versionemuniversity.com/redax/rpctb.pdf · 2014. 9. 15. · lem, e.g., cold, insect bite, tinea...

Rational Physician Coding for E/M

Services

VA-TX-MD-DE-DC

Peter R. Jensen, MD, CPC www.EMuniversity.com

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Goals

1) Improve physician E/M compliance 2) Avoid undercoding3) Decrease E/M coding anxiety4) Save time5) Keep the focus on patient care

Peter R. Jensen, MD, CPC

Rational Physician Coding for E/M Services

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A “Routine” Office PatientYou see an established office patient with stable HTN, DM2 and dyslipidemia. There is also a history of CAD, which is well controlled.

You make no changes in medications and schedule return visit in four months.Time spent is 15 minutesWhat is this encounter worth?

1394.6

12412

23 0.8

101 1236

MA/Cr = 28, LDL 77, HgbA1c 6.8

E/M Coding

E/M = Evaluation and ManagementHow patient encounters are translated into 5 digit numbers to facilitate billingWithin each type of encounter there are various levels of care

99211 $20.6099212 $36.8299213 $51.6399214 $80.5399215 $117.21

©2005 Peter R. Jensen, MD, CPC

50%

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E/M = Cognitive Labor

=The E/M Guidelines

The E/M Guidelines

Developed by the AMA and CMSFirst set released in 1995Second set released in 1997Based on three “Key Components”– History– Physical Exam– Medical Decision-Making

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History Physical

Problem FocusedExpanded Problem FocusedDetailedComprehensive

MDM

StraightforwardLow ComplexityModerate ComplexityHigh Complexity

History

PhysicalMDM

We think of the key components as being random, but they’re really not……

This is how auditors look at the E/M guidelines. They view the history, physical exam and medical decision-making in very concrete terms.

MDMHistory Physical

Straightforward

Problem Focused

Expanded Problem Focused

Detailed

Comprehensive

Problem Focused

Expanded Problem Focused

Detailed

Comprehensive

Low Complexity

Moderate Complexity

High Complexity

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Physical

Physical

ROS

HPI

PMHFH

SH

Exam Bullets

Organ Systems

Diagnoses

Data Reviewed

Risk

Our challenge is to find some way to translate our cognitive labor into the abstruse language of the E/M guidelines without wasting time on over-documentation or getting distracted from our real job of taking care of patients.

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MDM

H

RiskDataProblems

Primacy of Medical Decision-Making

MDM =

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Medical Necessity

“Correct” Level of Care

=

The Importance of Medical Necessity

“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 E/M service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed.”

RiskDataProblems

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MDM Points

High44High

Moderate33Moderate

Low22Low

Minimal11Straight Forward

RiskData Problems MDM Complexity

Need 2 out of 3 to qualify for given level of MDM

Determining the MDM

High Complexity

HighExtensiveExtensive

Moderate Complexity

ModerateModerateMultiple

Low Complexity

LowLimitedLimited

Straight-Forward

MinimalMinimalMinimal

Level of MDM

RiskData Reviewed

Number of Diagnoses


Given the importance of the MDM, it is essential that we be able to quan-tify this key component in an objective and repeatable manner. Unfortu-nately, the official table of MDM from both the 1995 and 1997 E/M guide-lines (shown above) makes this a very difficult thing to do. The problem is that the terms used to stratify the dimensions of MDM are too vague.

The framers of the E/M guidelines realized that the MDM rules were to vague to be used by auditors, so they came up with a weighted point sys-tem which was eventually released to all Medicare carriers to used on a “voluntary” basis.

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Points for Data Reviewed

1Decision to obtain old records

2Independent review of image, tracing, or specimen

1Review/order clinical lab tests

2Review and summation of old records

1Discussion of test results with performing MD

1Review/order tests in the medicine section (echo, EKG, LHC, PFTs)

1Review/order X-rays

PointsData Reviewed

Problem Points

1Self limited or minor (Max 2)

4New problem, additional work-up planned

3New problem, no additional work-up planned

2Established problem, worsening

1Established problem, stable

PointsProblems/DDx

The problem points are tabulated by referring to this table. You add up all the problems you are addressing during the encounter and come up with the final number of total problem points. “New” problems are defined relative to the physician, not the patient.

The data points are calculated using this table. You only get one data point for reviewing and/or ordering labs and ordering or reviewing X-ray reports. If you personally review any primary data (such as an EKG, an X-ray or a blood smear, etc.), you get two data points, but you must record your findings in the chart.

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Risk Presenting Problem(s) Diagnostic Procedures Management Options Selected

Minimal • One self-limited or minor prob-lem, e.g., cold, insect bite, tinea corporis

• Laboratory tests • Chest X-rays • EKG/EEG • Urinalysis • Ultrasound/

Echocardiogram • KOH prep

• Rest • Gargles • Elastic bandages • Superficial dressings

Low • Two or more self-limited or minor problems

• One stable chronic illness, e.g., well controlled HTN, DM2, cataract

• Acute uncomplicated injury or illness, e.g., cystitis, allergic rhinitis, sprain

• Physiologic tests not under stress, e.g., PFTs

• Non-cardiovascular imag-ing studies with contrast, e.g., barium enema

• Superficial needle biopsy • ABG • Skin biopsies

• Over the counter drugs • Minor surgery, with no identi-

fied risk factors • Physical therapy • Occupational therapy • IV fluids, without additives

Moderate • One or more chronic illness, with mild exacerbation, progres-sion, or side effects of treatment

• Two or more stable chronic ill-nesses

• Undiagnosed new problem, with uncertain prognosis, e.g., lump in breast

• Acute illness, with systemic symptoms, e.g., pyelonephritis, pleuritis, colitis

• Acute complicated injury, e.g., head injury, with brief loss of consciousness

• Physiologic tests under stress, e.g., cardiac stress test, fetal contraction stress test

• Diagnostic endoscopies,

with no identified risk factors

• Deep needle, or incisional biopsies

• Cardiovascular imaging studies, with contrast, with no identified risk factors, e.g., arteriogram, cardiac catheterization

• Obtain fluid from body cavity, (e.g., LP or thora-centesis)

• Minor surgery, with identified risk factors

• Elective major surgery (open, percutaneous, or endoscopic), with no identified risk factors

• Prescription drug manage-ment

• Therapeutic nuclear medicine • IV fluids, with additives • Closed treatment of fracture

or dislocation, without ma-nipulation

High • One or more chronic illness, with severe exacerbation, pro-gression, or side effects of treat-ment

• Acute or chronic illness or in-jury, which poses a threat to life or bodily function, e.g., acute MI, pulmonary embolism, severe respiratory distress, progressive severe rheumatoid arthritis, psy-chiatric illness, with potential threat to self or others, peritoni-tis, ARF

• An abrupt change in neurologi-cal status, e.g., seizure, TIA, weakness, sensory loss

• Cardiovascular imaging, with contrast, with identi-fied risk factors

• Cardiac EP studies • Diagnostic endoscopies,

with identified risk factors • Discography

• Elective major surgery (open, percutaneous, endoscopic), with identified risk factors

• Emergency major surgery (open, percutaneous, endo-scopic)

• Parenteral controlled sub-stances

• Drug therapy requiring inten-sive monitoring for toxicity

• Decision not to resuscitate, or to de-escalate care because of poor prognosis

Table of Risk

This is the official table of risk for both the 1995 and 1997 E/M guidelines. The rules explicitly stat that it only takes one element in any of the catego-ries above to qualify for any given level of risk. Use highest level of risk present to stratify the overall level of risk for any encounter.

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Calculating the Overall MDM

High44High

Moderate33Moderate

Low22Low

Minimal11Straight Forward

RiskData Problems MDM Complexity


The overall level of MDM is determined by

TrailBlazer Changes the Rules

Unfortunately, if you practice in VA, TX, MD, DE or Washington, D.C., your Medicare carrier (TrailBlazer) recently came up with a completely new medical decision-making point system. The rules are much more complex than the standard MDM rules used by everyone else. In addition, providers have to work harder to qualify for higher levels of medical decision-making.

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TrailBlazer Changes the Rules

TrailBlazer is the Medicare carrier for TX, MD, VA, DE and Washington, D.C.They have unilaterally changed the way that they audit the key component of Medical Decision-Making:– Number of points required is higher– Problem points are added up differently– Different values for data points– Risk is identical to the old rules

TrailBlazer MDM Points

≥High5 Moderate3 Low

≤Straight Forward

RiskData Problem D

MDM Complexity

Need 2 out of 3 to q

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High

ModerateLow

Straight Forward

PMDM Complexity

HighModerate

LowMinimal11Straight ForwardRiskData Pts Problem PtsMDM Complexity

New

Standard MDM Rules

Dx + Tx#Tx#DxNumber of Diagnoses and/or Management Options

Total

New or established problem and E/M is mentioned

New or established problem; no E/M mentioned and problem IS clearly a co-morbid condition

New of established problem; no E/M mentioned and problem IS NOT clearly a co-morbid condition

TrailBlazer Problem Points

?

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1Referral to another physician, consultation

2Hospital admit – other physician(s) contacted

1Hospital admit

1Pt educated on self or home care topics/techniques

1IM injection or other pain management procedure

1Radiation therapy

1Conservative therapy: rest, ice, bandages, diet

2Insulin prescription (sc or combo sc/iv), hyperal, insulin gtt, etc1IV fluids1Closed treatment for fracture/dislocation1Physical, occupational or speech therapy

1Open or percutaneous procedure

1Other – specify

2Drug management (more than 3 Δ’s)

1Drug management (new Rx or Δ dose)

1Continue same treatment and/or monitoring

PointsProblems/Therapeutic Options

1Discuss case with consultant or order consultation or discuss case with other physician managing patient

1Physiologic monitoring

1Order and/or summarize old records



1Discuss test results with performing MD

1Review/order tests in the medicine section (echo, EKG, LHC, PFTs)

1Review/order X-rays

PointsData Reviewed

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Calculating the MDM with the TrailBlazerPoints

High≥ 4≥ 7HighModerate35 - 6Moderate

Low23 - 4Low

Minimal≤ 1≤ 2Straight Forward

RiskData Pts

Problem DDx

MDM Complexity


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Problem FocusedExpanded Problem FocusedDetailedComprehensive

CCHPIROSPFSH

History

Levels of History

None1BriefEPF1 out of 32 – 9ExtendedDetailed

NoneNoneBriefPF

3 out of 310ExtendedComp

PFSHROSHPIHistory

There are four levels of history based on the documentation of the HPI, ROS and elements of past medical, family and social history.

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HPI

A narrative of the patient’s symptoms or illnesses since onset or since the previous encounterEvery level of history requires and HPI, which may be referred to as an “interval history” for follow-up encountersThe HPI is the only component of history which MUST be personally obtained and documented by the provider

Elements of HPI

• Location • Duration • Timing • Quality

• Severity • Context • Modifying factors • Associated signs or

symptoms

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HPI Elements

LocationQualitySeverityDurationTimingContextModifying FactorsAssociated Signs/Symptoms

Patient complains of stabbing intermittent chest pain which began 8 hours ago while watching TV. The pain is rated as 8/10 in severity, is worse with exertion and is associated with SOB and nausea.

Location

Severity

Quality

Timing

Modifying Factors

Duration

Context Associated Signs or

Symptoms

Example of an extended HPI using all eight of the HPI elements.

Levels of HPI

Brief HPIRequires only one to three HPI elements

Extended HPIRequires four HPI elements or the status of three chronic or inactive problems

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ROSConstitutional EyesEars, nose, mouth, throatCardiovascularRespiratoryGIGU

MusculoskeletalSkinNeurologicalPsychiatricEndocrineHem/LymphaticAllergic/Immunologic

The ROS may be completed by the physician, ancillary staff or by having the patient fill out a questionnaire.

Without a specific somatic complaint, it may be difficult or outright impossible to qualify for any level of HPI using the HPI elements. This problem was addressed in the 1997 E/M guidelines. If there are no somatic complaints, the 1997 E/M guidelines allow you to qualify for extended HPI by commenting on the status of three or more chronic or inactive problems.

What if the patient has no complaints?

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PFSH

Past Medical History– Previously existing illnesses, prior operations,

current medications, allergies, immunizationsFamily History– Health status of parents/siblings/children including

relevant or hereditary diseases Social History– Marital status, employment, DOA, education,

sexual history

The PFSH may be completed by the physician, ancillary staff or by having the patient fill out a questionnaire.

Levels of History

None1BriefEPF1 out of 32 – 9ExtendedDetailed

NoneNoneBriefPF

3 out of 310ExtendedComp

PFSHROSHPIHistory

The documentation requirements for each level of history are very specific. Therefore, the history should be recorded in a purpose-driven manner to ensure compliance while avoiding time-wasting over-documentation.

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History Tips and Shortcuts 1. You need a chief complaint for each and every encounter. It may be a symptom or it may be a state-

ment such as “follow-up HTN.”

setting. These codes are used in addition to the inpatient E/M codes.

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Physical Exam

1997 Physical Exam 15 Organ Systems and 59 bullets

6 - 11EPF12Detailed

1 - 5PF

18Comp

BulletsExam

1997 Physical Exam Organ Systems

• Constitutional • Eyes • Ears, nose, mouth and throat • Neck • Respiratory • Cardiovascular • Chest (breasts) • Gastrointestinal • GU (male, female) • Musculoskeletal • Lymphatic • Skin • Neurologic • Psychiatric

See individual bullets on next page.

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The 1997 Multi-System Exam Bullets Constitutional

• Three vital signs • General appearance

Eyes • Inspection of conjunctiva and lids • Examination of pupils and irises

(PERRLA) • Ophthalmoscopic discs and posterior

segments

Ears, Nose, Mouth, and Throat

• External appearance of the ears and nose

• Otoscopic examination of the exter-nal auditory canals and tympanic membranes

• Assessment of hearing • Inspection of nasal mucosa, septum

and turbinates • Inspection of lips, teeth and gums • Examination of oropharynx: oral

mucosa, salivary glands, hard and soft palates, tongue, tonsils and pos-terior pharynx

Neck

• Examination of neck (e.g., masses, overall appearance, symmetry, tra-cheal position, crepitus)

• Examination of thyroid

Respiratory

• Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic excursions)

• Percussion of chest • Palpation of chest (e.g., tactile fre-

mitus) • Auscultation of the lungs

Cardiovascular

• Palpation of the heart (PMI) • Auscultation of the heart • Assessment of lower extremity

edema • Examination of the carotid arteries • Examination of abdominal aorta • Examination of the femoral pulses • Examination of the pedal pulses

Chest (Breasts)

• Inspection of the breasts • Palpation of the breasts and axillae

Lymphatic Palpation of lymph nodes two or more areas

• Neck • Axillae • Groin • Other

Skin • Inspection of skin and subcutane-

ous tissue (e.g., rashes, lesions, ulcers)

• Palpation of the skin and subcu-taneous tissue (e.g., induration, subcutaneous nodules, tighten-ing)

Neurologic

• Test cranial nerves with notation of any deficits

• Examination of DTRs with nota-tion of any pathologic reflexes (e.g., Babinksi)

• Examination of sensation (e.g., by touch, pin, vibration, proprio-ception)

Psychiatric

• Description of patient’s judgment and insight

Brief assessment of mental status, which may include:

• Orientation to time, place, and person

• Recent and remote memory

• Mood and affect

Gastrointestinal (Abdomen)

• Examination of the abdomen with notation of presence of masses or ten-derness

• Examination of the liver and spleen • Examination for the presence or ab-

sence of hernias • Examination of anus, perineum, and

rectum, including sphincter tone, pres-ence of hemorrhoids, rectal masses

• Obtain stool for occult blood testing

Genitourinary (Male)

• Examination of the scrotal contents (e.g., tenderness of cord)

• Examination of the penis • DRE of the prostate

Genitourinary (Female)

• Examination of the external genitalia • Examination of the urethra • Examination of the bladder (e.g., full-

ness, masses, tenderness) • Examination of the cervix • Examination of the uterus (e.g., size,

contour, position, mobility) • Examination of the adnexa (e.g., masses,

tenderness, nodularity)

Musculoskeletal

• Examination of gait and station • Inspection and/or palpation of digits and

nails (e.g., clubbing, cyanosis, ischemia)

Examination of the joints, bones, and muscles of one or more of the following six areas:

1. Head and neck 2. Spine, ribs, and pelvis 3. Right upper extremity 4. Left upper extremity 5. Right lower extremity 6. Left lower extremity

The examination of a given area includes:

• Inspection and/or palpation with notation of presence of any mis-alignment, asymmetry, crepita-tion, defects, tenderness, masses or effusions

• Assessment of range of motion with notation of any pain, crepi-tation or contracture

• Assessment of stability with notation of any dislocation, sub-luxation, or laxity

• Assessment of muscle strength and tone with notation of any atrophy or abnormal movements

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1995 Exam Rules

♦Head/face ♦Neck ♦Chest/breast/axillae ♦Abdomen ♦Genitalia/groin/buttocks ♦Back/spine ♦Each extremity

♦Constitutional ♦Eyes ♦ENMT ♦Cardiovascular ♦Respiratory ♦GI ♦GU

♦Musculoskeletal ♦Skin ♦Neuro ♦Psychiatric ♦Hematologic-lymphatic

Problem Focused: a limited exam of affected body area or organ system Expanded Problem Focused: a limited exam of the affected body area or organ system and other symptomatic or related organ sys-tems Detailed: an extended exam of the affected body area or organ sys-tem and other symptomatic or related organ systems Comprehensive: a general multi-system exam or complete exam of a single organ system

Organ Systems Body Areas

The 1995 exam rules are included here for the sake of completeness. We recommend using the 1997 physical exam rules because they are

less open to individual interpretation and therefore more likely to stand up against an audit.

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Accounted for $11,155,924,872 in 200439% of E/M spendingFive levels of care99211 $21.0099212 $37.0099213 $52.0099214 $81.0099215 $117.00

Two out of three key components

Established Office Patients

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A “Routine” Office PatientYou see an established office patient with stable HTN, DM2 and dyslipidemia. There is also a history of CAD, which is well controlled.

You make no changes in medications and schedule return visit in four months.Time spent is 15 minutesWhat is this encounter worth?

1394.6

12412

23 0.8

101 1236

MA/Cr = 28, LDL 77, HgbA1c 6.8

Established Office Patients

40HighCompComp9921525ModDetailedDetailed9921415LowEPFEPF9921310SFPFPF992125NoneNoneNone99211

TimeMDMExamHistoryE/M Code

2 out of 3 key components must qualify

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Total

0

000New of established problem; no E/M mentioned and problem IS NOT clearly a co-morbid condition

Initial Problem Points

3

1 1

X ?

CAD

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Other – specifyReferral to another physician, consultationHospital admit – other physician(s) contactedHospital admitPt educated on self or home care topics/techniIM injection or other pain management proceduRadiation therapyConservative therapy: rest, ice, bandages, dietInsulin prescription (sc or combo sc/iv), hyperalIV fluidsClosed treatment for fracture/dislocationPhysical, occupational or speech therapyOpen or percutaneous procedureDrug management (more than 3 Δ’s)Drug management (new Rx or Δ dose)Continue same treatment and/or monitoring

Problems/Therapeutic Op



0New or established problem; no E/M mentioned and problem IS clearly a co-morbid condition


Final Problem Points

1 1

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•Drug therapy requiring intensive monitoring for toxicity•Obtain DNR or de-escalate care

factors•Cardiac EP studies•Diagnostic endoscopies, with identified risk factors

•One orwith sev•Acute or chronic illness or injury, which poses a threat to life or bodily function•An abrupt change in neurological status

High

•One chexacerb•Two st•Undiauncertai

Moderate

•Over the counter drugs•Minor surgery, with no risk factors•PT/OT•IV fluids, without additives

•Physiologic tests not under stress, e.g., PFTs•Non-cardiovascular imaging studies with contrast•ABG•Skin biopsies

•Two or more self-limited or minor problems•One stable chronic illness•Acute uncomplicated injury or illness, e.g., cystitis, allergic rhinitis, sprain

Low

•Rest•Gargles•Superficial dressings

•Laboratory tests •Chest X-rays•EKG/EEG, Echocardiogram

•One self-limited or minor problem, e.g., cold, insect bite, tinea corporis.

Minimal

Management Options

Diagnostic ProceduresPresenting ProblemsRisk

Discuss case with consultant or order consultation or discuss case with other physician managing patient

Physiologic monitoring

Order and/or summarize old records

Review/order clinical lab tests

Independent review of image, tracing, or specimen

Discuss test results with performing MD

Review/order tests in the medicine section (echo, EKLHC, PFTs)

Review/order X-rays

PointsData Reviewed

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Coding Based on Time

Adding Up the TrailBlazer MDM Points

Mo

StFo

MCo

Need

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In tcod

RequiredPresenceMDNo99211


Selecting the Target CodeEstablished Office Patients

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99214

25ModDetDet99214



ORNone1BriefEPF

1/32 – 9ExtDet

NoneNoneBriefPF

3/310ExtComp

PFSHROSHPIHx

6 – 11 from any systemsEPF

12 from any systemsDet

1 – 5 from any systemsPF

2 from EACH of NINE systemsComp

BulletsExam

How do you choose which one to do?

ModerateMDMExamHistoryTarget Code

tion

ualify

quires at om ANY

ur HPI of three lus 2 – 9 of PFSH

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99214Detailed HistoryDetailed ExamModerate MDM


Purpose-Driven Documentation

ModerateDetailedDetailed99214MDMExamHistoryTarget Code

In this example,

ModerateDetailedDetailed99214MDM

1/32 - 9ExtendedDetailedPFSHROSHPIHistory

CC: F/U HTN and DM2

Interval History: The patient’s HTN remains well controlled on

demia

eview of two ically relevant systems

mponent FSH

Status of Three ProblemsHTN, DM2, Dyslipidemia

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Physical ExaConstit ional Eyes ENMT Neck

Chest/Breasts

V

Skin

Musculoskeletal

Neurologic

1

ModerateDetailedDetailed99214MDMExamHistoryTarget Code

HEENT: No JVD or carotid bruits

Assessment1. Well controlled DM22. Well controlled HTN3. Stable dyslipidemia4. Underlying CAD

Plan1. Continue lisinopril unchanged for HTN2. Renal profile, Urine microalbumin, CBC on return3. Also check LFTs due to ongoing statin therapy4. Return visit in four months

Medical Decision-MakingHGBA1c = 6.8

0.812412

23101

two out of three

Here, only

.

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99214

Target Code History Exam MDM 99214 Detailed Detailed Moderate

Requires two out of three qualifying key components

CC: F/U HTN and DM2

Interval History: The patient’s s

is stable as well, with no sym a

remains stable on statin thera

PFSH is remarkable for CAD,

ROS CV: Negative for Che

Neuro: Negative for p

Vitals: 120/80, 18, 82, 98.6

General: NAD, conversant,

HEENT: No JVD, carotid bruit

Lungs: Clear to auscultation

CV: RRR, no MRG

Ext: No peripheral edema

s

H

OS cal

sed

y edema

iled exam)

Assessment

1. Well controlled DM2

2. Well Controlled HTN

3. Stable dyslipidemia

Plan

1. Continue lisinopril unchang

2. Renal profile, Urine microal

3. Also check LFTs due to ong

4. Return visit in four months

plexity e pres-out of matter

k

n

w

d

h

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Vitals: 120/80, 18, 82, General: NAD, conversLungs: Clear to auscultCV: RRR, no MRGAbd: Soft, non-tenderExt: No peripheral ede

CC: F/U HTN and DM2

Interval History: The patient’s HTN remains well controlled on current medications. Diabetes is stable as well, with nosymptomatic hypoglycemia or severe hyperglycemia. Dyslipidemia remains stable on statin therapy.

PFSH is remarkable for

ROS: CV: NegNeuro: N

Assessment1. Well controlled DM22. Well controlled HTN3. Stable dyslipidemia

Plan1. Continue lisinopril u2. Renal profile, Urine 3. Also check LFTs du4. Return visit in four m

2

Alternative Ending

99214Target Code

For established office patients, only two out of three qualifying key components are needed. In the above example,

The next page shows

how the documentation for this “alternative ending” might look.

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99214

Target 992

CC: F/U HTN

Interval Histor

Vitals: 120/80

General: NAD

HEENT: Anict

Neck: No JVD

Lungs: Clear

CV: RRR, no

Abd: Soft, no

Ext: No perip

Skin: Warm a

Assessment

1. Well contro

2. Well Contro

3. Stable dysli

Plan

1. Continue lis

2. Renal profil

3. Also check

4. Return visit

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MA/Cr =

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Accounted for a total of $4.9 billion in allowed charges in 2005This adds up to 16.5% of E/M spendingThree levels of care99231 $36.0099232 $64.0099233 $91.00

Requires documentation of 2 out of 3 key components

Hospital Progress Notes

35HighDetailedDetailed99233

25ModerateEPFEPF99232

15SF/LowPFPF99231


Only 2 out of 3 key components must qualify


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Hospital Progress NoteYou see a patient with CHF exacerbation which had been improving on oral diuretics. CAD has been stable on oral nitrates with no active chest pain.

You notice an empty bag of potato chips on the tray table. BP is 160/90, edema has worsened and patient c/o orthopnea requiring 2 liters NC O2 at rest. Echo report from yesterday shows an EF of 25%.You replete K+, change the patient to a strict 2 gram sodium diet, look at the CXR, order labs and repeat CXR for the a.m. You also change pt to IV Bumex.Total time spent is 25 minutes

©2005 Peter R. Jensen, MD, CPC

1383.1

12410

23 0.8

101 1236

BNP is 1450

Number of Diagnoses a

New or established proble

New or established probleproblem IS clearly a co-m

New of established probleproblem IS NOT clearly a

Initial Problem Points

0

H

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Other – specify

1

Pts #

Referral to another physician, consHospital admit – other physician(s) Hospital admitPt educated on self or home care toIM injection or other pain managemRadiation therapyConservative therapy: rest, ice, banInsulin prescription (sc or combo scIV fluidsClosed treatment for fracture/dislocPhysical, occupational or speech thOpen or percutaneous procedureDrug management (more than 3 Δ’Drug management (new Rx or Δ doContinue same treatment and/or monitoring

Problems/Therapeutic Options1

3

1

1



New or established problem; no E/M mentioned and problem IS clearly a co-morbid condition


Final Problem Points

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•One or mowith severe •Acute or cinjury, whicor bodily fu•An abrupt neurologica

High

•One chronexacerbatio•Two stable•Undiagnosuncertain pr

Moderate

•Over the counter drugs•Minor surgery, with no risk factors•PT/OT•IV fluids, without additives

•Physiologic tests not under stress, e.g., PFTs•Non-cardiovascular imaging studies with contrast•ABG•Skin biopsies

•Two or more self-limited or minor problems•One stable chronic illness•Acute uncomplicated injury or illness, e.g., cystitis, allergic rhinitis, sprain

Low

•Rest•Gargles•Superficial dressings

•Laboratory tests •Chest X-rays•EKG/EEG, Echocardiogram

•One self-limited or minor problem, e.g., cold, insect bite, tinea corporis.

Minimal

Management Options

Diagnostic ProceduresPresenting ProblemsRisk

Discuss case with consultant or order consultationdiscuss case with other physician managing patie

1Physiologic monitoring

1Order and/or summarize old records



Discuss test results with performing MD

Review/order tests in the medicine section (echo, LHC, PFTs)

Review/order X-rays

PointsData Reviewed

Total 4

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Selecting the Target Code

352515SF/LowPFPF99231





High≥ 4≥ 7HighMod35 - 6ModerateLow23 - 4Low

Minimal≤ 1≤ 2Straight Forward

RiskData Pts

Problem DDx

MDM Complexity


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Least frused cencounReimbuabout $

2 o

Time

99233

99233



99233

35HighDetDet99233


6 – 11 from any systemsEPF

12 from any systemsDet

1 – 5 from any systemsPF

2 from EACH of NINE systemsComp

BulletsExam

None1BriefEPF

1/32 – 9ExtDet

NoneNoneBriefPF

3/310ExtComp

PFSHROSHPIHx

OR

In this case, we knAND that we alreadperform and documaddition to our qualhow the documentaof the history.

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HPI: The patient says he fe

CC: F/U CHF

2 out

DetailedHistory

99233Target Code

DeDeHi

Rational Documentation

2 out of

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Plan: 1. D/C PO Lasix 2. Start IV Bumex 2 mg Q 6H3. Strict low Na+ diet4. Replete K+ per protocoll5. Repeat renal profile, BNP in a.m.6. Repeat CXR in a.m.

Me

Assessment: 1. Decompensated CHF 2. Poorly controlled HTN 3. Mild hypokalemia4. Stable CAD

CXR wshowevascul

0.81383.1

12410

28101 12

36

BNP 1450Echo:

DetailedDetailed99233ExamHistoryTarget Code

High

Mod

Low

SF

MDM

Re

Vitals: 160/90, 18, 82, General: NAD, well nouNeck: FROM, supple; nLungs: Bibasilar crackl

CV: RRR, no MRGs; nAbd: Soft, non-tender; Ext: 2+ peripheral ede

Skin: Warm and dry; w

Physical ExamConstitutional Eyes ENMT Neck

hest/Breasts

CV

Skin

sculoskeletal

Neurologic

Psychiatric

GI GULungs1 2 3 4 5 6 7 8 9 10

11

12

Requires AT LEAST12 bullets from ANYorgan systems

igh99233DMTarget Code

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s Risk

Min

Low

Mod

High

99233 Detailed Detailed High

CC:

Interv

HPI, ualify

Vitals

Gene

Neck

Lung

CV:

Abd:

Ext: 2

Skin:

ts:

edema

)

Asse

1. De

2. Po

3. Mil

4. Sta

Plan

1. D/

2. Sta

3. Str

4. Re

5. Re

6. Re

complexity based problem points n though risk is

sions

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CC: CHF

Interval History: TThe patient’ feels generally

Assessment1. Decompensated CHF2. Poorly controlled HTN3. Mild hypokalemia4. Stable CAD

Plan1. D/C PO Lasix2. Start IV Bumex 2 mg Q 6H3. Strict low Na+ diet4. Replete K+ per protocol5. Repeat renal profile and BNP in a.m.6. Repeat CXR in a.m.

t

ets

Echo: RCXR wpulmon

Vitals: 160/90, 18, 82, 98.6 General: NAD, conversant, Neck: FROM, supple; no JVDLungs: Bibasilar crackles; clear to percussioCV: RRR, no MRG; normal PMIAbd: Soft, non-tender; no HSM Ext: 2+ edema; no digital cyanosis Skin: Warm and dry; well perfused A

High

Mod

Low

Min

Risk

Deta99233HisTarget Code

Remember, for hospital progress note, only two out of three qualifying key components must be documented. In the above example,

next page shows how the documentation might look for this “alternative ending.”

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Targ9

CC: F/U HTN

Interval Histor

HTN is poorly

chest pain.

ROS CV: +

Pulmo

Lungs: Bibasil

CV: RRR, no

Ext: 2+ edema

Assessment

1. Decompens

2. Poorly contr

3. Mild hypoka

4. Stable CAD

Plan

1. D/C PO Las

2. Start IV Bu

3. Strict low N

4. Replete K+

5. Repeat ren

6. Repeat CX

sed ts is

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Accounted for $1.3 billion in allowed charges in 2005This adds up to 4.4% of E/M spendingThree levels of care99221 $84.0099222 $118.0099223 $172.00

Requires documentation of 3 out of 3 key components

Admission H&Ps


Documentation: Admission H&Ps

70HighCompComp99223

50ModerateCompComp99222

30SF/LowDetailedDetailed99221


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Admission H&P

You are on ER backup and asked to admit a 68 year old diabetic male with HTN and dyslipidemia who presents with chest pain. After reviewing the EKG, CXR and labs, you decide to admit the patient to a monitored bed in the CCU and consult cardiology.The chest pain improves with IV MSO4. You also order ASA, NTP and sliding scale insulin.Total time spent is 50 minutesWhat is the correct code and documentation?

Number of Diagnoses and

New or established problem

New or established problem; problem IS clearly a co-morbi

New of established problem; problem IS NOT clearly a co-

Initia

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Other – specifyReferral to another physician, consultationHospital admit – other physician(s) contactHospital admitPt educated on self or home care topics/teIM injection or other pain management proRadiation therapyConservative therapy: rest, ice, bandages,Insulin prescription (sc or combo sc/iv), hyIV fluidsClosed treatment for fracture/dislocationPhysical, occupational or speech therapyOpen or percutaneous procedureDrug management (more than 3 Δ’s)Drug management (new Rx or Δ dose)Continue same treatment and/or monitorin

Problems/Therapeutic

Number of Diagnoses and/or Managem

New or established problem and E/M is men

New or established problem; no E/M mentioproblem IS clearly a co-morbid condition

New of established problem; no E/M mentioproblem IS NOT clearly a co-morbid conditio

Final Proble

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•One or more chrwith severe exace•Acute or chronicinjury, which poseor bodily function•An abrupt changneurological statu

High

•One chronic illnexacerbation, •Two stable chron•Undiagnosed neuncertain prognos

Moderate

•Two or more selfminor problems•One stable chron•Acute uncomplicillness, e.g., cystitrhinitis, sprain

Low

•One self-limited problem, e.g., coltinea corporis.

Minimal

Presenting Risk

Discuss case with discuss case with o

Physiologic monito

Order and/or summ

Review/order clinic

Independent review

Discuss test results

Review/order tests LHC, PFTs)

Review/order X-ray

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E/


C

Ne

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Most used encouReimabout

3

Tim

99223

E/M Code

3

99233

E/M Code

BriefEPF

ExtDet

BriefPF

ExtComp

HPIHx

For this type of endocumented. Thisand document BOexam to maintain c

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• Qualifierecorde

• Qualifie

three c • At least

other s

Thi

ROS:

FH: Fatherand has Al

PMH: HTN

HPI: The pas “crushinsometimes

SH: Quit s

CC: Chest

9Targ

CoHis

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se at least two bullets from ormed and documented.

ultation of heart tion of heart

n minal Exam of liver/spleen

ction of skin tion of skin

ssment of affect ssment of orientation

mChest/Breasts

CV

Skin

Musculoskeletal

Neurologic

Psychiatric

GI GUungs

ST 2 H of NINE

10 11 12 13 14

15 16

17 18

19

stated ageERRLApalate

ar line

odules

HighmpMDMm

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Medical Decision-Making

1363.8 2

1

EKG showed LVH by voltage, NCXR was reviewed and showed

Assessment1. USA vs. AMI2. Stable HTN3. Stable DM2

Plan1. F/U enzymes ASAP2. Admit to monitored bed3. Start ASA, PPI, NTP a4. Sliding scale insulin5. Consult cardiology

Com99223HistoTarget Code

This example qualifies as beimaking due to the presence o

• Four or more pro• Four or more dat• High risk

Note: Even if we only had mocomplexity MDM because onlorder to qualify for any given l

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DM High

CC HP escribed as “cr is sometimes assIV

en HPI Elements on, Quality, Severity, Timing, ptoms, Modifying Factors

PM

mplete PFSH from all three components of and social history

FH:Alz

SH

RO

Complete ROS the accepted shortcut, “All other s reviewed and are negative.”

VitaGeEyHENeLunCVAbSkiPsy

Bullets Used onstitutional

Three vital signs General appearance

yes Exam of sclerae/lids Exam of pupils/irises

NT External appearance of ears/nose Exam of oropharynx

eck Exam of neck Exam of thyroid

ungs Auscultation of lungs Assess respiratory effort

V Auscultation of heart Palpation of heart

bdomen Abdominal Exam Exam of liver/spleen

kin Inspection of skin Palpation of skin

syche Assessment of affect Assessment of orientation

ualifies as a comprehensive exam)

Ass1. 2. 3.

Pla1. 2. 3. 4. 5.

M Prob Pts Data Pts Risk

≤ 2 ≤ 1 Min

3 - 4 2 Low

d 5 - 6 3 Mod

h ≥ 7 ≥ 4 High

EK

CX

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Determines the highest ethical level of care Driven by medical necessity Ensures 100% E/M compliance Saves time by avoiding over-documentationIncreases revenue by preventing undercodingFocuses on patient care

Rational Physician Coding

Peter R. Jensen, MD, CPC

Online and On-site Physician-to-Physician E/MCoding Education

1-888-U-EM-CODE

[email protected]

Practical E/M Coding Education

www.EMuniversity.com

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