Evaluation & Mangement ( E & M) Visits Adapted from 1997 CMS Guidance Using Single Organ System

Transcription

1 5/7/15 University of Rochester Center for Health & Behavioral Training 1 Evaluation & Mangement ( E & M) Visits Adapted from 1997 CMS Guidance Using Single Organ System New Patient Office Visit [Patient has not had a face-to-face service by a provider of the same specialty within a group practice in 3 years] Three of the three key components* must meet or exceed the stated requirements to qualify for a particular level of services Visit CPT Code Problem Focused Expanded Problem Focused Detailed Comprehensive Chief Complaint Required Required Required Required *History 1-3 HPI 1-3 HPI Problem Pert 1 ROS 4 HPI 2-9 ROS Pertinent 1 PFSH 4 HPI 10+ ROS 2-3 PFSH *Exam - Single organ system 1-5 bulleted 6 bulleted 12 bulleted All bulleted *Medical Decision Straight Straight Low Moderate Making forward forward Time not shown as this type of visit is not likely to occur in a public health clinic.

2 5/7/15 University of Rochester Center for Health & Behavioral Training 2 Evaluation & Mangement ( E & M) Visits Adapted from 1997 CMS Guidance Using Single Organ System Established Patient Office Visit [Patient HAS had a face-to-face service by a provider of the same specialty within a group practice in 3 years] Two of the three key components* must meet or exceed the stated requirements to qualify for a particular level of services CPT Visit Code Problem Focused Detailed Expanded Problem Focused * Chief Complaint Required Required Required Required *History May not be required or Brief HPI 1-3 HPI 1-3 HPI 1 ROS Pertinent PFSH 4 HPI 2-9 ROS 2-3 PFSH *Exam- Single Organ System May not be required* Or limited to c/o NA 1-5 bulleted 6 bulleted 12 bulleted *Medical Decision Straight Low Moderate Making forward Time not shown as this type of visit is not likely to occur in a public health clinic. ** May not require the presence of MD or NP/PA and may not include an exam. Patient must have been seen previously and this is a minimal ( 5 min) problem or follow up not a new problem. This does not apply to Medicaid as a patient must be seen by a QP (qualified provider) in order to bill for any visit, but does apply to 3 rd party payers.

3 5/7/15 University of Rochester Center for Health & Behavioral Training 3 Location Quality Severity Timing Duration Context Modifying factors Associated Signs/Symptoms 1. HISTORY COMPONENT* Elements HPI ROS PFSH Constitutional symptoms Eyes Ears, nose, mouth, throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Endocrine Hematologic/lymphatic/ immunologic Allergic/immunologic Past history Family history Social history HPI history of present illness ROS review of systems PFSH past, family and/or social history Summary of Category 1 History Type of History HPI ROS PFSH Problem Focused Brief (1-3) N/A N/A Expanded Problem Focused Brief (1-3) Problem pertinent (1) N/A Detailed Extended (4+) Extended (2-9) Pertinent (1) Comprehensive Extended (4+) Complete (10+) Complete (2-3)

4 5/7/15 University of Rochester Center for Health & Behavioral Training 4 2. EXAM* COMPONENT - Elements Single Organ System Genito-urinary System/Body Area Examination Elements Constitutional Measurement of any three of the following seven vital signs: 1. sitting or standing blood pressure, supine blood pressure 2. pulse rate and regularity, respiration, temperature 3. height, weight (May be measured and recorded by ancillary staff) Head and Face Eyes Ears, Nose, Mouth and Throat General appearance of patient (e.g., development, nutrition, body habitus, deformities, attention to grooming) NO ELEMENTS Neck Examination of neck ( eg, masses, overall appearance, symmetry, tracheal position, crepitus) Examination of the thyroid ( eg. enlargement, tenderness, mass) Respiratory Assessment of respiratory effort ( eg, intercostal retractions, use of accessory muscles, diaphragmatic movement) Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs) Cardiovascular Auscultation of heart with notation of abnormal sounds and murmurs Examination of peripheral vascular system by observation (eg, swelling, varicosities) and palpation (eg. pulses, temperature, edema, tenderness) Chest ( Breasts) See genito-urinary female Gastrointestinal Examination of abdomen with notation of presence of masses or tenderness Examination for presence or absence of hernia Examination of liver and spleen Obtain stool sample for occult blood when indicated Genitourinary Male Elements for Neck, Respiratory, cardiovascular, and Chest not included as not routinely performed in an STD Clinic Inspection of anus and perineum Examination (with or without specimen collection for smears and cultures) of genitalia including: Scrotum (e.g., lesions, cysts, rashes) Epididymides (e.g., size, symmetry, masses) Testes (e.g., size, symmetry, masses) Urethral meatus (e.g., size, location, lesions, discharge)

5 5/7/15 University of Rochester Center for Health & Behavioral Training 5 Penis (e.g., lesions, presence or absence of foreskin, foreskin retractability, plaque, masses, scarring, deformities) Genitourinary Female Digital rectal examination including: Prostate gland (e.g., size, symmetry, nodularity, tenderness) Seminal vesicles (e.g., symmetry, tenderness, masses, enlargement Sphincter tone, presence of hemorrhoids, rectal masses Includes at least seven of the following eleven identified by bullets: Inspection and palpation of breasts (e.g., masses or lumps, tenderness, symmetry, nipple discharge) Digital rectal examination including sphincter tone, presence of hemorrhoids, rectal masses Pelvic examination (with or w/out specimen collection for smears and cultures) including: External genitalia (e.g. general appearance, hair distribution, lesions) Urethral meatus (e.g., size, location, lesions, prolapse) Urethra (e.g., masses, tenderness, scarring) Bladder (e.g., fullness, masses, tenderness) Vagina (e.g., general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele) Cervix (e.g., general appearance, lesions, discharge) Uterus (e.g., size, contour, position, mobility, tenderness, consistency, descent or support) Adnexa/parametria (e.g., masses, tenderness, organomegaly, nodularity) Anus and perineum Lymphatic Palpation of lymph nodes in neck, axillae, groin, and other locations Musculoskeletal No And Extremities Skin Inspection and/or palpation of skin and subcutaneous tissue ( eg, rashes, lesions, ulcers Neurological/ Brief assessment of mental status including Psychiatric Orientation ( eg time, place and person) Mood and affect (eg depression, anxiety, agitation) 3. *MEDICAL DECISION MAKING COMPONENT Medical decision-making (MDM) refers to the complexity of establishing a diagnosis or selecting a management option. MDM Level Data Review Complication Risk Level of Decision Making Straightforward Minimal (1) or none Minimal Minimal (1)

6 5/7/15 University of Rochester Center for Health & Behavioral Training 6 Low Complexity Limited (2) Low Limited (2) Moderate Moderate (3) Moderate Multiple (3) Complexity High Complexity Extensive (4+) High Extensive (4+) Data Review: Amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed Complication Risk: Risk of significant complications, morbidity and/or mortality Level of Decision Making: Number of possible diagnoses and/or the number of management options Table of Risk need to meet one bullet in each Box Level of Risk Presenting Problem(s) Diagnostic Procedure(s) ordered Minimal Low Ex. STD Screening or simple acute STD Diagnosis Visit Moderate Ex. Testicular lesion, cervical lesion, PID Epididymitis Pyelonephritis One self-limited or minor problem, e.g., cold, insect bite, tinea corporis Two or more self-limited or minor problems One stable chronic illness e.g., well controlled hypertension, non-insulin dependent diabetes, cataract, BPH Acute uncomplicated illness or injury, e.g., cystitis, allergic rhinitis, simple strain One or more chronic illness with mild exacerbation, progression, or side effects of treatment Two or more stable chronic conditions Undiagnosed new problem with uncertain prognosis, Laboratory tests requiring venipuncture Chest x-rays EKG/EEG Urinalysis Ultrasound, e.g., echocardiography KOH prep Physiologic tests not under stress, e.g. pulmonary function tests Non-cardiovascular imaging studies with contrast, e.g. barium enema Superficial needle biopsies Clinical laboratory tests requiring arterial puncture Skin biopsies Physiologic tests under stress, e.g. cardiac stress test, fetal contraction stress test Diagnostic endoscopies with no Deep needle or incisional biopsy Cardiovascular imaging studies with contrast and no identified Management Options selected Rest Gargles Elastic bandages Superficial dressings Over the counter drugs Minor surgery with no Physical therapy Occupational therapy IV fluids without additives Minor surgery with Elective major surgery (open, percutaneous or endoscopic) with no Prescription drug management

7 5/7/15 University of Rochester Center for Health & Behavioral Training 7 Acute HIV infection High Ex. Visit with a mental health arrest Visit with syncope or seizure Possible ectopic pregnancy diagnosis e.g. lump in breast Acute illness with systemic symptoms, e.g. pyelonephritis, pneumonitis, colitis Acute complicated injury, e.g. head injury with brief loss of consciousness One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment Acute or chronic illnesses or injuries that pose a threat to life or bodily function, e.g. 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, e.g. seizure, TIA, weakness, sensory loss risk factors, e.g. arteriogram, cardiac catheterization Obtain fluid from body cavity, e.g. lumbar puncture, thoracentesis, culdocentesis Cardiovascular imaging studies with contrast with identified risk factors Cardiac electrophysiological tests Diagnostic endoscopies with Discography Therapeutic nuclear medicine IV fluids with additives Closed treatment of fracture or dislocation without manipulation Elective major surgery (open, percutaneous or endoscopic) with Emergency major surgery (open, percutaneous or endoscopic) Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Decision not to resuscitate or to deescalate care because of poor prognosis Time as a controlling factor When counseling and coordinating care comprise more than 50% of the face to face time spent with the patient and family, time becomes the key controlling factor in determining the level of E/M service. Both the extent of counseling and coordination of care and the total length of the visit must be documented in the medical record including the following statement: Greater than 50% of this minute visit was spent in counseling and coordinating care of. Prolonged Services Coding Code Typical Time for Code Threshold Time to Bill Code Threshold Time to Bill Codes and

8 5/7/15 University of Rochester Center for Health & Behavioral Training Prolonged Services Associated With E&M Services Based *** Counseling and/or Coordination of Care (Time-Based) When an E&M service is dominated by counseling and/or coordination of care (the counseling and/or coordination of care represents more than 50% of the total time with the patient) in a face-to-face encounter between the physician or the qualified NPP and the patient in the office/clinic the E&M code is selected based on the typical/average time associated with the code levels. The time approximation must meet or exceed the specific CPT code billed (determined by the typical/average time associated with the E&M code) and should not be rounded to the next higher level. Further, in E&M services in which the code level is selected based on time, you may only report prolonged services with the highest code level in that family of codes as the companion code Example: - A patient presents for pregnancy testing, tests positive once the patient is informed they test positive the patient breaks down and states they were raped, the provider spends a total of 40 with the patient counseling and coordinating care of resources available for rape victims, pregnancy options etc. This would get documented greater than 50% of this 40 minute visit was spent coordinating care of newly diagnosed pregnancy and then get billed under A patient presents and is status asthmaticus the provider spends a total of 55 minutes face to face assessing and treating the patient (no counseling or coordinating care takes place just face to face treatment). This would get documented Total time of this visit was 55 minutes and then bill (based on required E/M ) and **Generally in the setting of Health Department Clinic Services, Counseling and coordinating care dominates the visit so the appropriate E/M based on time is billed not a prolonged services code** *** reference CMS document on prolonged services at Learning-Network-MLN/MLNMattersArticles/downloads/mm5972.pdf Medicare Learning Network, Evaluation and Management Services Guide, November 2014