10/20/10 1 coding education

04/08/23 1

Coding Education & Training Program, HIM Department

Documentation Requirements forEvaluation & Management

Services

04/08/23 2


Presentation Goals

Introduce the 3 Key Components to an E/M Service History Examination Medical Decision MakingIntroduce the UC Davis Health System Audit Tool, version 2.4Review time and how it may effect a level of serviceReview critical care documentation guidelinesReview Teaching Physician Guidelines

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Overview of E/M Services

Classification of Common E/M ServicesOffice or Other Outpatient Services New Patient 99201-99205 Established Patient 99211-99215Consultations Office or Other Outpatient Consultations 99241-99245 Initial Inpatient Consultations 99251-99255Hospital Inpatient Services Initial Hospital Care 99221-99223 Subsequent Hospital Care 99231-99233 Hospital Discharge Services 99238-99239Emergency Department Services New or Established 99281-99285Critical Care Over 24 months of age 99291-99296Preventive Medicine Initial Preventive Medicine 99381-99387 Established Patient 99391-99397

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Overview of E/M Services

Classification of Other E/M Services

Nursing Facility/SNF/Rest Homes, etc 99304-99350

Prolonged Services 99354-99359

Care Plan Oversight 99374-99380

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Overview of E/M Section

Code assignment in the CPT E/M Section vary according to three factors:

Place of Service office, hospital, emergency room, nursing home

Type of Service consultation, admission, office visit

Patient Status new patient, established patient, inpatient, outpatient

Each E/M category includes three to five levels of service

The levels indicate the wide variations in skill, time, effort, responsibility and knowledge required to diagnose, treat or prevent an illness or injury

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In a Teaching Setting, a fourth factor needs to be considered:

Reimbursement Factor(s) Performing Provider vs Billing Provider (NP/PA vs

MD)? Are there additional Payor Specific Guidelines

(Medi-cal/Medicare)?1. Have the documentation guidelines been met?

Is the clinician (NP/PA) on the Hospital Cost Report?

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All providers who are licensed to provide medical services may use the same E/M codes for reporting their services regardless of specialty

The specific level is referring to the last digit in each E/M service code for example, a 99201 is referred to as a “New Patient, level 1”

This level requires meeting or exceeding the following Three Key Components:

a problem focused Historya problem focused Examstraightforward Medical Decision Making

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The E/M levels are selected based on the clinicians documentation

Therefore, it is important that the clinician documents each patient encounter as accurate and complete as possible

What should be considered when analyzing the patient’s medical record?

Does the documentation justify the medical necessity of the service and/or procedure performed?Does the documentation support the level of service reported?Is the documentation legible?Are there specific payer documentation guidelines and have they been met?

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Medical Necessity

Medicare defines "medical necessity" as services or items reasonable

and necessary for the diagnosis or treatment of illness or injury or to

improve the functioning of a malformed body member

Clinician vs Coder Questions regarding an extensive write up for a minor

problem should be referred back to the clinician for clarification

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Medicare-Selection of Level of E/M Service

The CMS Manual, Publication 100-4, Chapter 12, §30.6.1 - Selection of Level of Evaluation and Management Service states the following:

“Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code.

It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted.

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Medicare-Selection of Level of E/M Service, con’t

The volume of documentation should not be the primary influence upon which a specific level of service is billed.

Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.

Instruct physicians to select the code for the service based upon the content of the service.

The duration of the visit is an ancillary factor and does not control the level of the service to be billed unless more than 50 percent of the face-to-face time (for non-inpatient services) is spent providing counseling or coordination of care.”

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E/M Guidelines

There are two guidelines that may be utilized, 1995 or 1997

Providers/Coders may use either guideline

Whichever is most advantageous to the provider

Must follow one guideline per patient encounter

Cannot mix and match

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1995

Based on the number and/or extent of body areas or organ systems examined

1997

Based on the examination of specific bulleted items identified within a body area or organ system

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E/M Terms

New PatientAccording to the American Medical Association, a new patient is one who has not received any professional services from a given physician or another physician of the same specialty who belongs to the same group practice within the past three (3) years

Established PatientAccording to the American Medical Association, an established patient is one who has received professional services from that physician or another physician of the same specialty within the same group within the past three (3) years

ConsultationsA type of service provided by a licensed provider whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another licensed provider or appropriate source. For example, a Physician, NP, PA

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E/M Terms

Consultations vs ReferralConsultation Services rendered to give advice or an opinion to a requesting

provider about a patient’s diagnosis and/or management of a condition1. The 3 R’s

Request Render opinion Report

Referral Transfer of care Referring provider transfers the responsibility for managing

the patient’s complete care for a condition to the receiving physician and the receiving physician documents approval of care

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E/M Services

Remember, documentation must support the medical necessity and the level of service

Billed. The Level of Service is based on the documentation of the 3 Key Components and the Contributing Factors:

3 Key Components History Examination Medical Decision MakingContributing Factors Nature of Presenting Problem Time

1. Outpatient Setting (Counseling by Provider face-to-face)2. Inpatient Setting (Counseling by Provider face-to-face and/or

Coordination of Care)

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E/M – History Component

Now let’s take a look at the History Component on the Audit

Tool

The History is divided into four levels:

Problem Focused

Expanded Problem Focused

Detailed

Comprehensive

These levels are determined by……

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Four Elements

History levels are determined by the following 4 elements

1. Chief Complaint (CC)

2. History of Present Illness (HPI)

3. Review of Systems (ROS)

4. Past, Family, and/or Social History (PFSH)

The extent of the history is dependent upon clinical judgment and on the nature of the presenting problem(s)

Not all histories will have or need all elements

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The Four Elements of History

1. Chief Complaint (CC) A concise statement describing the symptom, problem, condition,

diagnosis, or other factor as the reason for the encounter. Example:a return visit recommended by the physician

2. History of Present Illness (HPI) Describes the patient’s developing condition/problem from the first

sign and/or symptom or from the previous encounter to the present or the status of three chronic or inactive conditions

3. Review of Systems (ROS) An inventory of body systems obtained through a series of questions

seeking to identify signs and/or symptoms the patient may be experiencing or has experienced

4. Past, Family, and Social History (PFSH) Review of the patient’s past history, family history, and social history

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Chief Complaint

The reason for seeking medical care should be recorded in the patient’s own words

“Patient complains of left foot pain due to fall last month.”

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The History of Present Illness (HPI)

Two types

1. Brief HPI 1 to 3 HPI Elements

2. Extended HPI 4 or more HPI Elements or the status of at least 3

chronic or inactive conditions

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The HPI ElementsLocation – Where the symptom or problem is occurring Abdomen, chest, leg, arm, headSeverity - A rating or description of severity of the symptom or pain Bad, intolerable, minimal, slightTiming – When symptom or pain occurs Before bed, upon waking, two hours after taking medicine, continuousQuality – The character of the sign or symptom Burning, dull, puffy, puss-filled, red, itchyDuration – How long a pain or symptom lasts, has been present, or persisted For two months, since prescription beganAssociated signs/symptoms – Any organ system or body area complaints associated with the chief complaint Rash with blistering, nausea and vomiting, abdominal painContext – Instances or items that can be associated with the chief complaint When walking, in company of smokers, at workModifying factors – Actions taken or things done to effect the symptom or pain, making it better or worse Improves when lying down, worse after eating

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The HPI

Example of an extended HPI with 4 or more elements

HPI: For the past two days she has had chills, fever and muscle aches. She feels worse in the evening. Her illness is so severe she has not been able to work.

Duration Associated Signs Timing Severity

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The HPI

Extended HPI with status of at least three chronic or inactive conditions.

Example:

The patient is currently under my care for the management of hypertension controlled with diet and exercise, diabetes controlled with insulin, and asthma requiring inhaler twice daily.

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The Review of Systems (ROS)

ROS includes 14 systems1. Constitutional symptoms (fever, weight loss, etc)

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

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The ROS

ROS has 3 types

1. Problem Pertinent 1 system

2. Extended 2-9 systems

3. Complete 10 or more systems

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The ROS

Medicare Documentation Guidelines

Problem Pertinent ROS The patient's positive responses and pertinent negatives for the system

related to the problem should be documented.Extended ROS The patient's positive responses and pertinent negatives for two to

nine system 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.

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The ROS

Example of a complete ROS:

The provider can list pertinent findings in 2 or more systems and note allother systems are negative

A patient is seen in the physician’s office with flu-like symptoms. For the past two days she has had chills, fever, and muscle aches. She feels worse in the evening. Her illness is so severe she has not been able to work. (Provider queries patient on at least ten systems, notes pertinent findings) She has lost 7 pounds in the last month. She denies abdominal pain, diarrhea, and vomiting. All other systems are negative.

Constitutional Gastrointestinal “All other systems are negative” gives provider credit for a complete ROS

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The Past, Family, and Social History (PFSH)

Past History The patient’s past experience with illnesses, operations,

injuries and treatments

Family History A review of medical events in the patient’s family, including

diseases that may be hereditary or place the patient at risk

Social History Age appropriate review of past and current activities

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The PFSHThere are two types of PFSH, pertinent and completeThe required elements for each differs based on the patient status New patient status

1. Pertinent 1 specific item from any of the 3 history areas

2. Complete 1 specific item from each of the 3 history areas

Established patient status1. Pertinent

1 specific item from any of the 3 history areas2. Complete

1 specific item from any 2 of the 3 history areas

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The PFSH

If the PFSH is non-contributory a statement is required in the documentation to qualify it for a complete PFSH Example:

1. “Reviewed PFSH, non-contributory to current condition.”

For those categories of E/M services that require only an interval history, it is not necessary to record information about PFSH Example:

1. Subsequent hospital care

2. Subsequent nursing facility care

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Overall History Component

Each history element must be met or exceeded to determine an overall history level

Let’s look at an exampleCC Must be present in patient’s medical recordHPI ExtendedROS CompletePSFH PertinentOverall History level = Detailed

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Example Outpatient Grid

Detailed

Pertinent

Extended2-9

Extended4 or more

Comprehensive

Complete

Complete

ExpandedProblem Focused

ProblemFocused

OVERALL HISTORY LEVEL

NonePFSHPast Medical History Family History Social HistoryEstablished Patient: only need 2 to be considered “Complete”New Patient: Requires all 3 to be considered “Complete”

Pertinent to

Problem1

None

ROSConstitutional Ears, Nose Throat, Mouth Skin/breast Endo Hem/LymphEyes Card/Vasc GI Neuro Allergy/ImmuneResp Musculo GU Psych All Others Neg

Brief1-3

HPILocation Severity Timing Modifying Factors

Quality Duration Context Associated Signs & Symptoms

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E/M History

Caveat

Patient is unable to speak

Physician must document this “Patient intubated, unable to obtain History”

Provider gets credit for a complete History!

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E/M – Examination Component

Now let’s look at the Examination Portion of the Audit Tool

Four Levels Problem Focused Expanded Problem Focused Detailed Comprehensive

Exam Elements Body Areas Organ Systems

(Cannot combine Body Areas and Organ Systems for Comprehensive Exam)

2 Types Multi-system Single Organ System

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E/M Examination Elements

Organ Systems:

Constitutional ears, nose, mouth, throat

Eyes resp GI GU

Cardio skin neuro psych

Hem, lymph, immune musculoComprehensiveDetailedExpanded

ProblemFocused

ProblemFocusedOVERALL EXAMINATION LEVEL

>=85-72-40-1Body Areas:

Head/face chest, including breasts & axillae

Neck back, spine each extremity

genitalia, groin, buttocks abdomen

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Examination Problem Focused ExpandedProblem Focused

Detailed Comprehensive

1995 1 Body Area or Organ System

Limited Exam2-4 Body Areas or Organ Systems

Extended Exam 5-7 Body Areas or Organ Systems

8 Organ Systems or a Comprehensive Single Organ System Exam

1997 Any 1-5 Bullets Any 6+ Bullets General: 2 bullets from 6 or more organ systems/body areas or 12 bullets from 2 or more organ systems/body areasEye/Psych: 9+ bulletsAll Others: 12+ bullets

General: Perform all, document 2 bullets from 9 Organ Systems/body areas

All Others: Perform all, document all elements in each bolded box and 1 element in each un-bolded box

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E/M – Medical Decision Making Component

Now let’s look at the Medical Decision Making Portion of the Audit Tool

Four Levels1. Straightforward2. Low Complexity3. Moderate Complexity4. High ComplexityTo determine the level of Medical Decision Making, two of the three following Elements must meet or exceed

Elements Number of Diagnoses or Treatment Options Amount and/or Complexity of Data to be Reviewed Risk of Complication and/or Morbidity/Mortality

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Number of Diagnoses or Treatment Options

3 Categories

1. Self-limited or minorstable, improved or worse

2. Established problem stable, improved, worsening

3. New problem to examinerno additional work up plannedadditional work-up planned

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1.Self-limited or minor (stable, improved or worse)

Sore throatEarache (simple)Simple laceration This category does not indicate that the problem is new or

established American Medical Association (AMA)

1. “A problem that runs a definitive and prescribed course, is transient in nature, and is not likely to permanently alter health status or has a good prognosis with management/compliance.”

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2.

Established problem; stable, improved

For this provider/specialty group – usually diagnosis and treatment has already been started

Established problem; worsening

For this provider/specialty group; must be documented or CLEARLY implied, (pain has increased, etc.)

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3.

New problem to examiner; no additional work- up planned

New problem to examiner; additional work-up Planned Starting treatment does not constitute “additional work-up”. Any diagnostic study or plan to help find a definitive diagnosis.

Example: Radiology Laboratory Consultation with another physician

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NUMBER OF DIAGNOSES AND/OR TREATMENT OPTIONS

A B C = D

Problem(s) status Number Points Result

Self–limited or minor (stable, improved or worse)

max=2 1

Est. problem; stable, improved

1

Est. problem; worsening 2

New problem; no additional workup planned

max=1 3

New Problem; additional workup planned

4

Total

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Amount and/or Complexity of Data to be Reviewed

Review &/or order of clinical lab tests

Review &/or order in the radiology section of the CPT

Review &/or order of tests in the medicine section

Discussion of test results with performing physician

Decision to obtain old records &/or history from someone other than patient

Review and summarization of old records &/or obtaining history from someone other than patient &/or discussion of case with another health care provider

Independent visualization of image, tracing or specimen itself (not simple review of report)

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Review &/or order of clinical lab tests

Any documentation of the review of tests previously ordered

Example(s): Test results documented in notes Documentation that Provider reviewed results

Documentation that indicates tests are ordered

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Review &/or order in the radiology section of the CPT

Review of Report not actual film

Example(s): Documentation of review of x-ray report Documentation that a x-ray was ordered

Not viewed in Stentor (review of actual film)

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Review &/or order of tests in the medicine Section

Report(s) is reviewed or ordered

Example(s): EKG Report Stress Test Documentation that a medicine test was ordered

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Discussion of test results with performing physician

Discussion = verbal communication and NOT a report or letter

Example: Pathologist viewing specimen then pages ordering MD to discuss

results PCP MD pages MD Specialist to discuss test results

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Decision to obtain old records &/or history from someone other than

patient

Documentation should support the reason/need to get old records or obtain the history from someone other than the patient

Does not include: Parent’s of pediatric patient Interpreter

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Review and summarization of old records &/or obtaining history from

someone other than patient &/or discussion of case with another

health care provider

Summarize the review of old record or history and document how it pertains to the patients current problem

It must be Additional/Relevant information

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Independent visualization of image, tracing or

specimen itself (not simple review of written report)

Does not include: Rapid Strep Test Urine Pregnancy Test

Does include: Reviewing image in Stentor, etc. EKG Strip

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AMOUNT AND/OR COMPLEXITY OF DATA REVIEWED

Points

Review &/or order of clinical lab tests 1

Review &/or order in the radiology section of CPT 1

Review &/or order of tests in the medicine section of CPT 1

Discussion of test results with performing physician 1

Decision to obtain old records &/or obtain history from someone other than patient

1

Review and summarization of old records &/or obtaining history from someone other than patient &/or discussion of case with another health care provider

2

Independent visualization of image, tracing or specimen itself (not simply review of report)

2

Total

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Risk of Complication and/or Morbidity/Mortality

Four Levels Minimal Low Moderate High

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Table of Risk

Level of Risk

Presenting Problem(s) Diagnostic Procedure(s) Ordered Management Option Selected

Minimal * One self–limited or minor problem, e.g. cold, insect bite

* Lab tests requiring venipuncture* CXRs* ECG/EEG, U/A, echo

* Rest* Gargles* Elastic bandages* Superficial dressings

Low * 2 or more self–limited or minor problems* 1 stable chronic illness•* Acute uncomplicated illness or injury, e.g. cystitis, sprain

* Physiologic tests not under stress, e.g. PFTs* Non–CV imaging with contrast, e.g. barium enema* Superficial needle biopsy* Clinical lab test requiring arterial puncture* Skin biopsies

* OTC drugs* Minor surgery w/ no identified risk factors* PT, OT•IV fluids w/out additives

Moderate

* 1 or more chronic illnesses with mild exacerbation, progression, or side effects of treatment* 2 or more stable chronic illnesses* Undiagnosed new problem with uncertain prognosis, e.g., lump in breast* Acute illness with systemic symptoms, e.g. pyelonephritis, pneumonia, colitis* Acute complicated injury, e.g. head injury with brief LOC

* Physiologic test under stress, e.g. cardiac stress test, fetal contraction stress test* Diagnostic endoscopies with no identified risk factors* Deep needle or incisional biopsy* CV imaging studies with contrast and no identified risk factors, e.g. arteriogram and cardiac cath* Obtain fluid from body cavity

* Minor surgery with identified risk factors* Elective major surgery (open, percutaneous, or endoscopic) with no identified risk factors* Prescription drugs* Therapeutic nuclear medicine* IV fluids w/ additives* Closed tx of fracture or dislocation without manipulationHigh * 1 or more chronic illnesses with severe

exacerbation, progression, or side effects of treatment* Acute or chronic illnesses or injuries that may pose a threat to life or bodily functions, e.g. peritonitis, acute failure, multiple injuries, acute MI* An abrupt change in neurological status, e.g. seizure

* CV imaging studies with contrast with identified risk factors* Cardiac EP test* Diagnostic endoscopies with identified risk factors* Discography

* Elective major surgery w/ identified risk factors* Emergency major surgery* Parenteral controlled substances* Drug therapy requiring intensive monitoring for toxicity* Decision not to resuscitate or to de–escalate care because of poor prognosis

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Final Medical Decision-Making Level

2 of the 3 Elements must be met or exceeded

Number of Diagnosis or Treatment Options

Amount and/or Complexity of Data Reviewed

Risk of Complication and/or Morbidity/Mortality

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Final Result for Medical Decision Making (must meet or exceed two out of three elements)

Number diagnoses/treatment options

<=1Minimal

2Limited

3Multiple

>=4Extensive

Amount & complexity of data

<=1Minimal

2Limited

3Multiple

>=4Extensive

Highest risk Minimal Low Moderate High

Type of decision making

Straight forward

Low Complex

Moderate Complex

High Complex

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Example of Medical Decision Making

Number of Diagnoses or Treatment Options

Assessment: The diabetes is controlled with diet and exercise, blood glucose levels are within acceptable limits. The high blood pressure that we have been monitoring and trying to control with diet and exercise is now far above an acceptable range. The first problem is considered an established stable problem while the blood pressure is an established problem worsening.

Established Problem – Stable Improved Established Problem – Worsening

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Amount &/or Complexity of Data Reviewed

The patient comes in for a recheck of diabetes that is controlled with diet and exercise, blood glucose levels are within acceptable limits, and high blood pressure that you have been monitoring and trying to control with diet and exercise is through the roof. A CBC, Chemical profile, urinalysis,electrocardiogram, and chest x-ray are ordered.

Review &/or order of clinical lab tests Review &/or order of tests in the medicine section of CPT Review &/or order in the radiology section of CPT

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Risk of Complications &/or Morbidity of Mortality

The patient comes in for a recheck of diabetes that is controlled with diet and exercise, blood glucose levels are within acceptable limits, and high blood pressure that you have been monitoring and trying to control with diet and exercise is through the roof. A CBC, Chemical profile, urinalysis,electrocardiogram, and chest x-ray are ordered. Impression: 1. Diabetes-controlled. 2. Hypertension- uncontrolled. Atenolol 50 mg prescribed. The patient is to return in one week for recheck.

1 or more chronic illnesses with mild exacerbation, progression or side effects of treatment

Lab test requiring venipuncture/CXRs/ECG Prescription Drugs

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Contributing Factors

Time The American Medical Association guidelines state that when counseling and/or coordination of care dominates (MORE THAN 50%) the physician/patient and/or family encounter (face-to-face time) then time may be considered the key or controlling factor to qualify for a particular level of E/M services

Documentation of time is key if time is the determining factor The total amount of time spent with the patient must be clearly documentedThe record should describe the counseling and/or activity to coordinate care “A total of 30 minutes was spent with the patient, more than half

of this time was spent discussing treatment options and subsequent effects of chemotherapy.”

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Time

Typical Times

New Office Visit 99201-10 99202-20 99203-30 99204-45 99205-60Office Consult 99241-15 99242-30 99243-40 99244-60 99245-80Inpatient Consult 99251-20 99252-40 99253-55 99254-80 99255-

110

Established Office Visit 99211- 5 99212-10 99213-15 99214-25 99215-40

Initial Hospital Observation 99218-30 99219-50 99220-70Initial Hospital Visit 99221-30 99222-50 99223-70

Subsequent Hospital Visit 99231-15 99232-25 99233-35

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E/M – Critical Care

Critical Care

Definition

Critical care is the care of critically ill or critically injured patients who require the full, exclusive attention by a physician(s). A critical illness or injury “acutely impairs one or more vital organ systems such that there is high probability of imminent or life threatening deterioration in the patient’s condition”.

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Critical Care, con’t

Documentation RequirementsSince critical care is a time-based code, the physician progress note must contain documentation of the total time involved providing critical care services. In a teaching environment, the time recorded as critical care time is the actual time spent by the physician, not a resident, fellow, or allied health provider. The time must be personally documented by the teaching physician. Teaching time does not count toward critical care time. Critical care of less than 30 minutes duration on any given day is reported with an evaluation and management code.

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Critical Care, con’t

Example Documentation

Patient seen and examined with Dr. Resident. Reviewed and agree with his note and the plan of care we developed together.

One hour of critical care time personally performed due to patient’s hemodynamic instability. Patient was resuscitated with 2 units of packed red blood cells. Obtained additional studies to determine possible causes for patient’s instabilities.

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E/M – Teaching Facility

Teaching Facility

Documentation requirements for State and Federal Payers The teaching physician saw the patient The teaching physician reviewed the resident’s note, and

agreed or revised the findings The teaching physician actively participated in the care by

either documenting involvement in the development of the plan or by changing the plan

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Teaching Physician

Examples of minimally acceptable documentation “I saw the patient with the resident and agree with the

resident’s findings and plan we developed.” “I saw and evaluated the patient. Discussed with the resident

and agree with the resident’s findings and plan we developed as documented in the resident’s note.”

“See the resident’s note for details. I saw and evaluated the patient and agree with the resident’s findings and plans we developed as written.”

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Teaching Physician

Examples of unacceptable documentation for State and Federal Payers “Agree with above.” “Rounded, Reviewed, Agree.” “Discussed with resident.” “Agree.” “Seen and Agree.” “Patient seen and evaluated.” A legible countersignature and/or identity alone does not meet

State and Federal payer requirements

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Teaching Physician

Non-State and Non-Federal Documentation Requirements

(Commercial Payers):

Minimum evidence of review by the attending shall be demonstrated by countersignature in the patient medical record

Other requirements:

The teaching physician shall be promptly available

If the service includes direct patient contact, the teaching physician’s availability must include the ability to be physically present to review the resident’s note and ensure the services were furnished appropriately

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Medical Students

The teaching physician and/or resident must reference the medical student’s dated documentation

The medical student’s documentation may only contribute in two elements of the History component The Review of Systems and the Past Medical, Family, Social

History (ROS and PFSH)

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E/M – Differences, Inpatient vs Outpatient

Inpatient Encounters vs Outpatient Encounters

Inpatient Encounters Key Components are the same

1. History

2. Examination

3. Medical Decision Making Elements within each component are the same Difference

1. Levels Example: Initial H&P has 3 levels, not 5

2. Number of Elements Required Example: Initial H&P requires a Complete ROS (10 or more

systems) for levels 2 and 3

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E/M – Differences, Inpatient vs Outpatient

Inpatient Encounters vs Outpatient Encounters Inpatient Encounters

Initial Hospital Visit/Hospital Observation Levels1. Detailed2. Comprehensive

Subsequent Hospital Visit/Follow-up Consult Levels1. Problem Focused2. Expanded Problem Focused3. Detailed

Initial Hospital Consultation Levels1. Problem Focused2. Expanded Problem Focused3. Detailed4. Comprehensive

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Pulling it All Together

Overall E/M Code SelectionPlace of Service

Hospital vs Physician’s OfficeType of Service

Consultation vs Office Visit vs Admission Patient Status

New Patient vs Established Patient Outpatient vs Inpatient

Documentation Requirements State/Federal Payer vs Non-State/Non-Federal Payer

Any Contributing Factors? Time

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Pulling It All Together

Overall E/M Code Selection

Key Components must be met or exceeded New Patient/ER/Consultation

1. Requires all three key components Established Patient

1. Requires two of three key components

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Resources

UCDHS Coding Education & Training Programhttp://www.ucdmc.ucdavis.edu/cet

(916) 734-8856

Coding Advisory Board (CAB)http://intranet.ucdmc.ucdavis.edu/cab/

Medicare Medlearn Mattershttp://www.cms.hhs.gov/MedlearnMattersArticles/

Compliance Officehttp://www.ucdmc.ucdavis.edu/compliance/

(916) 734-8808

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