UM

TA T

H E K

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REVISED MARCH 2020

Unless otherw ise noted, no part of this material may be reproduced, stored in a retrieval system, or transmitted, in w hole or in part, in any form, or by any means, to include but not limited to: electronic, mechanical, photocopying, recording or otherwise

w ithout w ritten consent of CU Medicine.

This pocket card was developed for providers and coders to use as a reference tool to assist in determining the levels of Evaluation and Management services. CU Medicine makes every effort to keep the information current and up to date to include the latest changes in the Center for Medicare and Medicaid (CMS) requirements.

EVALUATION & MANAGEM ENT DOCUMENTATION / 3 PRIMARY KEY COMPONENTS MEDICAL NECESSITY MUST BE CONSIDERED WHEN SELECTING LEVEL OF SERVICE

HISTORY EXAMINATION MEDICAL DECISION MAKING

CHIEF COMPLAINT- ALWAYS

HISTORY OF PRESENT ILLNESS

REVIEW OF SYSTEMS

PAST, FAMILY, SOCIAL

7 BODY AREAS

AND/OR

12 ORGAN SYSTEMS

NUMBER OF DIAGNOSES

OR MANAGEMENT

OPTIONS

AMOUNT AND/OR

COMPLEXITY

OF DATA

RISK OF

COMPLICATIONS,

MORBIDITY, MORTALITY

NEW INITIAL VISIT: MUST DOCUMENT HISTORY + EXAMINATION + MEDICAL DECISION MAKING ESTABLISHED/FOLLOW UP VISIT: MUST DOCUMENT 2 OF THE 3 KEY COMPONENTS: HISTORY OR EXAMINATION AND

MEDICAL DECISION MAKING

Severity of Presenting Problem Counseling and/or

Coordination of care

Average Time

(attending time)

minimal self -limited or minor

low

moderate high

diagnostic results, prognosis, risks or benef its, instruction

f or management, importance of

compliance, risk f actor reduction, patient and f amily education

phy sician/patient encounter

outpatient f ace-to-f ace time

inpatient: f loor/unit time

TIME AS CONTROLLING FACTOR When counseling and/or coordination of care dominates (more than 50% of the total time), time may be considered the key or control ling f actor to qualif y f or a

particular lev el of E/M serv ices. Documentation should include the total time of the encounter as well as the time spent in counseling. Example: “Today I spent 25 minutes with the patient and 15 minutes of that time was spent counseling.” Documentation must also include a summary of the discussion.

HISTORY

Chief Complaint mostly a short, concise statement of why the patient is seen.

HPI = History of Present Illness Chronological description of development

of i l lness that can be classified into elements that will reflect an accurate

picture of the patient’s condition. OR the status of chronic conditions of a

patient also qualifies. The following 8 elements are defined:

1. Associated signs and symptoms- has a fever of 102.2, no rash, no cough, colicky 2. Location- where on the body (upper, left, right, bilateral) 3. Quality- description of symptom (throbbing, sharp, radiating, acute or chronic) 4. Sev erity- (child fussy today, increased fever, extremely red throat, pain scale from (1-10) 5. Timing- vomited overnight, rash appears after eating fruit, occasional diarrhea 6. Context- description of where or what patient is doing (running at school, bit by dog while playing, occurred at daycare) 7. Duration- how long (for the last 2 hours, no voiding since am)

8. Modifying factors- what has been done to relieve symptoms, what makes them worse (MOC gave Tylenol, applied heat or cold, was exposed to flu or virus) If documenting the status of 1 – 3 chronic conditions each condition must be summarized, as shown in the following examples:

1. Diabetes well controlled 2. HTN need to continue monitoring 3. Dermatitis under control and patient seen regularly in Dermatology clinic

ROS= Rev iew of Systems An inventory of body systems obtained by questions seeking to identify signs and/or symptoms. Symptoms with positive or pertinent negative responses must be documented. Examples of statements follow: Normal, negative responses such as: 1. Constitutional- not afebrile, no

chills 2. GI - no nausea, no vomiting 3. Skin- no rashes, no lesions 4. Allergy/immuno- no seasonal allergies

Abnormal/positive responses such as: 1. Constitutional- positive for fatigue and night sweats 2. GI- positive for diarrhea 3. Skin- recent development of rash and itching 4. All/immuno- penicillin; rash

PFSH= Past, Family and Social History 1. Past- patient’s i l lnesses, operations, injuries and treatments includes meds and immunizations. MOC status at birth. 2. Family-health status of parents, siblings. Disease related to current patient problems. 3. Social- An age appropriate review of past and current activities, l iving arrangements, # of family members, school details, drug alcohol habits of patient or MOC, occupation history. If documented by ancillary staff use .UPIPASTHX to recognize you have

reviewed, verified and agree with the PFSH.

If unable to obtain a history from the patient/other source, the medical record should detail the patient’s condition or other circumstance which precludes obtaining the history. Reasonable efforts must be made to obtain history.

EXAMINATION

Understand the difference between “Expanded Problem-Focused” (EPF)

and “Detailed” (D) examination under 1995/1997 guideline requirements: The difference is not the number of systems examined. 2-7 body area/systems are required for both examinations. The difference is the detail in which the examined systems are described. EPF= 2-7 or total range of bullets must equal 6-11, D= 2-7 and bullets must equal 12+. For unaffected or

asymptomatic organ systems, “normal“, “negative” or “WNL” documentation is acceptable. Always examine the system(s) related to the presenting problem and do not describe it as “normal” or “negativ e.” You may document either a general multi-system exam (as referenced throughout this pocket card) or a complete single specialty exam.

MEDICAL DECISION MAKING Need to meet 2 of the 3 areas to determine MDM. Use points from 2 of the 3 categories to determine overall medical decision making.

1. Number of Diagnosis or Management Options

Categories of problems (to the examiner) as follows: Self-limited or minor problem (1 point — Max=2) Established problem that is improv ed, well controlled (1 point) Established problem, other than self-limited that is worsening or inadequately controlled (2 points) New problem/without additional workup planned (3 points — Max=1) New problem/with additional workup planned (4 points) You may use a combination of points to reach total points for management options.

Minimal (1 point) Limited (2 points) Multiple (3 points) Extensive (4 or more points)

2. Amount and/or Complexity of Data Order/review of services in pathology/lab (1 point) Order/review tests or services in radiology (1 point) Order/review studies or services of medicine (1 point) Direct v isualization/interpretation of specimen, image or tracing (2 points) Discussion of test results with performing physician (1 point) Decision to obtain old records/history (1 point) Summarization of review of old records or additional history from other sources (2 points) You may use a combination of points in this category to reach total points.

Minimal (1 point) Limited (2 points) Multiple (3 points) Extensive (4 or more points)

3. Risk of Significant Complications and/or Morbidity or Mortality

The risk can be determined by either the presenting problems, diagnostic procedures ordered or management options selected. The highest lev el of risk in any one of these categories determines the overall risk. Refer to the E/M guidelines for the complete table of risk.

Minimal Risk Low Risk Moderate Risk High Risk

TABLE OF RISK

Level of

Risk

Presenting Problem(s) Diagnostic Procedure(s)

Ordered

Management Options

Selected

Minimal

One self –l imited or minor problem, eg.

cold, insect bite, tinea corporis

Laboratory tests requiring venipuncture,

PKU Chest x-rays

EKG/EEG Urinalysis

Ultrasound, eg. echo-cardiography KOH prep

Rest

Gargles Elastic bandages Superficial dressing Cool mist humidifier

Low

Two or more self-l imited or minor problems

One stable chronic il lness, eg. well-controlled hypertension, non-insulin dependent diabetes, cataract, BPH

Acute uncomplicated illness or injury, eg. cystitis, allergic rhinitis, simple sprain, diaper rash, jaundice

Physiologic tests not under stress, eg. pulmonary function tests, urodynamic testing

Non-cardiovascular imaging studies with contrast, eg. barium enema

Superficial needle biopsies, cervical bx

colposcopy Clinical laboratory tests requiring

arterial puncture

Skin biopsies

Over-the-counter drugs

Minor surgery with no identified risk factors

Circumcision

Physical therapy Occupational therapy IV fluids without additive Phototherapy Gavage feedings

Moderate

One or more chronic il lnesses with mild

exacerbation, progression, or side effects of treatment

Two or more stable chronic illnesses Undiagnosed new problem with uncertain

prognosis, eg. lump in breast Acute il lness with systemic symptoms, eg.

pyelonephritis, pneumonitis, croup, colitis Acute complicated injury, eg. head injury

with brief loss of consciousness

Physiologic tests under stress, eg.

cardiac stress test, fetal contraction stress test

Diagnostic endoscopies with no identified risk factors, eg. bronch, ERC, colonoscopy

Deep needle or incisional biopsy, colposcopy w/ bx

Cardiovascular imaging studies with contrast and no identified risk factors eg. arteriogram, cardiac catheterization

Obtain fluid from body cavity eg. lumbar puncture, thoracentesis, culdocentesis

Minor surgery with

identified risk factors Elective major surgery (open,

percutaneous or endoscopic) with no identified risk factor

Prescription drug management Therapeutic nuclear medicine IV fluids with additive Closed treatment of fracture or

dislocation without manipulation

High

One or more chronic il lnesses with severe exacerbation, progression, or side effects of treatment

Acute or chronic il lnesses or injuries that pose a threat to life or bodily function, eg. multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, RSV broncholithiasis, progressive severe rheumatoid arthritis, psychiatric i l lness with potential threat to self or others, peritonitis, acute renal failure, acute gastroenteritis w/ dehydration

An abrupt change in neurologic status, eg. seizure, TIA, weakness, sensory loss

Cardiovascular imaging studies with contrast with identified risk factor

Cardiac electrophysiological tests Diagnostic endoscopies with

identified risk factors Discography

Elective major surgery (open, percutaneous or endoscopic) with identified risk factor

Emergency major surgery (open, percutaneous or endoscopic)

Parenteral controlled substances eg. TPN

Drug therapy requiring intensive monitoring for toxicity eg. chemo, rheum, cardio, drugs, Methotrexate, Remicade, Amiodarone

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

OBSERVATION CARE

NEW OR ESTABLISHED PATIENT (must document history, examination and medical decision making)

Severity of Problem Low Moderate High

*For Codes 99218, 99219 and 99220 average time respectively is 30 minutes, 50 minutes, 70 minutes. **For Codes 99234, 99235 and 99236 average time respectively is 40 minutes, 50 minutes, 55 minutes.

Medical necessity must always be considered when selecting a level of service. When documenting the ROS f or billing purposes, each sy stem rev iewed must be specif ically referenced

documented)

Hospital determines if serv ice is classified as observ ation care. 99218, 99219, and 99220 i f the observation stay is under 8 hours or spans more than one calendar date (midnight). (i.e. The admitting provider bil ls only the initial observation code 99218-99220 if the patient is admitted and discharged from observation care less than 8 hours on the same calendar date. No discharge code can be reported with these codes). 99217 observation care discharge – Code to report all services provided to patient on discharge from observation status if the discharge is on other than the initial date of observ ation status. When an observation care visit is less than 8 hours but care continues to the next calendar day (midnight) bil l 99217 discharge for the following calendar day. 99234, 99235, and 99236 if admitted and discharged from observation on same calendar date and stay is at least 8 hours. Codes include both admission and discharge from observation. Documentation must support the length of the stay in observation care.

Level 1 Level 2 Level 3

HISTORY

CC

HPI

ROS PFSH

EXAMINATION

Organ System or Body Area

MEDICAL DECISION COMPLEXITY Num of Dx/Mgt Option Data Review Risk

99218* or 99234** Detailed

Chief Complaint Extended 4-8 or Status of 3 chronic conditions

Extended 2-9 Pertinent 1 or 2

Detailed extended and related (2-7 organ/body) with (12-17 bullets)

Straight Forward/Low

Limited-1-2 Limited-1-2

Low

99219* or 99235** Comprehensive Chief Complaint

Extended 4-8 or Status of 3 chronic conditions

Complete 10+ Complete 3

Comprehensive multiple (8+) or complete single

(18+ bullets)

Moderate

Multiple-3 Multiple-3 Moderate

99220* or 99236** Comprehensiv e Chief Complaint

Extended 4-8 or Status of 3 chronic conditions

Complete 10+ Complete 3

Comprehensive multiple (8+) or complete single

(18+ bullets)

High

Extensive-4 Extensive-4

High

Subsequent

observation codes are only to be used by the

admitting service.

SUBSEQUENT OBSERVATION CARE (must document 2 of 3 key factors; history, examination and medical decision making)

Level 1 Level 2 Level 3

HISTORY

CC

HPI

ROS PFSH

EXAMINATION Organ System or Body Area

MEDICAL DECISION COMPLEXITY Num of Dx/Mgt Option Data Review Risk

99224 Problem Focused Interv al

Chief Complaint Brief 1-3 or Status of 1-2

chronic conditions

------- -------

Problem Focused Limited

(1 organ/body) (1-5 bullets)

Straight Forward/Low Limited-1-2 Limited-1-2

Low

99225 Expanded Problem Interv al

Chief Complaint Brief 1-3 or Status of 1-2

chronic conditions Problem Pertinent

-------

Expanded Problem

Limited or related (2-7 organ/body)

(6-11 bullets)

Moderate Multiple-3 Multiple-3

Moderate

99226 Detailed Interv al

Chief Complaint Extended 4-8 or Status of

3 chronic conditions

Extended 2-9 -------

Detailed

Extended and related (2-7

organ/body) with (12-17 bullets)

High

Extensive-4 Extensive-4

High

Average Time 15 minutes 25 minutes 35 minutes

Outpatient: WHEN SPENDING GREATER THAN 50% OF THE TOTAL FACE/FACE VISIT IN COUNSELING, LEVEL OF SERVICE CAN BE SUPPORTED BY TOTAL

FACE/FACE TIME (TIMES NOTED FOR EACH LEVEL ABOVE). DOCUMENT TOTAL TIME AND TIME SPENT IN COUNSELING W ITH A SUMMARY OF DISCUSSION.

Inpatient: WHEN SPENDING GREATER THAN 50% OF THE TOTAL VISIT FACE/FACE AT BEDSIDE AND ON HOSPITAL UNIT/FLOOR IN COUNSELING, LEVEL OF SERVICE

CAN BE SUPPORTED BY TOTAL TIME (TIMES NOTED FOR EACH LEVEL ABOVE).

GENERAL RULES

1. The following are some potential risks associated with the use of an EMR system;

• Inaccurate or outdated information that may adversely impact patient care

• Documentation may not clearly reflect the author or their personal information of a clear indication that copied findings have been reviewed,

confirmed, performed and edited

• Inability to identify when the documentation was created or the correct date of service

• Inability to accurately support or defend E/M codes

• Propagation of false information

• Internally inconsistent or unnecessarily lengthy progress notes

2. Definitions of Scribes-Documentation Requirements

• A scribe essentially follows the doctor around and writes, word-for-word, what the doctor says as they are examining the patient. A scribe may not prompt a provider for unsolicited documentation.

• Medical Students, Residents, or Fellows may not act as a "scribe" for another provider.

• The documentation must clearly identify the provider who performed the service.

• A scribe may not document the attending/supervising provider's tie-in statement or physical presence statement.

• Scribed services may be performed in any setting; excluding operating cases and sedation procedures.

• When a nurse, APP or other employee acts as a scribe for a physician, the medical record must clearly reflect who performed the service,

who recorded the service and the qualifications (i.e., professional degree, medical title, etc.) of each individual.

• The documentation must be signed by both the "scribe" and the rendering provider.

Shared Services

To support the bil l ing of a split/ shared service between a MD and an APP, each provider must document their respective face-to-face involvement with the patient. The MD must document at least one element of the E/M component. A tie-in or co-signature by the MD attached to a APP’s note

will not support a split/ shared service. The shared service concept does not apply to critical care, consultations, procedural services or E/M services

performed in the skil led nursing facility (SNF).

The CU Medicine recommended smart phrase for physicians should use when documenting split/shared services is .UPISHARE

“I saw @FNAME@, reviewed the case and collaborated with ***, {SELECT APP’S CREDENTIALS:25781} in develop ing the assessment and plan. My involvement with @FNAME@ includes {Document Provider Portions: 25782}. My assessment includes ***. Signed by: @MEMD@. @TD@,

@NOW@

3. Precharting Any precharted information must be reviewed, updated and verified on the date of service with the patient and must be reflected in the note.

4. Copy/Paste

• Add patient specific information about the date of service; this information must be relevant to the patient on the current date of service.

• When copying history (CC, HPI, ROS, PFSH) from another provider, include the approved smart phrase .UPIPASTHX “I have reviewed and

verified history with the (USE THE APPROPRIATE DROPDOWN)”.

• When copying another provider’s exam, the original author and date of the original encounter must be documented.

5. EMR Note Functionality

• Information in macros, smart blocks, phrases, etc. should be provided by a positive action and not by defaulting to normal findings.

• The time statement and attestation must be a positive action.

6. Addendums

• Addendums should only be documented when medically appropriate.

• Addending medical records to meet payment policy guidelines is prohibited.

• Co-signature only is not a bil lable service.

• Documentation addendums to E&M services will not be allowed for bil ling after 24 hours from the date of completion of the E&M note.

• Communication from a coder and/or an auditor to a provider submitting an operative report/procedural code/diagnostic code, where objective evidence exists and to clarify a particular code in a given code set from either a physician directed or abstracted encounter , documentation

addendums will be allowed up to 10 days from the date of service.

For questions on documentation and billing requirements please contact Audit, Compliance and Education at

ACEAuditEd@cumedicine.us.