age Siblings: OS: 4 brothers, 1 sister. Marital Cardiovascular Status: Married, lives with spouse of 40 years. BA: Three Each children; 1 daughter; 2 sons. Extremities OS: Eyes Social History Drug OS: BA: abuse: Abdomen No history of smoking, alcohol or drug abuse. Caffeine: I cup coffee per day. Occupation: OS: Retired Disabled Exercise: Occasionally Musculoskeletal OS: Neurologic Integumentary Allergies Phenergan, Demerol: both cause outbreak of rash Vital Signs T: 98.2; BP 163/92; HR 63; WT 203 lbs; Ht 68; BMI 31.57; RBS 128 CC / HPI: Patient here today complaining of sudden redness and flushing of skin, especially his face, neck, shoulders and arms. Began 2 days ago, with progressive intensity of skin color redness. Claims not to be under stress, but does have hot flashes. Has applied OTC hydrocortisone cream to the area, but not been effective. ROS: No changes in weight. Skin redness and flushing. No ulcers or rest pain. Patient states that finger sticks WNL. Exam: HEENT: Eyes clear, EOMI, PERRLA. Neck-Thyroid: No palpable nodes, no JVD, no thyromegaly, bruits. CHEST: Normal. Lungs: Clear, no rales, no ronchi. HEART: RRR, no murmurs, gallops, rubs, normal S1 S2. ABDOMEN: Soft and non tender, no abnormal BS, no organomegaly. EXTREMITIES: PVD, No edema, no cyanosis. NEUROLOGIC: No focal, motor, or sensory deficits. MUSCULOSKELETAL: Reveals appropriate muscle bulk and strength with FROM in joints. INTEGUMENTARY: Erythema noted of skin, no evidence of rash or lesions Assessment 1. Sudden Redness and flushing of skin (primary) 2. Diabetic PVD, Type II, controlled and HTN, Essential Administer Influenza VI vaccine - (G0008) Plan 1. Sudden Redness and flushing of skin: Begin Medrol dose pack, orally. Apply Cortisporin ointment q.i.d. x 7-days, recheck if necessary.. 2. Diabetic PVD, Type II, controlled: Continue Januvia tabs, 100 mg orally: disp 30 tabs; one tab once per day. Continue Actos tabs, 15 mg, orally, disp 90 tabs; one tab once per day. Labs: Glucose fingerstick RGS: 128, reported on no necessary changes in current Rx. 3. HTN, Essential, controlled: Continue Normodyne, 100 mg orally: disp 30 tabs: one tab twice daily. no necessary changes in current Rx. Exam: Number Of Elements = 10 OS = 8 BA = 2 Total 10 Ingenix, Inc. 79

80 E/M Audit Tool Key Elements of HPI* Elements of ROS* Exam: (Organ Systems)* 1. Location 2. Quality 3. Severity 4. Duration 5. Timing 6. Context 7. Modifying Factors 8. Associated SX/sx 1. Constitutional (subjective) 2. Eyes 3. Ears, Nose, Mouth, Throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary 8. Musculoskeletal 9. Integumentary (skin and/or breast) 10. Neurological 11. Psychiatric 12. Endocrine 13. Hematologic/Lymphatic 14. Allergic/Immunologic 1. Constitutional (objective) 2. Eyes 3. Ears, Nose, Mouth, Throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary 8. Musculoskeletal 9. Skin 10. Neurologic 11. Psychiatric 12. Hematologic / Lymphatic / Immunologic Elements of PFSH* 10 BA s and OS s 1. Past (PH) = Medications, Allergies, Injuries, Illnesses, Surgeries 2. Family (FH) = Family History of Diseases, Medical Events 3. Social (SH) = Marital Status, Living Arrangements, Employment, Drug/Tobacco Use, etc. 1. Head, including face 2. Neck 3. Chest, incl. breasts & axillae 4. Abdomen Exam: (Body Areas)* 5. Genitalia, groin, buttocks 6. Back, including spine 7. Each extremity MDM (Medical Decision Making)* To qualify for a given type of Medical Decision Making, 2 of the 3 elements in the table below must be met or exceeded. Elements of MDM Straightforward Low Complexity Mod Complexity High Complexity 1. # Diagnoses or Management Options Minimal 1 DX or Trmt Point Limited 2 DXsor Trmt Points Multiple 3 DXs or Trmt Points Extensive 4DXs or Trmt Points 2. Amount and/or Complexity of Data to be Reviewed Minimal or None 1 Data point Limited 2 Data points Moderate 3 Data points Extensive 4 Data points 3. Risk of Complications and/or Morbidity / Mortality (Select highest risk bullet item) Ingenix, Inc. 80 Minimal Low Moderate High If counseling and/or coordination of care = > 50% of physician/patient and/or family encounter, TIME is the key factor. Refer to pink columns. *Centers for Medicare & Medicaid Services, CMS. (1995) documentation guidelines for evaluation & management services. Retrieved from

81 E/M Audit Tool (95) Established Patient 1,2 To qualify for a given level of service, Two of Three of the key components (History, Exam, & MDM) must be met or exceeded in documentation. Established Patient Office Visit 1 History*. A chief complaint is required for all levels. HPI ROS PFSH Exam* (MDM) Medical Decision Making* (Providers typically spend 5 minutes face-toface with patient) May not require an MD to be present. The patient presents with minimal problems. N/A N/A N/A Straightforward (Physicians typically spend 10 minutes face-to-face with patient) Brief (1-3 elements or 1-2 associated chronic conditions) N/A N/A Problem Focused (1 body area or organ system) Straightforward (Physicians typically spend 15 minutes face-to-face with patient) Brief (1-3 elements or 1-2 associated chronic conditions) Problem Pertinent (1 system) N/A Expanded Problem Focused (2-7) body areas +/or organ systems) Low Complexity (Physicians typically spend 25 minutes face-to-face with patient) Extended X(4+ elements or status of 3 + associated chronic conditions) X Extended (2-9 systems) X Pertinent (1 of 3) Detailed (2-7) body areas +/or organ systems) Moderate Complexity (Physicians typically spend 40 minutes face-to-face with patient) X X X Extended (4+ elements or status of 3 + associated chronic conditions) Complete (10+ systems) Complete (2 of 3) Comprehensive (8+ organ systems or complete exam of single system) High Complexity Ingenix, Inc. 81

82 The 3rd Key Component (MDM) Medical Decision Making Component Ingenix, Inc. 82

83 The 3rd Key Component (MDM) Medical Decision Making refers to: Ingenix, Inc. 83 The complexity of establishing a diagnosis. Determining the extent of the necessary testing and diagnostic evaluations to perform. Selecting a management and treatment option. All conditions affecting the patient should be taken into account and noted. Information about the patient s medical condition obtained from others. If data reviewed is found somewhere else in the medical record it should be referenced (i.e. see lab report ). Bring pertinent findings into the progress note and document the definitive diagnosis Documentation of the thought process of the physician.

84 The 3rd Key Component (MDM) There are 3 components to Medical Decision Making: (To qualify at a given level of MDM Complexity, 2 of 3 elements must be met or exceeded) 1. Number of DX s and/or Management Options (or Diagnosis Codes) 2. Amount and/or Complexity of Data to be Reviewed tests and/or diagnostics actually reviewed, not just ordered. 3. Risk of Complications and Comorbidities What is the possibility of the patient dying without treatment? Ingenix, Inc. 84» Risk of significant complications» Morbidity and/or mortality» Any and all associated comorbidities

85 The 3rd Key Component (MDM) Represents the Number of Management Options and/or Diagnosis Codes Documentation should include all established problems pertinent to the visit, whether they are stable, improved, worsening or resolved. Documentation should include any new problems. Management and treatment options should include changes or initiation of new treatment plans and medications, referrals, or consultations. Ingenix, Inc. 85

86 The 3rd Key Component (MDM) Number of Management Options and/or Diagnosis Codes For a presenting problem with an established diagnosis, the record should reflect whether the problem is improved, well controlled, resolving or resolved OR inadequately controlled, worsening, or failing to change as expected. For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form possible, probable, etc. but must be coded in terms of signs and symptoms until a definitive diagnosis is established. Ingenix, Inc. 86

87 CMS - The Directive The Listing of all Pertinent Diagnosis Codes is Important! Any Condition that is taken into account or affects patient care, treatment or management should be documented and ultimately coded. This will raise the level of risk overall for the encounter. The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), (2009, October). ICD-9-CM official guidelines for coding and reporting. Retrieved November 9, 2009, from Department of Health and Human Services (DHHS) Web site: Ingenix, Inc. 87

88 MDM Number of Diagnoses Ingenix, Inc. 88 "Trailblazer Medicare E & M Service Coding and Audit Worksheet." TrailBlazer Health Enterprise, LLC. e-medtools, Web. 23 May <

89 MDM (Or) Management Options Ingenix, Inc. 89 "Trailblazer Medicare E & M Service Coding and Audit Worksheet." TrailBlazer Health Enterprise, LLC. e-medtools, Web. 23 May <

90 The 3rd Key Component (MDM) Data to be Reviewed: If a diagnostic test or procedure is ordered it should be documented. The review of laboratory, radiology or other diagnostic tests should be documented. A decision to obtain old records should be documented. Relevant Findings from the review of old records should be documented. The direct visualization and independent interpretation of an image, tracing or specimen previously interpreted by another physician should be documented. Ingenix, Inc. 90

91 MDM Data Reviewed or Ordered "Trailblazer Medicare E & M Service Coding and Audit Worksheet." TrailBlazer Health Enterprise, LLC. e-medtools, Web. 23 May < Ingenix, Inc. 91

92 MDM - Level of Risk Defining the term Risk Co-morbidities, underlying diseases, or other factors that increase the complexity of MDM by increasing the risk of complications, morbidity, or mortality should be documented. If a surgical or invasive diagnostic procedure is ordered, planned, or scheduled at the time of the E/M encounter, the type of procedure should be documented. Ingenix, Inc. 92 Centers for Medicare & Medicaid Services, Initials. (1995) documentation guidelines for evaluation & management services. Retrieved from

93 Table of Risk Level of Risk Presenting Problem(s) Diagnostic Procedure(s) Ordered Management Options Selected Minimal One self-limited or minor problem, eg cold, insect bite, tinea corporis Laboratory tests requiring venipuncture Chest x-rays EKG/EEG Urinalysis Rest Gargles Elastic bandages Superficial dressings Ultrasound, eg echocardiography KOH prep Low Two or more self-limited or minor problems One stable chronic illness, eg well controlled hypertension or 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 Over-the-counter drugs Minor surgery with no identified risk factors Physical therapy Occupational therapy IV fluids without additives Skin biopsies Ingenix, Inc. 93 *Centers for Medicare & Medicaid Services, CMS. (1995) documentation guidelines for evaluation & management services. Retrieved from

94 Table of Risk Level of Risk Presenting Problem(s) Diagnostic Procedure(s) Ordered Management Options Selected 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 drug medicine IV fluids with additives Closed treatment of fracture or dislocation without manipulation High One or more chronic illnesses with severe exacerbation, progression, or side effect 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 An abrupt change in neurologic status, eg seizure, TIA, weakness, or sensory loss 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 Ingenix, Inc. 94 *Centers for Medicare & Medicaid Services, CMS. (1995) documentation guidelines for evaluation & management services. Retrieved from

95 MDM - Level of Risk Ingenix, Inc. 95 Levels of MDM Complexity Straightforward minimal diagnosis and/or management options, amount of data to review and risk. Low Complexity limited number of diagnoses and/or management options, data to review and low risk of complications or death if untreated. *Moderate Complexity multiple diagnoses and management options, moderate data to review; *moderate risk to the patient of implications or death if untreated. *High Complexity extensive diagnoses and management options, extensive amt of complex data to review and *high risk to the patient for complications or death if the problem is untreated. Centers for Medicare & Medicaid Services, Initials. (1995) documentation guidelines for evaluation & management services. Retrieved from

96 The 3rd Key Component (MDM) New Patient 1995 Office Visit MDM* Est Patient 1995 Office Visit MDM* (Physicians typically spend 10 minutes face-to-face with patient) Straightforward (Physicians typically spends 5 minutes face-to-face with patient) Straightforward (Physicians typically spend 20 minutes face-to-face with patient) Straightforward (Physicians typically spends 10 minutes face-to-face with patient) Straightforward (Physicians typically spends 30 minutes face-to-face with patient) Low Complexity (Physicians typically spends 15 minutes face-to-face with patient) Low Complexity (Physicians typically spend 45 minutes face-to-face with patient) Moderate Complexity (Physicians typically spends 25 minutes face-to-face with patient) Moderate Complexity (Physicians typically spend 60 minutes face-to-face with patient) High Complexity (Physicians typically spends 40 minutes face-to-face with patient) High Complexity * MDM (Medical Decision Making) To qualify for a given type of Medical Decision Making, 2 of the 3 elements in the table below must be met or exceeded. Elements of MDM Straightforward Low Complexity Moderate Complexity High Complexity 1. # Diagnoses or Management Options Minimal 1 DX or Trmt Point Limited 2 DXs or Trmt Points Multiple 3 DXs or Trmt Points Extensive 4 DXs or Trmt Points 2. Amount and/or Complexity of Data to be Reviewed 3. Risk of Complications and/or Morbidity / Mortality (Select highest bullet item from Table of Risk) Minimal or None 1 Data Point Limited 2 Data Points Moderate 3 Data Points Extensive 4 Data Points Minimal Low Moderate High Ingenix, Inc. 96

97 E/M Audit Tool (95) Established Patient 1,2 To qualify for a given level of service, Two of Three of the key components (History, Exam, & MDM) must be met or exceeded in documentation. Established Patient Office Visit 1 History* A chief complaint is required for all levels. HPI ROS PFSH Exam* (MDM) Medical Decision Making* (Providers typically spend 5 minutes face-toface with patient) May not require an MD to be present. The patient presents with minimal problems. N/A N/A N/A Straightforward (Physicians typically spend 10 minutes face-to-face with patient) Brief (1-3 elements or 1-2 associated chronic conditions) N/A N/A Problem Focused (1 body area or organ system) Straightforward (Physicians typically spend 15 minutes face-to-face with patient) Brief (1-3 elements or 1-2 associated chronic conditions) Problem Pertinent (1 system) N/A Expanded Problem Focused (2-7) body areas or organ systems) Low Complexity (Physicians typically spend 25 minutes face-to-face with patient) X Extended (4+ elements or status of 3 + associated chronic conditions) X Extended (2-9 systems) X Pertinent (1 of 3) Detailed (2-7) body areas or organ systems) Moderate Complexity (Physicians typically spend 40 minutes face-to-face with patient) X X X Extended (4+ elements or status of 3 + associated chronic conditions) Complete (10+ systems) Complete (2 of 3) Comprehensive (8+ organ systems or complete exam of single system) High Complexity Ingenix, Inc. 97

98 MDM - E/M Audit Tool Key Elements of HPI* Elements of ROS* Exam: (Organ Systems)* 1. Location 2. Quality 3. Severity 4. Duration 5. Timing 6. Context 7. Modifying Factors 8. Associated SX/sx 1. Constitutional (subjective) 2. Eyes 3. Ears, Nose, Mouth, Throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary Elements of PFSH* 8. Musculoskeletal 9. Integumentary (skin and/or breast) 10. Neurological 11. Psychiatric 12. Endocrine 13. Hematologic/Lymphatic 14. Allergic/Immunologic 1. Constitutional (objective) 2. Eyes 3. Ears, Nose, Mouth, Throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary 8. Musculoskeletal 9. Skin 10. Neurologic 11. Psychiatric 12. Hematologic / Lymphatic / Immunologic Exam: (Body Areas)* 1. Past (PH) = Medications, Allergies, Injuries, Illnesses, Surgeries 1. Head, including face 5. Genitalia, groin, 2. Family (FH) = Family History of Diseases, Medical Events 2. Neck buttocks 3. Social (SH) = Marital Status, Living Arrangements, Employment, 3. Chest, incl. breasts & 6. Back, including spine MDM (Medical Decision Drug/Tobacco Making)* Use, etc. axillae 7. Each extremity To qualify for a given type of Medical Decision Making, 2 of the 3 elements in 4. the Abdomen table below must be met or exceeded. Elements of MDM Straightforward Low Complexity Mod Complexity High Complexity 1. # Diagnoses or Management Options Minimal 1 DX or Trmt Point Limited 2 DXsor Trmt Points Multiple 3 DXs or Trmt Points Extensive 4DXs or Trmt Points 2. Amount and/or Complexity of Data to be Reviewed Minimal or None 1 Data point Limited 2 Data points Moderate 3 Data points Extensive 4 Data points 3. Risk of Complications and/or Morbidity / Mortality (Select highest risk bullet item) Ingenix, Inc. 98 Minimal Low Moderate High If counseling and/or coordination of care = > 50% of physician/patient and/or family encounter, TIME is the key factor. Refer to pink columns. *Centers for Medicare & Medicaid Services, CMS. (1995) documentation guidelines for evaluation & management services. Retrieved from

99 MDM - Progress Note Sample Past Medical History DM Type II Controlled, w/ Periph Circulatory Disease & Renal Disease Nephritis & Nephropathy HTN, Hyperlipidemia, Status CABG, Allergic Number Rhinitis of DXs Cardiovascular Disease Angiopathy Nephralgia Family History Father: Diseased with DM complications at 94 yrs of age. Mother: Diseased with cardiovascular complications 90 yrs of age Siblings: 4 brothers, 1 sister. Marital Status: Married, lives with spouse of 40 years. Three children; 1 daughter; 2 sons. Social History Drug abuse: No history of smoking, alcohol or drug abuse. Caffeine: I cup coffee per day. Occupation: Retired Disabled Exercise: Occasionally Allergies Phenergan, Demerol: both cause outbreak of rash Vital Signs T: 98.2; BP 163/92; HR 63; WT 203 lbs; Ht 68; BMI 31.57; RBS 128 CC / HPI: Patient here today complaining of sudden redness and flushing of skin, especially his face, neck, shoulders and arms. Began 2 days ago, with progressive intensity of skin color redness. Claims not to be under stress, but does have hot flashes. Has applied OTC hydrocortisone cream to the area, but not been effective. ROS: No changes in weight. Skin redness and flushing. No ulcers or rest pain. Patient states that finger sticks WNL. Exam: HEENT: Eyes clear, EOMI, PERRLA. Neck-Thyroid: No palpable nodes, no JVD, no thyromegaly, bruits. CHEST: Normal. Lungs: Clear, no rales, no ronchi. HEART: RRR, no murmurs, gallops, rubs, normal S1 S2. ABDOMEN: Soft and non tender, no abnormal BS, no organomegaly. EXTREMITIES: PVD, No edema, no cyanosis. NEUROLOGIC: No focal, motor, or sensory deficits. MUSCULOSKELETAL: Reveals appropriate muscle bulk and strength with FROM in joints. INTEGUMENTARY: Erythema noted of skin, no evidence of rash or lesions Assessment 1. Sudden Redness and flushing of skin (primary) 2. Diabetic PVD, Type II, controlled and HTN, Essential Administer Influenza VI vaccine - (G0008) Plan 1. Sudden Redness and flushing of skin: Begin Medrol dose pack, orally. Apply Cortisporin ointment q.i.d. x 7-days, recheck if necessary.. 2. Diabetic PVD, Type II, controlled: Continue Januvia tabs, 100 mg orally: disp 30 tabs; one tab once per day. Continue Actos tabs, 15 mg, orally, disp 90 tabs; one tab once per day. Labs: Glucose fingerstick RGS: 128, reported on no necessary changes in current Rx. 3. HTN, Essential, controlled: Continue Normodyne, 100 mg orally: disp 30 tabs: one tab twice daily. no necessary changes in current Rx. MDM: Number Of DXs = 4 MDM: Number Of Treatment options = Ingenix, Inc. 99

100 MDM Number of DXs 4 Ingenix, Inc. 100 "Trailblazer Medicare E & M Service Coding and Audit Worksheet." TrailBlazer Health Enterprise, LLC. e-medtools, Web. 23 May <

101 MDM - Progress Note Sample Past Medical History DM Type II Controlled, w/ Periph Circulatory Disease & Renal Disease Nephritis & Nephropathy HTN, Hyperlipidemia, Status CABG, Allergic Rhinitis Cardiovascular Disease Angiopathy Nephralgia Family History Father: Diseased with DM complications at 94 yrs of age. Mother: Diseased with cardiovascular complications 90 yrs of age Siblings: 4 brothers, 1 sister. Marital Status: Married, lives with spouse of 40 years. Three children; 1 daughter; 2 sons. Social History Drug abuse: No history of smoking, alcohol or drug abuse. Caffeine: I cup coffee per day. Occupation: Retired Disabled Exercise: Occasionally Allergies Phenergan, Demerol: both cause outbreak of rash Vital Signs T: 98.2; BP 163/92; HR 63; WT 203 lbs; Ht 68; BMI 31.57; RBS 128 CC / HPI: Patient here today complaining of sudden redness and flushing of skin, especially his face, neck, shoulders and arms. Began 2 days ago, with progressive intensity of skin color redness. Claims not to be under stress, but does have hot flashes. Has applied OTC hydrocortisone cream to the area, but not been effective. ROS: No changes in weight. Skin redness and flushing. No ulcers or rest pain. Patient states that finger sticks WNL. Number of Treatment Options Exam: HEENT: Eyes clear, EOMI, PERRLA. Neck-Thyroid: No palpable nodes, no JVD, no thyromegaly, bruits. CHEST: Normal. Lungs: Clear, no rales, no ronchi. HEART: RRR, no murmurs, gallops, rubs, normal S1 S2. ABDOMEN: Soft and non tender, no abnormal BS, no organomegaly. EXTREMITIES: PVD, No edema, no cyanosis. NEUROLOGIC: No focal, motor, or sensory deficits. MUSCULOSKELETAL: Reveals appropriate muscle bulk and strength with FROM in joints. INTEGUMENTARY: Erythema noted of skin, no evidence of rash or lesions Assessment 1. Sudden Redness and flushing of skin (primary) 2. Diabetic PVD, Type II, controlled and HTN, Essential Administer Influenza VI vaccine - (G0008) Plan 1. Sudden Redness and flushing of skin: Begin Medrol dose pack, orally. Apply Cortisporin ointment q.i.d. x 7-days, recheck if necessary.. 2. Diabetic PVD, Type II, controlled: Continue Januvia tabs, 100 mg orally: disp 30 tabs; one tab once per day. Continue Actos tabs, 15 mg, orally, disp 90 tabs; one tab once per day. Labs: Glucose fingerstick RGS: 128, reported on no necessary changes in current Rx. 3. HTN, Essential, controlled: Continue Normodyne, 100 mg orally: disp 30 tabs: one tab twice daily. no necessary changes in current Rx. MDM: Number Of DXs = 4 MDM: Number Of Treatment options = 4 Management of Current Meds Ingenix, Inc. 101

102 MDM Management Options 4 diagnoses overrides 2 management options points. Therefore, use the # of DXs (4) 2 Ingenix, Inc. 102 "Trailblazer Medicare E & M Service Coding and Audit Worksheet." TrailBlazer Health Enterprise, LLC. e-medtools, Web. 23 May <

103 MDM - E/M Audit Tool Key Elements of HPI* Elements of ROS* Exam: (Organ Systems)* 1. Location 2. Quality 3. Severity 4. Duration 5. Timing 6. Context 7. Modifying Factors 8. Associated SX/sx 1. Constitutional (subjective) 2. Eyes 3. Ears, Nose, Mouth, Throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary Elements of PFSH* 8. Musculoskeletal 9. Integumentary (skin and/or breast) 10. Neurological 11. Psychiatric 12. Endocrine 13. Hematologic/Lymphatic 14. Allergic/Immunologic 1. Constitutional (objective) 2. Eyes 3. Ears, Nose, Mouth, Throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary 8. Musculoskeletal 9. Skin 10. Neurologic 11. Psychiatric 12. Hematologic / Lymphatic / Immunologic Exam: (Body Areas)* 1. Past (PH) = Medications, Allergies, Injuries, Illnesses, Surgeries 1. Head, including face 5. Genitalia, groin, 2. Family (FH) = Family History of Diseases, Medical Events 2. Neck buttocks 3. Social (SH) = Marital Status, Living Arrangements, Employment, 3. Chest, incl. breasts & 6. Back, including spine MDM (Medical Decision Drug/Tobacco Making)* Use, etc. axillae 7. Each extremity To qualify for a given type of Medical Decision Making, 2 of the 3 elements in 4. the Abdomen table below must be met or exceeded. Ingenix, Inc. 103 Elements of MDM Straightforward Low Complexity Mod Complexity High Complexity 1. # Diagnoses or Management Options 2. Amount and/or Complexity of Data to be Reviewed 3. Risk of Complications and/or Morbidity / Mortality (Select highest risk bullet item) Minimal 1 DX or Trmt Point Minimal or None 1 Data point Limited 2 DXsor Trmt Points Limited 2 Data points Multiple 3 DXs or Trmt Points Moderate 3 Data points Extensive 4DXs or Trmt Points Extensive 4 Data points Minimal Low Moderate High If counseling and/or coordination of care = > 50% of physician/patient and/or family encounter, TIME is the key factor. Refer to pink columns. *Centers for Medicare & Medicaid Services, CMS. (1995) documentation guidelines for evaluation & management services. Retrieved from X

104 MDM - Amount of Data to be Reviewed Past Medical History DM Type II Controlled, w/ Periph Circulatory Disease & Renal Disease Nephritis & Nephropathy HTN, Hyperlipidemia, Status CABG, Allergic Rhinitis Cardiovascular Disease Angiopathy Nephralgia Family History Father: Diseased with DM complications at 94 yrs of age. Mother: Diseased with cardiovascular complications 90 yrs of age Siblings: 4 brothers, 1 sister. Marital Status: Married, lives with spouse of 40 years. Three children; 1 daughter; 2 sons. Social History Drug abuse: No history of smoking, alcohol or drug abuse. Caffeine: I cup coffee per day. Occupation: Retired Disabled Exercise: Occasionally Allergies Phenergan, Demerol: both cause outbreak of rash Vital Signs T: 98.2; BP 163/92; HR 63; WT 203 lbs; Ht 68; BMI 31.57; RBS 128 CC / HPI: Patient here today complaining of sudden redness and flushing of skin, especially his face, neck, shoulders and arms. Began 2 days ago, with progressive intensity of skin color redness. Claims not to be under stress, but does have hot flashes. Has applied OTC hydrocortisone cream to the area, but not been effective. ROS: No changes in weight. Skin redness and flushing. No ulcers or rest pain. Patient states that finger sticks WNL. Order and/or Reviewed Medically Reasonable & Necessary Clinical Laboratory Procedures Exam: HEENT: Eyes clear, EOMI, PERRLA. Neck-Thyroid: No palpable nodes, no JVD, no thyromegaly, bruits. CHEST: Normal. Lungs: Clear, no rales, no ronchi. HEART: RRR, no murmurs, gallops, rubs, normal S1 S2. ABDOMEN: Soft and non tender, no abnormal BS, no organomegaly. EXTREMITIES: PVD, No edema, no cyanosis. NEUROLOGIC: No focal, motor, or sensory deficits. MUSCULOSKELETAL: Reveals appropriate muscle bulk and strength with FROM in joints. INTEGUMENTARY: Erythema noted of skin, no evidence of rash or lesions Assessment 1. Sudden Redness and flushing of skin (primary) 2. Diabetic PVD, Type II, controlled and HTN, Essential Administer Influenza VI vaccine - (G0008) Plan 1. Sudden Redness and flushing of skin: Begin Medrol dose pack, orally. Apply Cortisporin ointment q.i.d. x 7-days, recheck if necessary.. 2. Diabetic PVD, Type II, controlled: Continue Januvia tabs, 100 mg orally: disp 30 tabs; one tab once per day. Continue Actos tabs, 15 mg, orally, disp 90 tabs; one tab once per day. Labs: Glucose fingerstick RGS: 128, reported on no necessary changes in current Rx. 3. HTN, Essential, controlled: Continue Normodyne, 100 mg orally: disp 30 tabs: one tab twice daily. no necessary changes in current Rx. MDM: Number Of DXs = MDM: Number Of Treatment options = MDM: 4 4 Management of Current Meds Amount and/or Complexity of Data to be Reviewed = 1 Ingenix, Inc. 104

105 MDM Amount of Data to be Reviewed 1 "Trailblazer Medicare E & M Service Coding and Audit Worksheet." TrailBlazer Health Enterprise, LLC. e-medtools, Web. 23 May < Ingenix, Inc. 105

106 MDM - E/M Audit Tool Key Elements of HPI* Elements of ROS* Exam: (Organ Systems)* 1. Location 2. Quality 3. Severity 4. Duration 5. Timing 6. Context 7. Modifying Factors 8. Associated SX/sx 1. Constitutional (subjective) 2. Eyes 3. Ears, Nose, Mouth, Throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary Elements of PFSH* 8. Musculoskeletal 9. Integumentary (skin and/or breast) 10. Neurological 11. Psychiatric 12. Endocrine 13. Hematologic/Lymphatic 14. Allergic/Immunologic 1. Constitutional (objective) 2. Eyes 3. Ears, Nose, Mouth, Throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary 8. Musculoskeletal 9. Skin 10. Neurologic 11. Psychiatric 12. Hematologic / Lymphatic / Immunologic Exam: (Body Areas)* 1. Past (PH) = Medications, Allergies, Injuries, Illnesses, Surgeries 1. Head, including face 5. Genitalia, groin, 2. Family (FH) = Family History of Diseases, Medical Events 2. Neck buttocks 3. Social (SH) = Marital Status, Living Arrangements, Employment, 3. Chest, incl. breasts & 6. Back, including spine MDM (Medical Decision Drug/Tobacco Making)* Use, etc. axillae 7. Each extremity To qualify for a given type of Medical Decision Making, 2 of the 3 elements in 4. the Abdomen table below must be met or exceeded. Ingenix, Inc. 106 Elements of MDM Straightforward Low Complexity Mod Complexity High Complexity 1. # Diagnoses or Management Options 2. Amount and/or Complexity of Data to be Reviewed 3. Risk of Complications and/or Morbidity / Mortality (Select highest risk bullet item) Minimal 1 DX or Trmt Point X Minimal or None 1 Data point Limited 2 DXsor Trmt Points Limited 2 Data points Multiple 3 DXs or Trmt Points Moderate 3 Data points Extensive 4DXs or Trmt Points Extensive 4 Data points Minimal Low Moderate High If counseling and/or coordination of care = > 50% of physician/patient and/or family encounter, TIME is the key factor. Refer to pink columns. *Centers for Medicare & Medicaid Services, CMS. (1995) documentation guidelines for evaluation & management services. Retrieved from X

107 MDM - Table of Risk Level of Risk Moderate High Presenting Problem(s) 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 One or more chronic illnesses with severe exacerbation, progression, or side effect 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 An abrupt change in neurologic status, eg seizure, TIA, weakness, or sensory loss Diagnostic Procedure(s) Ordered 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 Cardiovascular imaging studies with contrast with identified risk factors Cardiac electrophysiological tests Diagnostic endoscopies with identified risk factors Discography Management Options Selected Minor surgery with identified risk factors Elective major surgery (open, percutaneous or endoscopic) with no identified risk factors Prescription drug management Therapeutic nuclear drug medicine IV fluids with additives Closed treatment of fracture or dislocation without manipulation The highest bullet item achievable on the Table of Risk determines the level of risk 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 Ingenix, Inc. 107 *Centers for Medicare & Medicaid Services, CMS. (1995) documentation guidelines for evaluation & management services. Retrieved from

108 E/M Audit Tool Key Elements of HPI* Elements of ROS* Exam: (Organ Systems)* 1. Location 2. Quality 3. Severity 4. Duration 5. Timing 6. Context 7. Modifying Factors 8. Associated SX/sx 1. Constitutional (subjective) 2. Eyes 3. Ears, Nose, Mouth, Throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary Elements of PFSH* 8. Musculoskeletal 9. Integumentary (skin and/or breast) 10. Neurological 11. Psychiatric 12. Endocrine 13. Hematologic/Lymphatic 14. Allergic/Immunologic 1. Constitutional (objective) 2. Eyes 3. Ears, Nose, Mouth, Throat 4. Cardiovascular 5. Respiratory 6. Gastrointestinal 7. Genitourinary 8. Musculoskeletal 9. Skin 10. Neurologic 11. Psychiatric 12. Hematologic / Lymphatic / Immunologic Exam: (Body Areas)* 1. Past (PH) = Medications, Allergies, Injuries, Illnesses, Surgeries 1. Head, including face 5. Genitalia, groin, 2. Family (FH) = Family History of Diseases, Medical Events 2. Neck buttocks 3. Social (SH) = Marital Status, Living Arrangements, Employment, 3. Chest, incl. breasts & 6. Back, including spine MDM (Medical Decision Drug/Tobacco Making)* Use, etc. axillae 7. Each extremity To qualify for a given type of Medical Decision Making, 2 of the 3 elements in 4. the Abdomen table below must be met or exceeded. Ingenix, Inc. 108 Elements of MDM Straightforward Low Complexity Mod Complexity High Complexity 1. # Diagnoses or Management Options 2. Amount and/or Complexity of Data to be Reviewed 3. Risk of Complications and/or Morbidity / Mortality (Select highest risk bullet item) Minimal 1 DX or Trmt Point X Minimal or None 1 Data point Limited 2 DXsor Trmt Points Limited 2 Data points Multiple 3 DXs or Trmt Points Moderate 3 Data points Extensive 4DXs or Trmt Points Extensive 4 Data points Minimal Low Moderate High If counseling and/or coordination of care = > 50% of physician/patient and/or family encounter, TIME is the key factor. Refer to pink columns. *Centers for Medicare & Medicaid Services, CMS. (1995) documentation guidelines for evaluation & management services. Retrieved from X X

109 Time Component Ingenix, Inc. 109

110 E/M: The Time Factor 1 Time: A variable that is predictive of the work of E/M services OP (Office): Face-to-face time Provider spends face-to-face with the patient and/or family Time is used when counseling or coordination of care represents more than 50% of the time spent with the patient Documentation of the total length of time (face-to-face) and description of the counseling and/or coordination of care is required. Non-face-to-face time not included in the time component IP (Hospital): Unit/floor time Provider present on the patient s hospital unit and at the bedside Documentation of the total length of time (unit/floor) and description of the counseling and/or coordination of care is required. Pre- and post-visit time off the floor is not included in the time component Ingenix, Inc Current Procedural Terminology CPT Professional ed. Chicago, IL: American Medical Association, Print.

111 E/M: The Time Factor 1 When counseling and coordination of care dominates the encounter (>50%) Time may be considered the key or controlling factor to qualify for a particular level of E/M Includes time spent with parties who have assumed responsibility for care of the patient or decision making whether or not they are family members e.g. foster parents, person acting as legal guardian Extent of counseling and coordination of care must be documented in the medical record. Total length of time of the encounter should be documented Ingenix, Inc Current Procedural Terminology CPT Professional ed. Chicago, IL: American Medical Association, Print.

112 Time As A Component of E/M Time as a Component of E/M New Pt Visit Time (minutes) Est. Pt Visit Time (minutes) Ingenix, Inc. 112

113 Consultation Coding (Medicare) Ingenix, Inc. 113

114 Elimination of Consult Codes in 2010 Effective January 1, 2010, the Centers for Medicare and Medicaid Services (CMS) has eliminated the use of: E&M Consultation CPT codes ( ) for its Medicare providers requiring them to bill the most appropriate office visit or hospital inpatient CPT codes ( , ) CMS instructs that any physician who sees a patient in the office or other outpatient setting will need to select either a new or established outpatient evaluation and management code ( or ) rather than a consultation code for Medicare claims depending on the status of the patient (new vs. established). Source: MLN Matters Number: MM6740 Revised Revisions to Consultation Services Payment Policy Ingenix, Inc. 114

115 Accuracy of Diagnostic Coding for Medicare Advantage

116 HCC Risk Adjustment Model Hierarchical Condition Category Applies hierarchies to disease categories 70 disease categories; over 3,100 diagnoses A risk factor is assigned to each category Additive Model includes all qualifying diagnoses Predictive Model 2010 payment based on 2009 DOS CMS-HCC model was phased-in over time Payment in 2007 based on 100% risk adjustment Adjusts payments based on health status Chart documentation and diagnostic coding Ingenix, Inc. 116

117 How The Funding Flows Payments to the Medicare Advantage plans are determined based on diagnoses Health plans are funded by CMS to provide services to Medicare beneficiaries based on bids submitted to CMS by the plans and also on the member s Severity of Disease. 1 Severity of Disease is based on Diagnosis Codes submitted to CMS by the health plans. The specific documentation of each individual patient s diagnoses and comorbid conditions is classified within the highly specific HCC classification system. 2 The CMS mandated Risk Adjustment Model places the member in the appropriate risk category for expected resource utilization. 2 Ingenix, Inc Galen Institute. (2007, March 22). The facts: Medicare Advantage. Retrieved from 2 CMS (2008). Risk adjustment data technical assistance for Medicare advantage organizations participant guide. Centers for Medicare/Medicaid services.

118 HCC Risk Adjustment Model RAF score simply identifies patient health status. The patient s health status is re-determined each year. Higher importance to document and code all conditions that are evaluated at each visit. Ingenix, Inc. 118

119 ICD-9-CM The Source Document ICD-9-CM 2010 Is the official source of current codes and guidelines Provides the most up-to-date coding information Includes all new codes, deleted codes, revised or expanded codes Includes the ICD-9-CM Official Guidelines for Coding and Reporting as a reference guide for the coder A current year edition of ICD-9-CM should be available to the coder Understanding ICD-9 is a prerequisite to fully and accurately adopting ICD-10 in the near future Go to: Ingenix, Inc. 119

120 Q&A Ingenix, Inc. 120