Evaluation and Management Services Presentation

 After this presentation, you should be able to:

› Know that E/M stands for

› Know the 3 components of the E/M

› Distinguish different categories of E/M

› Understand levels of complexity

› Level Medical Decision Making

› Know when modifiers apply (and look them up)

› Appropriately document according to E/M level

 E/M

› Professional face-to-face service between doctor and patient

› Documentation to support the above

›

›

›

›

S: History

O: Physical

A: Decision Making

P: Decision Making

 Categories of E/M Services

 Elements of the E/M Visit

 Modifiers

PPO patient seen by your partner last year, consult requested by the ED, you see the patient and document

 Encounter type?

A.

B.

C.

D.

E.

Hospital/inpatient new

Hospital/inpatient consultation

Office/outpatient new

Office/outpatient consultation

Office/outpatient established

PPO patient seen by your partner last year, consult requested by the ED, you see the patient and document

 Encounter type?

A.

B.

C.

D.

E.






Medicare patient seen by your partner last year, consult requested by the ED, you see the patient and document

 Encounter type?

A.

B.

C.

D.

E.






Medicare patient seen by your partner last year, consult requested by the ED, you see the patient and document

 Encounter type?

A.

B.

C.

D.

E.






Medicare patient never seen by you or your partner, consult requested by the ED, you see the patient and document

 Encounter type?

A.

B.

C.

D.

E.






Medicare patient never seen by you or your partner, consult requested by the ED, you see the patient and document

 Encounter type?

A.

B.

C.

D.

E.






 Office or other outpatient (includes ED)

› New (requires all 3 key components)

› Established (2 of 3 components)

 Hospital inpatient

› Initial hospital care (3 components)

› Subsequent hospital care (2 of 3 components)

› Hospital discharge

 Consultations

› Office or other outpatient

› Initial inpatient

 Office or other outpatient

› New (requires all 3 key components of E/M)

 Never seen by your group

 Seen by you or group member more than 3 years ago

› Established (2 of 3 components of E/M)

 Not New visit

 Not Consultation

 Consultations

› Definition

 “A consultation is defined as a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.”

 Consultations

› Guidelines

 The consultant’s opinion is requested by another physician

 Documentation of verbal or written request

 Documentation of consultant’s opinion

 Consultant may initiate treatment

 Communication of consultant’s opinion to the requesting physician

 Consultations

› Situations

 Requests between physicians of the same group

 Report consultation code if guidelines are met

 Initiation of treatment

 Usually stems from medical decision making portion of the E/M service

 “Even though treatment is initiated, the initial service is still considered a consultative visit.”

 If the consulting physician assumes care, the initial service should be reported as a consult.

 Consultations

› Medicare eliminated this whole category



 Modifiers

Wrist pain, dull, constant, with numbness

ROS Gen: weight gain, CV: none

H/O DM

 History type?

A.

Problem focused (level 1)

B.

C.

D.

Expanded problem focused (level 2)

Detailed (level 3)

Comprehensive (levels 4 and 5)

Wrist pain, dull, constant, with numbness

ROS Gen: weight gain, CV: none

H/O DM

 History type?

A.


B.

C.

D.


Detailed (level 3)


 Detailed level

› HPI-ROS-PFS

4-2-1

Wrist pain, sharp, dull, throbbing, aching

ROS 10+

PMH: none, PSH: none, Meds: none

 History type?

A.


B.

C.

D.


Detailed (level 3)


Wrist pain, sharp, dull, throbbing, aching (2 elements)

ROS 10+

PMH: none, PSH: none, Meds: none

 History type?

A.


B.

C.

D.


Detailed (level 3)


Wrist pain, constant, worsening, with numbness

ROS 10+

PMH: none, FHx: Heart disease, SocHx: +EtOH

 History type?

A.


B.

C.

D.


Detailed (level 3)


Wrist pain, constant, worsening, with numbness

ROS 10+

PMH: none, FHx: Heart disease, SocHx: +EtOH

 History type?

A.


B.

C.

D.


Detailed (level 3)


 History

› CC (1 element)

 Describe reason for visit

 Every visit must have the CC stated

 History

› HPI (4 elements)

 Location: site of the problem

 Quality: sharp, dull, throbbing

 Severity: minor, moderate, severe

 Duration: intermittent, constant

 Timing: with exercise, nightly, after meals

 Context: worsening, recurrent

 Modifying factors: rest, heat, cold, elevation

 Associated symptoms: numbness, tingling

 History

› ROS (10 elements)

 Constitutional

 Eyes

 Ear, nose, throat

 Cardiovascular

 Respiratory

 Gastrointestinal

 Genitourinary

 Musculoskeletal

 Integumentary

 Neurologic

 Psychiatric

 Endocrine

 Hematologic

 Immunologic

 History

› PFSH (3 elements)

 Past history

 Illnesses

 Operations

 Allergies

 Family history

 Social history

 Occupation

 Tobacco and alcohol use

History

Problem focused

Expanded problem

Detailed

Comprehensive

1

1

CC

1

1

HPI

1-3

1-3

4

4

ROS

0

1

2-9

10

PFSH

0

0

1

3

No distress, intact cap refill in all fingers

B UE: nontender except over palpable dorsal wrist mass, functional ROM, no dislocations, no atrophy, no wounds

 Exam type?

A.

B.

C.

D.



Detailed (level 3)


No distress, intact cap refill in all fingers

B UE: nontender except over palpable dorsal wrist mass, functional ROM, no dislocations, no atrophy, no wounds

 Exam type?

A.

B.

C.

D.



Detailed (level 3)


 Physical examination—Musculoskeletal

› Constitutional (2 elements)

› Cardiovascular and/or lymphatic (1 element)

› Musculoskeletal (17 elements)

› Skin (4 elements)

› Neuropsychiatric (5 elements)


› Constitutional (2 elements)

 Vital signs (any 3 of the following items)

 Temperature

 Pulse

 Respiration

 Blood pressure

 Height

 Weight

 General appearance


› Cardiovascular and/or lymphatic (1 element)

 Pulse

 Capillary refill

 Skin perfusion

 Edema

 Lymph node palpation


› Musculoskeletal (17 elements)

 Gait examination

 In 4 of 6 body areas:

(head/neck, trunk, 4 extremities)

 Inspect/palpate

 Assess ROM

 Assess stability

 Assess strength, tone, atrophy, or spasticity


› Skin (4 elements)

 In 4 of 6 body areas:

(head/neck, trunk, 4 extremities)

 Inspection and/or palpation


› Neuropsychiatric (5 elements)

 Coordination

 Reflexes (deep tendon or pathologic)

 Sensation

 Orientation

 Mood and affect

Physical examination

Problem focused

Expanded problem

Detailed

Comprehensive

Elements

1

6

12

All

Problem: New fracture, HTN, DM

Risk: Major surgery with risk factors

Data: Reviewed films

 Decision type?

A.

Straightfoward (levels 1 and 2)

B.

C.

D.

Low (level 3)

Moderate (level 4)

High (level 5)

Problem: New fracture, HTN, DM (HIGH)

Risk: Major surgery with risk factors (HIGH)

Data: Reviewed films (LOW)

 Decision type?

A.


B.

C.

D.

Low (level 3)

Moderate (level 4)

High (level 5)

Problem: F/U fracture with displacement

Risk: ORIF

Data: Reviewed films

 Decision type?

A.


B.

C.

D.

Low (level 3)

Moderate (level 4)

High (level 5)

Problem: F/U fracture with displacement (LOW)

Risk: ORIF (MOD)

Data: Reviewed films (LOW)

 Decision type?

A.


B.

C.

D.

Low (level 3)

Moderate (level 4)

High (level 5)

Problem: New onset numbness, DM stable

Risk: Major surgery

Data: Read EMG report

 Decision type?

A.


B.

C.

D.

Low (level 3)

Moderate (level 4)

High (level 5)

Problem: New onset numbness, DM stable (HIGH)

Risk: Major surgery (MODERATE)

Data: Read EMG report (STRAIGHTFORWARD)

 Decision type?

A.


B.

C.

D.

Low (level 3)

Moderate (level 4)

High (level 5)

 Decision making

› Number of diagnosis/management options

› Risk of complications

› Amount/complexity of data reviewed

 Decision making

› Number of diagnosis/management options

 Self-limited or minor problem

 Established problem

 Worsening problem

 New problem, no additional workup

 New problem, additional workup planned

2

3

4

1

1

 Add up points

 Score = 1, 2, 3, 4+

 Decision making

› Risk of complications

 Minimal

 Suture removal, lab tests, rest

 Low

 Two minor problems, sprain, order PT/OT, minor surgery without risk factors

 Moderate

 Two chronic illness, CT, MRI, aspiration, Rx, fx management, major surgery without risk factors, minor surgery with risk factors

 High

 Illness with severe exacerbation, abrupt neurological change, major surgery with risk factors, emergency surgery

 Decision making

› Amount/complexity of data reviewed



 Order test

Review test result

1

1

 Discuss test with performing physician 1

 Decide to obtain records 1

 Review and summarize records

 Review x-ray or specimen

2

2

 Add up points

 Score = 1, 2, 3, 4+

Decision making

(2 of 3)

Options

Straightforward 1

Low complexity

Moderate complexity

High complexity

2

3

4

Risk

Minimal

Low

Moderate

High

Data

1

2

3

4

 How do you decide level of service?

› Components

 History

 Physical examination

 Decision making

› New patients and consultations

 Need all 3 components

 Code for lowest component

› Established patients

 Code for 2 out of 3 components

New or

Consult

Level 1 Level 2 Level 3 Level 4 Level 5

History

Problem focused

Expanded problem

Detailed

Comprehensive

Comprehensive

Physical

Exam

Problem focused

Expanded problem

Detailed

Decision making

Straightforward

Comprehensive

Comprehensive

Straightforward

Low complexity

Moderate complexity

High complexity

Return Level 1 Level 2 Level 3 Level 4 Level 5

History None

Physical

Exam

Decision making

None

None

Problem focused

Expanded problem

Detailed

Comprehensive

Problem focused

Expanded problem

Detailed

Comprehensive

Straightforward

Low complexity

Moderate complexity

High complexity



 Modifiers

 What are modifiers?

› Modifiers indicate that a service or procedure has been altered by circumstance but not changed in definition

 How are modifiers reported?

› Two digits appended to CPT code

 Example: 99214-25

Patient presents with new finger triggering after carpal tunnel release

 Codes?

A.

B.

C.

D.

Postop-24 (unrelated E/M during postop)

Return-24

Postop-25 (separate E/M on day of procedure)

Return-25

Patient presents with new finger triggering after carpal tunnel release

 Codes?

A.

B.

C.

D.

Postop-24 (unrelated E/M during postop)

Return-24

Postop-25 (separate E/M on day of procedure)

Return-25

New patient seen in ED for radius fracture, and then taken to surgery the same day

 Codes?

A.

B.

C.

D.

E.

Inpatient consult and surgical code (radius ORIF)

Outpatient consult and surgical code

Inpatient consult-57 (decision for major surgery) and surgical code

Outpatient consult-57 and surgical code

Surgical code only

New patient seen in ED for radius fracture, and then taken to surgery the same day

 Codes?

A.

B.

C.

D.

E.





Surgical code only

New patient seen in ED for radius fracture, and then decision to schedule surgery next week

 Codes?

A.

B.

C.

D.

E.





Surgical code only

New patient seen in ED for radius fracture, and then decision to schedule surgery next week

 Codes?

A.

B.

C.

D.

E.





Surgical code only

 CPT modifiers

-21: Prolonged E/M services

-24: Unrelated E/M during postop period

New problem, management of complication, etc.

-25: Significant and separate E/M on the same day of procedure

Note: chief complaint should be different than diagnosis, and procedure should be separately documented from the E/M note

-57: Decision for surgery

Appended to E & M code that resulted in the decision for surgery

 Leveling an E/M visit

› 58 y/o RHD male

› Motorcycle accident

› Left wrist pain


› History (comprehensive)

 CC (1)

 Left wrist injury

 HPI (4)

 58 y/o RHD male sustains a motorcycle injury (context) this morning (timing), and has sharp pain (quality) in the left wrist

(location).

 ROS (10)

 PFSH (3)

 The patient has hypertension (past). Family history includes heart disease (family). He smokes 1 ppd x 23 yrs (social).


› Physical examination (comprehensive)

 Constitutional (2)

 T: 98.4, P 72, B/P 152/90 (3 vital signs)

 The patient appears well developed and is in moderate distress

(general appearance).

 Cardiovascular (1)

 He has good capillary refill in all fingertips of the left hand without lymphedema.



 Musculoskeletal (17)

 The patient is on bedrest, and gait cannot be examined (1).

 Examination of the left upper extremity shows gross deformity at the wrist (1). ROM (1) and strength (1) is decreased due to pain. There is no joint laxity but definite motion across the fracture site (1) on examination.

 Examination of the right upper and bilateral lower extremities reveals no tenderness (3), functional ROM (3), no dislocations

(3), and no atrophy/weakness (3).



 Skin (4)

 No wounds are present on bilateral upper (2) and bilateral lower extremities (2).

 Neuropsychiatric (5)

 Patient has normal fine motor control (coordination). Babinski is symmetrically downgoing (reflex). He has intact sharp-dull differentiation to the radial, median, and ulnar nerve distributions of the left hand (sensation). He is oriented person, place, and time (orientation). His mood and affect are appropriate (mood and affect).


› Decision making (2 of 3 components)

 Number of options

 This patient presents with a new problem, and no further workup is necessary (3 points). He also has HTN, which is stable at this time (1 point). HIGH

 Risk of complications

 I recommend major surgery, with open treatment. His risk factors include HTN and tobacco use. HIGH

 Complexity of data

 I ordered x-ray films (1 point), and have personally reviewed them. The findings show a left distal radius fracture with intraarticular comminution (2 points). MODERATE


Decision making (2 of 3) Options

Straightforward

Low complexity

Moderate complexity

High complexity

3

4

1

2

Risk

Minimal

Low

Moderate

High

Data

3

4

1

2


New patient Level 1 Level 2 Level 3 Level 4 Level 5

History

Problem focused

Expanded problem

Detailed

Comprehensive

Comprehensive

Physical Exam

Problem focused

Decision making

Straightforward

Expanded problem

Straightforward

Detailed

Comprehensive

Comprehensive

Low complexity

Moderate complexity

High complexity

 Selecting the correct category

 A 30 y/o patient presents to your office for redness and swelling in the forearm. You obtain the history, perform examination, and order blood tests. You admit the patient on the same day for treatment. After completion of your office hours that day, you see him in the hospital.


 A 30 y/o patient presents to your office for redness and swelling in the forearm. You obtain the history, perform examination, and order blood tests. You admit the patient on the same day for treatment. After completion of your office hours that day, you see him in the hospital.

›

›

You will not separately report the office visit and the initial hospital care.

Only the initial hospital care (99221-99223) is reported.


 A 30 y/o patient presents to your office on Wednesday for redness and swelling in the forearm. You obtain the history, perform examination, and order blood tests.

You admit the patient on the same day for treatment.

On Thursday, you make rounds and see him as an inpatient. The patient is seen again on Friday.


 A 30 y/o patient presents to your office on Wednesday for redness and swelling in the forearm. You obtain the history, perform examination, and order blood tests.

You admit the patient on the same day for treatment.

On Thursday, you make rounds and see him as an inpatient. The patient is seen again on Friday.

›

›

›

You report the Wednesday office E/M code (99201-99205).

You also report the appropriate initial hospital care code (99221-99223) for

Thursday, which is when you had his first inpatient encounter.

Rounds on Friday will be reported as subsequent hospital care (99231-

99233).


 Dr. A (ED physician) requests your opinion and advice regarding the patient’s displaced tibia fracture. The request and the need for the consultation are documented. You perform the consultation, document your opinion and advice, and communicate this opinion and advice to Dr. A. You then assumes responsibility for the management by taking her to the OR the same day.


 Dr. A (ED physician) requests your opinion and advice regarding the patient’s displaced tibia fracture. The request and the need for the consultation are documented. You perform the consultation, document your opinion and advice, and communicate this opinion and advice to Dr. A. You then assumes responsibility for the management by taking her to the OR the same day.

›

›

You report your E/M services as an office or other outpatient consultation

(99241-99245), with -57 modifier appended.

You also report the procedure code for treatment of tibial fracture using intramedullary device (27759).

 Modifiers

 Your patient presents for post-op visit after R carpal tunnel release. At the same visit, he brings up a new complaint of L long finger stiffness and triggering, worse in the morning.

 Modifiers

 Your patient presents for post-op visit after R carpal tunnel release. At the same visit, he brings up a new complaint of L long finger stiffness and triggering, worse in the morning.

›

›

›

For post-op visit, the E/M code is usually 99024.

But he has a new complaint, unrelated.

The E/M code for the L long finger trigger should be reported, with modifier:

99213-24.

 Modifiers

 Your patient presents for post-op visit after R carpal tunnel release. At the same visit, he brings up a new complaint of L long finger stiffness and triggering, worse in the morning. You decide to inject the L long finger with Kenalog, and you perform the procedure in your office.

 Modifiers

 Your patient presents for post-op visit after R carpal tunnel release. At the same visit, he brings up a new complaint of L long finger stiffness and triggering, worse in the morning. You decide to inject the L long finger with Kenalog, and you perform the procedure in your office.

›

›

›

The E/M code for the L long finger trigger should be reported (99213).

 Because this is within the post-op period, add modifier -24.

 For decision for minor office procedure, add modifier -25.

Report the injection of tendon sheath (20550).

 Unrelated procedure during post-op period (-79).

Final code set: 99213-24-25, and 20550-79.

 History

 CC

 HPI (4)

 ROS (10)

 PFSH (3)

 Examination

 General, cardiovascular, gait, 4/6 extremities, skin, neuropsychiatric (29)

 Decision (2/3)

 Options

 Risks

 Data

 After this presentation, you should be able to:

› Know that E/M stands for

› Know the 3 components of the E/M

› Distinguish different categories of E/M

› Understand levels of complexity

› Level Medical Decision Making

› Know when modifiers apply (and look them up)

› Appropriately document according to E/M level

Evaluation and Management Services Presentation

› Medicare eliminated this whole category

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› Medicare eliminated this whole category

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