Basic Evaluation and Management Coding and Documentation

1
Basic Evaluation and ManagementCoding and
Documentation

• Rebecca England, MHA, RHIA
• March 17, 2005

2
Objectives

• Understand the three key components of E/M
  Service
• Know the role contributing components play in E/M
  Service
• Understand 97 95 Guidelines

3
Objectives

• Understand the general rules and requirements of
• consultations
• outpatient visits
• inpatient encounters
• emergency room visits
• Understand updates for Reasonable Charges V2.2
  related to EM Services

4
Evaluation Management Services

• The most frequently used codes for capturing
  clinical services
• office visits
• emergency department
• inpatient visits
• consultations
• Tool to measure services consistently
• Reimbursement some VERA allocation based on EM
  Codes

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DOCUMENTATION TIPS

• The medical record should be complete legible

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DOCUMENTATION includes

• Chief Complaint
• History
• Physical Examination findings
• Results services provided
• Assessment, clinical impression or diagnosis
• Plan for care
• Dated and signed with credentials by provider
• If Counseling, include time what pt. was
  counseled about

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DOCUMENTATION TIPS

• If not documented, the rationale for ordering
  diagnostic services should be easily inferred.
• Past present diagnoses should be accessible to
  the treating and/or consulting physician.
• Appropriate health risk factors should be
  identified.

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DOCUMENTATION TIPS

• Patients progress, response to treatment, and
  revision of diagnosis should be documented.
• CPT ICD-9 codes reported should be supported by
  documentation in the medical record.
• REMEMBER!!! The encounter information in PCE, IS
  NOT a permanent part of the medical record.

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DOCUMENTATION TIPS

• Each section Does not need to be labeled
• Coder should be able to identify ROS, HPI, etc.
• Complete PFSH initial visit, reviewed updated
  as needed
• ROS-some positive all others negative-complete
  review

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95 vs 97 Guidelines

• Both guidelines have the same 3 components
• 97 allow for status of 3 chronic conditions to
  count towards extended HPI
• 95 requires Body Area or Organ System exam-no
  documentation elements Defined

11
95 vs 97 Guidelines

• 97 clearly defined bullets for multi-system or
  single organ system exam
• Medical Decision Making critieria is the same
• Either guideline can be used
• Service must use one or the other
• What about the 2000 Guidelines?

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New vs Established Patients

• NEW PATIENT - a patient that has not received any
  Professional Services from the clinician or
  another clinician of the same specialty who
  belongs to the same group practice, within the
  past THREE (3) YEARS.

Professional Services are those face-to-face
services rendered by a physician and reported by
specific CPT code(s).
13
New vs Established Patients

• ESTABLISHED PATIENT - a patient who has received
  Professional Services from the clinician or
  another clinician of the same specialty who
  belongs to the same group practice, within the
  past THREE (3) YEARS.

Professional Services are those face-to-face
services rendered by a physician and reported by
specific CPT code(s).
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New vs Established (in the VA)

• For VA Services
• Patient established in Primary Care clinic, is
  seen for the first time in Specialty clinic (I.e.
  ortho), patient is NEW to Ortho.
• Patient established in the Medical Facility, is
  seen for first time in CBOC (contract), patient
  is established, NOT new.

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Evaluation Management Services

• Every EM service is divided into three (3) areas
  of documentation
• HISTORY
• EXAMINATION
• COMPLEXITY and/or MEDICAL DECISION MAKING

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Evaluation Management Services

• 3 of 3 Areas are required/needed for
• New Patient (Outpatient)
• ALL Consultations (except as noted on next slide)
• ER Visits
• Hospital Observations
• Initial Hospital Admits

17
Evaluation Management Services

• 2 of 3 Areas are required/needed for
• Established Patient (Outpatient)
• Follow-up Inpatient Consultations
• Subsequent Hospital Visits

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HISTORY

• Chief Complaint
• History of Present Illness
• HINT Document 3 or more chronic or inactive
  conditions AND THEIR STATUS (if applicable)
• Review of Systems - All others Negative
• Past Medical, Family Social History

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History of Present Illness

• Elements of an HPI
• Location
• Severity
• Timing
• Modifying Factors
• Quality
• Duration
• Context
• Signs/Symptoms

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History of Present Illness

• Brief HPI - Consists of 1-3 elements
• Extended HPI - Consists of 4 or more elements or
  the status of at least three chronic or inactive
  conditions
• Note - An HPI may be documented by ancillary
  staff and reviewed by the clinician. Provider
  should document concurrence and/or changes as
  necessary.

21
REVIEW OF SYSTEMS

• Hem/Lymph
• Cardiovascular
• Musculoskeletal
• Neurological
• Allergy/Imm
• Respiratory
• Psych

Constitutional ENMT GI Integumentary Endocrine Eye
s GU
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REVIEW OF SYSTEMS
OR All other Negative or Unremarkable Note
The patients positive responses and negatives
for the system related to the problem should be
documented.
23
PAST, FAMILY and/or SOCIAL HISTORY (PFSH)

• Past history
• Family History
• Social History
• Pertinent PFSH
• Complete PFSH

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Levels of Examinations

• Problem Focused
• Expanded Problem Focused
• Detailed
• Comprehensive

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1995 Examination Guidelines
Body Areas Recognized
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1995 Examination Guidelines
Organ Systems Recognized
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1997 EXAMINATIONS

• General Multi-System Examination
• Single Organ System Examination
• Eyes
• Ears,Nose,Mouth,Throat
• Skin
• Cardiovascular
• Respiratory
• Genitourinary
• Psychiatric
• Neurologic
• Musculoskeletal
• Hematologic/Lymphatic/Immunologic

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1997 Levels of Examinations

• Problem Focused
• 1-5 Elements
• Expanded Problem Focused
• 6-11 Elements
• Detailed
• 12 or more Elements
• Comprehensive
• Perform all elements

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1997 Exam Documentation Hints

• The statement vital signs normal no longer
  counts, you have to document the vital signs,
  i.e. height, weight, bp, pulses.
• Cant indicate that an entire body system is
  normal, documentation must address specifically
  what was checked, i.e. lungs CTA, instead of
  lungs/chest normal.

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General Exam Documentation Hints

• Specific findings that are abnormal should be
  documented. A notation of abnormal without
  elaboration is insufficient.
• Remember to document ALL problems, each diagnosis
  assessed or treated, requires documentation.

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Coding Hints

• ROS can be a checklist
• HPI, ROS PFSH can be gathered from nurse or
  other source but
• HPI MUST match the exam Medical Decision Making
  
• Complexity of Medical Decision Making based on 2
  of 3-Dx./management options, Data OR Risk of
  Complication Comorbidity

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Inpatient Hospital Care

• Initial Hospital Care
• 99221 Detailed/Comprehensive History
  Detailed/Comprehensive Exam SF or Low Medical
  Decision Making
• 99222 Comprehensive History Comprehensive Exam
  Moderate Decision Making
• 99223 Comprehensive History Comprehensive Exam
  High Decision Making

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Inpatient Hospital Care

• includes all related E/M services provided in a
  calendar day by the attending physician
• is intended to be reported for the first hospital
  encounter with the patient by the attending
  physician.
• Attending must meet, examine, and evaluate the
  patient within 24 hours of admission. This must
  be documented in the record by the end of the
  next calendar day.

34
Subsequent Hospital Care

• Codes are assigned Per Day for the EM of a
  patient which requires at least 2 of the 3 key
  components
• 99231 Problem Focused interval history
  Problem Focused exam SF or low decision making
• 99232 Expanded PF interval history Expanded
  PF exam moderate decision making
• 99233 Detailed interval history Detailed
  exam high medical decision making

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Subsequent Hospital Care

• These codes include
• review of diagnostic studies and changes in the
  patients status since the last assessment
• reviewing medical record
• reviewing diagnostic studies
• changes in patients status (i.e. changes in
  history, physical condition and response to
  management)

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Hospital Discharge Services

• 99238 Hospital discharge day management 30
  minutes or less
• 99239 Hospital discharge day management, gt 30
  minutes

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EMERGENCY DEPARTMENT

• Hospital based facility
• Patients require immediate medical attention.
• 24 hours per day.
• New or Established patients
• Requires three key components

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Emergency Dept. Codes

• 99281 - problem focused history and exam and
  straightforward MDM
• 99282 - expanded problem focused history and
  exam and straightforward MDM
• 99283 - expanded problem focused history and
  exam and moderate MDM

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Emergency Dept. Codes

• 99284 - detailed history and exam moderate MDM
• 99285 - comprehensive history and exam and high
  MDM

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Consultations

• Outpatient
• (99241 - 99245)
• Requires 3 of 3
• key components
• Consult Requirements
• REQUEST
• RECORD
• RESPONSE

• Inpatient
• INITIAL
• (99251 - 99255)
• FOLLOW-UP
• (99261 - 99263)
• Requires 3 of 3
• key components

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Consultations Guidelines

• KEY FACTORS THAT DEFINE A CONSULTATION
• These codes are not defined by new or
  established status of the patient.
• Consultations provide an opinion or advise from
  one physician to another.
• A consultant may initiate diagnostic and/or
  therapeutic services and the initial service
  still be considered a consultative visit.

Information from AMA CPT and CPT Assistant
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Consultation vs VisitReferral vs Consult
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Preventive Medicine Services

• Performed in the absence of symptoms or
  complaints
• Include risk factor reduction guidance or
  counseling
• well visits
• screenings
• routine yearly exams

• Codes are driven by the AGE of the patient
• Comprehensive exam
• Exam is multi-system, complete, but the extent is
  based on age and risk factors identified.

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MODIFIERS
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Modifier 21 Prolonged EM Service

• Used only with the highest level of E/M code
• Used when face-to-face or floor/unit service
  provided is prolonged or otherwise greater than
  that usually required for the highest level of
  E/M service within a given category.

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Modifier 24 Unrelated E/M Service by the same
physician during a postoperative period

• E/M service performed during a postoperative
  period for a reason(s) unrelated to the original
  procedure.

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Modifier 25 Significant separately identifiable
E/M service by the same physician on the same day
of the procedure or other service

• Identifies that the patients condition required
  a significant, separate E/M service above and
  beyond the other service provided.
• Append to the E/M service on the day of a
  procedure or other service identified by a CPT
  code (usually those minor services with a 0 or
  10 day global period).

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Modifier 57 - Decision for Surgery

• Appended to an E/M service that resulted in the
  initial decision to perform surgery (usually
  those with 90 day global periods).
• For Medicare, this should be used only in cases
  in which the decision for surgery was made during
  the preoperative period of a surgical procedure.
• the pre-operative period is
• the day before and the day of surgery

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FAQs
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Software EnhancementsReasonable Charges V2.2

• The Chief Business Office announced the software
  release of patch IB2287, Billing Enhancements,
  Version 2.2 on March 3rd, 2005.
• Version 2.2 will improve software functionality
  for billing certain medical services as well as
  enhance several reports used for billing.
• This is a software enhancement patch only and no
  charges will be updated or exported with this
  patch.

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E/M Charges

• Certain insurance companies only pay for one
  charge, the other is denied as duplicate
• For those carriers Facility and Professional
  charges may be combined on a single bill
• This process will be automated

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Note!

• Other procedure codes that have both Facility and
  Professional charges may be on the bill. Only
  the E/M charges should be combined
• Procedures codes potentially combined
  90801-90815, 90845-90899, 99201-99215,
  99241-99245, 99271-99288, 99385-99387,
  99395-99429, 99499
• This function is only available if one of the
  procedures listed previously is on the bill and
  the site is Provider Based with both Facility and
  Professional Charges.

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Version 2.2

• A new question has been added when re-calculating
  the charges on a bill (screens 6/7, option 6).
  This question is asked only if one of the
  procedures is present.
• Combine Institutional and Professional Charges
  for EM Procedures?
• Default is No
• If Yes then the charges for the applicable
  procedures will be combined for facility and
  professional charge for the procedure to one
  charge line item on the bill.

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Version 2.2

• Use of the Combine Charges function is optional
  and intended for those cases where combining
  charges is currently done manually.
• Note Charges should not be combined for MRA
  bills as Medicare requires the Institutional and
  Procedure charges to be sent to Part A and Part B
  separately.

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Resident Supervision Handbook 1400.1 Updates

• 1400.1 re-written with specific
• emphasis on the following areas
• Updated Accreditation Council for Graduate
  Medical Education (ACGME) standards for residency
  training programs
• Enhances the description of supervision and the
  documentation requirements in various settings

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Resident Supervision Handbook 1400.1 Updates

• Reflects new standards for documentation of new
  outpatient encounters, including consultations
• Reflects the level of documentation needed for
  intensive care unit inpatient settings
• Reflects the level of documentation needed for
  inter-service or inter-ward transfers and from
  one level of care to another

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Resident Supervision Handbook 1400.1 Updates

• Provides a definition of functional description
  of the Department of Veterans Affairs (VA)
  based designated education officer (DEO) and the
  ACGME functional description for the designated
  institutional official (DIO)
• Updated handbook will be going into concurrence
  shortly

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SUMMARY

• Determine the type of service provided, whether
  office, inpatient, emergency room, etc
• Review all the guidelines found at the beginning
  of each category to determine if there are any
  special guidelines to follow.
• Make sure that the documentation supports the
  care given.
• Reasonable Charges Version 2.2
• Resident Supervision Handbook 1400.1 updates

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REFERENCES

• VHA Handbook for Coding Guidelines version 4.0
  February 27, 2004
• Basic CPT/HCPCS for Physician Office Coding
  (AHIMA)
• CPT 2004 - Evaluation and Management Service
  Guidelines
• CPT Assistant
• Coding Answer Book
• Ingenix Coding Lab Understanding Modifiers
• The Art of EM Auditing, Intelicode, 2001
• Reasonable Charges IB_2_287 RC v2.2 Patch
  Description
• Resident Supervision Handbook, 1400.1

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Submitting Questions

• VHA Coding Council
• http//vaww.appc1.va.gov/codequest/index.cfm
• For additional information concerning billing or
  Version 2.2
• VHA Reasonable Charges QA database
• http//vaww.va.gov/cbo/rcbilling.html

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What did they say?????

• Rebecca England, MHA, RHIA
• Rebecca.England_at_med.va.gov
• [phone]