Webcast Session II An Introduction to Evaluation and Management EM Coding Accurate Coding for Evalua

1

• Webcast Session IIAn Introduction to
  Evaluation and Management (EM) CodingAccurate
  Coding for Evaluation and Management (EM)
  Services A webcast designed for headache and
  migraine specialistsPresentersStuart B. Black,
  MDAmerican Headache Society (AHS)Sheila J.
  Madhani, MA, MPH, CCS-PMARC Associates
• October 16, 2007

2
Goals

• Introduction to CPT EM codes
• How to properly select the appropriate level of
  Medical Decision Making (MDM) for a specific EM
  encounter
• Application of CPT coding guidelines and
  practices to clinical scenarios relevant to
  headache specialists

3
What Will We Discuss?

• Importance of accurate coding
• Key components of EM codes
• How to properly select the appropriate level of
  Medical Decision Making (MDM) for a specific EM
  encounter
• General principles of medical record
  documentation
• Clinical examples
• Coding resources

4
Importance of Accurate Coding

• Full and fair description of services provided
• Avoid over-coding (fraud and abuse) and
  under-coding (not reporting all the services you
  have provided)
• Improve quality of patient care

5
Importance of Accurate Coding

• Physicians use EM codes to report professional
  services
• Documentation in the medical record must support
  the EM code and ICD-9 code(s) submitted
• Submitting a code that is not supported by
  documentation may be considered fraud

6
Key Components of EM Codes

• Three key components must be considered and
  supported by documentation in the medical record
  before selecting a code
• History
• Examination
• Medical decision making (MDM)

7
Key Components History

• Summary

8
Key ComponentsPhysical Examination

• Summary 1997 Guidelines, Single System
  Specialty Exam, Neurological

9
How to properly select the appropriate level of
Medical Decision Making (MDM) for a specific EM
encounter
10
Medical Decision Making (MDM)

• What is medical decision making (MDM)?
• MDM refers to the complexity of establishing a
  diagnosis and/or selecting a management option
• Of the three key components of EM, MDM is the
  most challenging to meet and document

11
Medical Decision Making (MDM)

• MDM Factors
• Factor 1 Number of diagnoses or management
  options
• Number of possible diagnoses
• Number of options that must be considered
• Levels
• Minimal
• Limited
• Multiple
• Extensive

12
Medical Decision Making (MDM)

• MDM Factors
• Factor 2 Amount and/or complexity of data to be
  reviewed
• Amount and/or complexity of medical records,
  diagnostic tests and/or other information that
  must be obtained, reviewed and analyzed
• Levels
• Minimal or none
• Limited
• Moderate
• Extensive

13
Medical Decision Making (MDM)

• MDM Factors
• Factor 3 Risk of complications and/or morbidity
  or mortality
• The risk of significant complications, morbidity
  and/or mortality associated with the patients
  presenting problem
• The risk of comorbidities associated with the
  patients presenting problem
• The risk of the diagnostic procedure(s) and/or
  the possible management options
• Levels
• Minimal
• Low
• Moderate
• High

14
Medical Decision Making (MDM)

• What are the different levels of MDM?
• Straightforward
• Low complexity
• Moderate complexity
• High complexity

15
Medical Decision Making (MDM)

• How do I determine the level of MDM for a
  specific EM encounter?
• The level of MDM is based on the level of
  complexity of the 3 factors of MDM
• Number of diagnoses or management options
• Amount and/or complexity of data to be reviewed
• Risk of complications and/or morbidity or
  mortality

16
Medical Decision Making (MDM)

• How do I determine the level of MDM for a
  specific EM encounter?
• The level of MDM is based on the level of
  complexity of the 3 factors of MDM

17
Medical Decision Making (MDM)

• The next few slides provide the following
  guidance
• Issues to consider when determining the level of
  complexity of the 3 factors of MDM
• Recommendations for documenting MDM
• Based on 1997 EM Guidelines, Centers for Medicare
  and Medicaid Services (CMS)

18
Medical Decision Making (MDM)

• Factor 1 Number of diagnoses or management
  options
• Issues to consider
• MDM is easier for a diagnosed problem than for an
  identified but undiagnosed problem
• Problems which are improving are less complex
  than problems that are worsening or failing to
  change as expected
• The need to ask advice from an outside source is
  an indication of complexity of diagnosis

19
Medical Decision Making (MDM)

• Factor 1 Number of diagnoses or management
  options
• Documentation recommendations
• An assessment, clinical impression or diagnosis
  should be documented
• Initiation of treatment or changes in treatment
  should be documented
• Any referrals or consultations, advice sought
  should be documented

20
Medical Decision Making (MDM)

• Factor 2 Amount and/or complexity of data to be
  reviewed
• Issues to consider
• The type of diagnostic testing ordered or
  reviewed
• Decision to review old medical records and/or
  obtain history from a source other than the
  patient increases complexity
• Discussion of contradictory or unexpected results
  with the physician who performed or interpreted
  test increases complexity

21
Medical Decision Making (MDM)

• Factor 2 Amount and/or complexity of data to be
  reviewed
• Documentation recommendations
• Any of the following tasks should be documented
• Any diagnostic services ordered, planned or
  scheduled
• The review of lab, radiology and/or other
  diagnostic tests
• Decision to obtain old records or obtain
  additional history from other sources that the
  patient
• Relevant findings from the review of old records
  and/or additional history
• Discussion of diagnostic tests with the physician
  who performed them
• The direct visualization and independent
  interpretation of an image, tracing or specimen

22
Medical Decision Making (MDM)

• Factor 3 Risk of significant complications,
  morbidity, and/or mortality
• Issues to consider
• Risk associated with the presenting problem
• Risks associated with the diagnostic procedure(s)
• Risks associated with the possible management
  problems

23
Medical Decision Making (MDM)

• Factor 3 Risk of significant complications,
  morbidity, and/or mortality
• Documentation recommendations
• Any of the following risks should be documented
• Comorbidities/underlying diseases
• Surgical or invasive diagnostic procedures
  ordered, planned or scheduled at the time of the
  EM
• Any invasive or surgical diagnostic procedure
  performed at the time of the EM encounter
• The referral for or decision to perform a
  surgical or invasive diagnostic procedure on an
  urgent basis

24
Medical Decision Making (MDM)

• Risk Table
• CMS has developed a risk table to help determine
  the level of medical decision making for a
  specific EM encounter (minimal, low, moderate,
  high)
• Table includes common clinical scenarios
• Table provides an assessment of risk in 3
  categories
• Presenting problem(s)
• Diagnostic procedure(s) ordered
• Management options selected
• Highest level of risk in any 1 category
  determines the overall risk

25
Centers for Medicare and Medicaid Services (CMS),
Documentation Guidelines for EM, 1997.
26
Key Components Medical Decision Making (MDM)

• Table of Risk
• For headache specialists the most important risk
  categories are
• Number of treatment options
• The levels of risk complications and/or morbidity
  or mortality

27
Medical Decision Making (MDM)

• Table of Risk Comparison elements relevant to
  headache specialists extracted from Table of Risk

28
Medical Decision Making (MDM)

• MDM scoring system
• Methodology to determine level of MDM developed
  by private organizations
• There are several systems currently in use
• Based on a point system that takes qualitative
  information collected by the provider and
  translates it into quantitative data
• More points higher level of service
• Example that follows was developed by the
  American Health Information Management
  Association (AHIMA)
• In general scoring systems are not part of any
  CMS guidelines or recommendations

29
Medical Decision Making (MDM)

• MDM scoring system example
• Factor 1 Number of Diagnoses or Treatment
  Options (more than 1 may apply)

30
Medical Decision Making (MDM)

• MDM scoring system example
• Factor 2 Amount/Complexity of Data Reviewed
  (more than 1 may apply)

31
Medical Decision Making (MDM)

• MDM scoring system example
• Factor 3 Risk of significant complications
• Minimal
• Low
• Moderate
• High

32
Medical Decision Making (MDM)

• MDM scoring system example

33
Medical Decision Making (MDM)

• Summary

34
Choosing an appropriate level of EM service

• Based on Key Components
• The three key components must be considered and
  supported by documentation in the medical record
  before selecting a code
• History
• Examination
• Medical decision making (MDM)

35
Choosing an appropriate level of EM service

• New patient, office/outpatient and office
  consultations
• You must meet or exceed ALL of the requirements
  to qualify for a particular level of an EM
  service
• Established patient, office/outpatient
• You must meet or exceed 2 out of the 3
  requirements to qualify for a particular level of
  an EM service

36
Summary

• New Patient Office/OP (3 out of 3)

37
Summary

• Office or other Outpatient Consultation (3 out of
  3)

38
Summary

• Established Patient Office/OP (2 out of 3)

39
Time

• Time determines the level of E/M service when
  counseling and/or coordination of care dominate
  ( 50) the encounter
• Counseling and coordination is separate from the
  history, physical exam and medical decision
  making
• More common scenario for headache specialists
• The extent of counseling and/or coordination of
  care must be documented in the medical record
  independent of the three key components

40
Documentation

• General Principles of Medical Record
  Documentation¹
• Medical record should be complete and legible
• The documentation of each patient encounter
  should include
• Reasons for the encounter and relevant history,
  physical examination findings and prior
  diagnostic test results
• Assessment, clinical impression or diagnosis
• Plan for care and
• Date and legible identity of the provider
• If not documented, the rationale for ordering
  diagnostic and other ancillary services should be
  easily inferred

¹ 1997 EM Guidelines, Centers for Medicare and
Medicaid Services (CMS)
41
Documentation

• General Principles of Medical Record
  Documentation¹
• Past and present diagnoses should be accessible
• Appropriate health risk factors should be
  identified
• Patients progress and response to changes in
  treatment should be included
• CPT and ICD-9 codes submitted should be supported
  by documentation in the medical record

¹ 1997 EM Guidelines, 1997 EM Guidelines, Centers
for Medicare and Medicaid Services (CMS)
42
Documentation

• Elements of a consultation
• There are three documented elements that comprise
  a consultation
• A written request, asking a question, for
  specific advice or specific management direction
  in the care of a patient
• Documentation of the patient evaluation
• A specific written response i.e. the answer to
  the question, as simple as Yes, the patient
  didnt have a PE and you may proceed with the
  surgery
• The unspoken fourth component- all of the above
  must materially contribute to the evaluation
  and/or management of the patient or the consult
  is not medically necessary

43
Clinical examples
44
Case 1 History (HPI, ROS, PFSH)

• 70 yr old man with hx of DM. 6 months ago
  developed herpes zoster right V1 distribution.
  After Rx of acute zoster developed constant, deep
  burning pain in V1 (R) with tic like pain and
  pain to light touch. Also developed severe (R)
  hemicranial headaches Under care of PCP pain
  refractive to Rx. Referred to H/A Specialist for
  consult.

45
Case 1

46
Case 1

• Pre-service
• Reviewed all the patients referral records.
  Reviewed the medical history form completed by
  the patient, vital signs, additional information
  obtained by PA. Personal communication with
  referring physician
• Intra-service
• Comprehensive HP performed
• Reviewed relevant data, risks, and explained
  clinical features of Post Herpetic Neuralgia
• Discussed diagnostic and therapeutic options
• Discussed recommended treatment plan
• Medical Decision Making
• Number of Diagnoses or Treatment Options 4
• Amount / Complexity of Data Reviewed 4
• Using the Table of Risk
• Acute or chronic illnesses or injuries that pose
  a threat to life or bodily function, e.g..
  multiple trauma, acute MI, pulmonary embolus,
  progressive severe rheumatoid arthritis,
  psychiatric illness with potential threat to self
  or others, peritonitis, acute renal failure
• Drug therapy requiring intensive monitoring for
  toxicity
• .

47
Case 1

• Post-service
• Complete medical record documentation and send
  written report to referring physician
• Post 1st visit communicate with referring doctor
  and treat any treatment failures or AEs if need
• Receive and respond to any interval testing
  results or correspondence
• Revise treatment plan if necessary and
  communicate with patient as necessary
• The level of care would meet CPT criteria for
  an Office Consultation 99245. It includes a
  comprehensive H P and MDM of high complexity.
  There has been no transfer of care.

48
Case 2 History (HPI, ROS, PFSH)

• 27 year old woman, established pt, seen in
  follow up B/O MOH. Post hospital visit
  following detoxification week ago. Detailed
  review of post hospital instructions discussed
  all medications discussed Dx and risks of MOH
  discussed situation with family and importance of
  family support. Scheduled for support group.

49
Case 2

50
Case 2

• Pre-service
• Reviewed medical record and hospitalization in
  detail before encounter with patient and her
  family.
• Intra-service
• Counseling and Coordination of care comprised
  more than 50 of the encounter in fact it
  comprised 100 of the encounter. This was face
  - to face time with the patient and family.
  Although time is not taken into account as a
  factor for determining the level of E/M care for
  most medical encounters, time is often the key or
  controlling factor in selecting the level of
  service in headache management.
• When counseling and Coordination of care is the
  CPT determining factor, there is no consideration
  of the extent of the history, the exam, the
  medical decision making required, or the nature
  of the presenting problem.

51
Case 2

• Intra-service (cont.)
• The time spent in Counseling/Coordination of
  care is the sole determinant of the E/M code.
• Counseling is defined as a discussion with the
  patient and/or family or other care giver
  concerning diagnostic results, prognosis, risks
  and benefits of treatment, instructions for
  management, compliance issues, risk factor
  reduction, patient and family education.
• Coordination is defined as discussions about the
  patients care with other providers or agencies.
  Time is defined in the CPT codebook. For an
  established patient 99212 10min 99213 15 min
  99214 25 min 99215 40 min.

52
Case 2

• Post-service
• The Physician must document the total length of
  time of the visit / encounter. In addition, the
  description of the counseling and / or activities
  involved in coordinating care must be documented.
• The physician also must document that more than
  50 of the encounter was involved in Consultation
  and / or Coordination of care. The E/M code for
  this visit would be 99214. Consultation and
  Coordination of care is a major factor in the
  management of headache patients.

53
Coding resources
54
Coding resources

• American Headache Society (AHS)
• AHSs Headache Coding Corner
• http//www.americanheadachesociety.org/professiona
  lresources/AHSsHeadacheCodingCorner.asp
• American Medical Association
• CPT-related resources
• http//www.ama-assn.org/ama/pub/category/3113.html
  
• Centers for Medicare and Medicaid Service (CMS)
• Evaluation and Management Services Guide
• http//www.cms.hhs.gov/MLNProducts/downloads/eval_
  mgmt_serv_guide.pdf
• 1997 Documentation Guidelines for Evaluation and
  Management Services
• http//www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp

55
Thank You

• The American Headache Society thanks you for
  your participation.
• Please contact American Headache Society (AHS)
  headquarters for further information
  ahshq_at_talley.com or 856-423-0043.