Advanced Procedure Coding
for Emergency Medicine
February 5-7, 2013
San Diego, California
Basic E/M Coding for Physician
Services in the ED



Review in detail an ED specific approach to the
application of the Medicare 1995
Documentation Guidelines.
Review current concepts and myths
surrounding thescoring of medical decision
making.
Identify documentation requirements for the
evaluation and management codes 9928199285, including the three key elements, and
four contributing elements.
2/5/2013
1:30 PM - 3:30 PM
(+)No significant financial relationships to disclose.
(+)Todd Thomas, CCS-P
President, ERcoder, Inc; Oklahoma City, Oklahoma;
Past-President, Oklahoma City Chapter, American
Academy of Professional Coders; Member, ED
Coding Alert Editorial Advisory Panel; Member,
Coding and Nomenclature Advisory Committee,
ACEP; 2009-10 Outstanding Speaker of the Year
Award, ACEP
1/12/2013
Putting the Pieces Together
E&M Coding for ED Physician Services
ED E&M Codes
99281
99282
99283
99284
99285
1
1/12/2013
Components of an E&M code
•
•
•
•
•
•
•
Historyy
History
Examination
MDM
Medical Decision Making
Counseling
Coordination of Care
Nature of Presenting Problem
Time
Exam
NOPP
E&M Key Elements
Chief complaint (CC)
History of present illness (HPI)
(ROS)
Review of systems (ROS)
Past,, Family, Social history (PFS
Past
(PFS))
2
1/12/2013
E&M Key Elements
• The ROS and/or PFSH may be recorded
b ancillary
ill
t ff or on a fform completed
l t d
by
staff
by the patient. To document that the
physician reviewed the information,
there must be a notation supplementing or
confirming the information recorded by
others.
1995 E&M DG
CHIEF COMPLAINT (CC)
• The CC is a concise statement describing
th symptom,
t
bl
diti
di
i
the
problem,
condition,
diagnosis,
physician recommended return, or other
factor that is the reason for the encounter.
• The medical record should clearly reflect the
chief complaint.
3
1/12/2013
History of Present Illness
• History of Present Illness is distinguished by
the amount of detail needed to accurately
characterize the clinical problem(s).
•
•
•
•
•
Location
Context
Quality
Timing
Severity
• Duration
• Modifying Factors
• Associated Signs and
Symptoms
History of Present Illness
Location
Quality
Severity
Anatomic
descriptor
Characteristic of
symptoms
Intensity of CC
Left
sharp
moderate
distal
pounding
8 out of 10
Epigastric
jagged
improving
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1/12/2013
History of Present Illness
Duration
Timing
Context
Length of time since
Circumstances in
Pattern of recurrence
which the CC occur
onset or injury
MVA yesterday
Intermittent
Tripped and fell
Just PTA
Continuous
with exertion
Since this morning
In the mornings
MVA
History of Present Illness
Modifying Factors
Associated Signs & Symptoms
Factors that relieve or
exacerbate symptoms
Symptoms accompanying CC
Treatment PTA
Diaphoresis associated with chest
pain
Worse with movement
Blurring vision with a headache
Previous encounter for same
condition
Denies SOB
5
1/12/2013
Audit Issues
• Some presenting problems include a
location component. In the ED chest pain,
abdominal pain, headache and back pain
are the most common.
•
Some auditors are not counting location for
complaints like chest pain, headache and
abdominal pain
pain.
• Argued that chest pain was the complaint
and they wanted a location descriptor like
left, right, substernal etc.
Audit Issues
• Per physician auditor "When a patient presents
complaining of abdominal pain the MD cannot
perform a clinically appropriate history without
asking specifically where the pain is. Left upper,
right lower, flank, etc all have their own list of
potential causes and the MD has to know where the
p
p a list of differential diagnoses,
g
,
pain is to develop
where he should examine, what type of exam he
should do, what tests should he order, etc, etc... If
the MD did not inquirer about a specific location
that's poor clinical judgment.”
6
1/12/2013
History of Present Illness
• A brief HPI consists of one to three elements.
– 99281
– 99282
– 99283
• An extended HPI consists of at least four
elements.
– 99284
– 99285
Extended HPI
The patient is complaining of headache that
t t d yesterday.
t d
N
b
iti and
d
started
Nausea
butt no vomiting
photophobia since this morning. Typical
migraine headache, primarily over left side. It
was mild at onset but is now moderate to
severe.
Extended HPI consists of four or more HPI
elements. The medical record should describe four
or more elements of the present illness (HPI) or
associated comorbidities.
7
1/12/2013
EMR HPI Concerns
• EMR vendors are telling our physicians
th t the
th ancillary
ill
t ff may enter
t th
that
staff
the HPI
information from the patient and the
physician may mark a box as reviewed.
• Our physicians are very excited about
that. Must the physician physically sit at
the computer and input the information,
even though he has reviewed it?
HPI Concerns
• The ROS and/or PFSH may be recorded
by ancillary staff or on a form completed
by the patient.
• The HPI refers to the subjective
information obtained by the provider.
Although ancillary staff can perform the
other parts of the history, only the
provider can perform the HPI.
8
1/12/2013
Who can document the HPI?
CPT Assistant April 1996 Volume 6, Issue 4
Th clinician
li i i should
h ld h
d t di as tto
– The
have an understanding
the location….
– The physician should encourage the patient to
describe the quality…
– The physician should get some idea about the
severity…
it
– Establishing onset for each symptom or
problem…, the physician may ask…
– To understand the context, a physician may
obtain a description…
Who can document the HPI?
From WPS
• Q. If the nurse takes the History of Present
Illness (HPI), can the physician then state
"HPI as above by the nurse" or just "HPI as
above" in the documentation?
• A. No, the physician needs to fully document
the HPI.
9
1/12/2013
Who can document the HPI?
From Palmetto GBA
• Can the Physician Assistant (PA), Medical
Assistant (MA), or Registered Nurse (RN)
document the HPI and the physician/NPP
refer to what the PA, MA, or RN
documented? For example, "agree
agree with
above note."
Who can document the HPI?
Answer:
P l tt GBA received
i d clarification
l ifi ti ffrom
• Palmetto
CMS on the answer to this question. Only the
physician or NPP who is conducting the E/M
visit can PERFORM the History of Present
Illness (HPI). This is physician work and
cannot be relegated to ancillary staff
staff. The
exam and medical decision making are also
physician work and cannot be relegated to
ancillary staff.
10
1/12/2013
The physician must write an HPI Statement. It is understood the
residents and other ancillary staff may collect some of this information as
well but this does not absolve the physician of the duty to verify the
information and summarize the HPI statement his / herself.
The ROS past family and social history maybe obtained and
documented by someone other than the physician. However, the
physician must review and comment on the information, whereas in the
HPI the entire thing must be done by the physician.
Quote from Bart McCann, MD
Executive Medical Director HCFA
Printed in Physician Practice Coder,
December 1997.
HPI
Medicare B News Issue 255 July 17 2009
The HPI must be obtained by a physician
during the E/M service. Reviewing this
information obtained by ancillary
employees
and
l
d writing
iti a declarative
d l ti
sentence DOES NOT suffice for obtaining
history of present illness.
11
1/12/2013
Review of Systems
• A ROS is an inventory of body systems obtained
through a series of questions seeking to identify
signs and/or symptoms which the patient may be
experiencing or has experienced.
– The ROS is designed to bring out clinical
symptoms which the patient may have
overlooked or forgotten. In theory, the ROS may
illuminate the diagnosis by eliciting information
which the patient may not perceive as being
important enough to mention to the physician.
Review of Systems
•
•
•
•
•
•
•
Constitutional
Eyes
ENT
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
•
•
•
•
•
•
•
Musculoskeletal
Integumentary
Neurological
Psychiatric
Endocrine
Hemato
Hemato/Lymphatic
/Lymphatic
Allergic/Immunologic
12
1/12/2013
Review of Systems
99282 / 99283
• A problem pertinent ROS inquires about the
system directly related to the problem(s)
identified in the HPI.
– The patient's positive responses and
pertinent negatives for the system related
to the problem should be documented.
Review of Systems
99284
• An extended ROS inquires about the system
directly related to the problem(s) identified in
the HPI and a limited number of additional
systems.
– The patient's positive responses and
pertinent negatives for two to nine systems
should be documented.
13
1/12/2013
Review of Systems
99285
• A complete ROS inquires about the system(s)
directly related to the problem(s) identified in
the HPI plus all additional body systems.
Review of Systems
Complete ROS
l
t ten
t organ systems
t
i
d
• At least
mustt b
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.
14
1/12/2013
Review of Systems
• It is not necessary that the EDMD personally
perform the ROS
ROS. Ancillary staff may record the
ROS or the patient may fill out an ROS
questionnaire. However, the physician MUST make
a notation supplementing or confirming the
information recorded by others.
• Document an ROS for the system(s) related to the
presenting problem. It is required for all levels of
systemic review
Review of Systems
• Don’t count physical observations as ROS
(count them as Physical Examination).
• The ROS may be recorded separately or may
be included in the description of the history of
the present illness.
15
1/12/2013
Review of Systems
• It is not necessary to list each system
i di id ll It iis acceptable
t bl tto d
individually.
documentt
pertinent positive or negative findings
combined with the statement “All other
systems reviewed and negative.”
• Don’t
D ’t record
d unnecessary information
i f
ti solely
l l
to meet requirements of a highhigh-level E&M
when the nature of the visit dictates a lower
E&M to have been medically appropriate.
Review of Systems
• “10 point review of systems was completed and
is negative unless otherwise stated”
• “Review of systems per HPI otherwise negative”
• “Negative for chest pain, ROS otherwise
negative”
• None of the above examples specify that all
systems or even 10 systems were reviewed.
16
1/12/2013
Review of Systems
Additional concerns about "All others negative”:
• "All others negative" for a patient that is
unconscious with CPR in progress.
• “All others negative" and "unable to obtain
due to patients condition".
• “All others negative" for a patient documented
as nonnon-responsive to verbal and tactile
stimulation.
CMS ROS Q&A
• Can I use information from the
ti t pastt history
hi t
i
patients
as review
off
systems or history of present
illness elements?
• No.
No The ROS and HPI elements
pertain to the chief complaint
and the reason for the patients
visit that day, not past history
information.
17
1/12/2013
CMS ROS Q&A
• Can I use “Allergies: none” or “NKDA” as an element
of the review of systems?
• According to the Documentation Guidelines (DGs)
and the CPT manual, the ROS is defined as “an
inventory of body systems obtained through a series
of questions seeking to identify signs
and/or symptoms which the patient may be
experiencing or has experienced.”
CMS ROS Q&A
none” or “NKDA”
Usually a notation of “Allergies:
Allergies: none
NKDA
should be read as "no past history of allergies"
indicating the patient has no history in the past of any
conditions or problems related to allergies; it’s the
same kind of statement as, "no past history of
hypertension, diabetes, ulcers or fractures".
18
1/12/2013
PAST, FAMILY AND/OR
SOCIAL HISTORY (PFSH)
The PFSH consists of a review of three areas:
P t hi
t
(th
ti t' pastt experiences
i
ith
• Past
history
(the patient's
with
illnesses, operations, injuries and treatments);
• Family history (a review of medical events in the
patient's family, including diseases which may be
hereditary
or place
the
h dit
l
th patient
ti t att risk);
i k)
• Social history (an age appropriate review of past
and current activities).
PAST, FAMILY AND/OR
SOCIAL HISTORY (PFSH)
99284
• A pertinent PFSH - At least one specific item
from any of the three history areas must be
documented for a pertinent PFSH.
99285
• A complete PFSH - At least one specific item
from two of the three history areas must be
documented for a complete PFSH.
19
1/12/2013
PAST, FAMILY AND/OR
SOCIAL HISTORY (PFSH)
• "Non
"Non--contributory" or "negative,“ are not
id d appropriate
i t d
t ti
considered
documentation.
Documentation of PFSH must include social
and/or family history information, such as
alcohol consumption, smoking history,
occupation, or familial hereditary conditions.
PAST, FAMILY AND/OR
SOCIAL HISTORY (PFSH)
• "Past medical history is nonnon-contributory" or
"S i l hi
t
iis nont ib t
“ would
ld nott
"Social
history
non-contributory.“
indicate the provider had actually addressed
the issues. It must be clear that the PFSH
was discussed with the patient. To use the
term "non"non-contributory" alone does not clearly
indicate PFSH was addressed.
20
1/12/2013
History
Problem Focused History
• Chief Complaint
• Brief History of Present Illness
= 99281
Expanded Problem Focused History
• Chief Complaint
• Brief History of Present Illness
• Problem Pertinent Review of Systems
= 99282 / 99283
History
Detailed History
• Chief Complaint
• Extended History of Present Illness
• Extended Review of Systems
• Problem Pertinent Past, Family Social
History.
= 99284
21
1/12/2013
History
Comprehensive History
• Chief Complaint
• Extended History of Present Illness
• Complete Review of Systems
• Complete Past, Family Social History
= 99285
The Acuity Caveat
CPT
t
t visit
i it ffor the
th
• 99285 - E
Emergency d
department
evaluation and management of a patient, which
requires these three key components: within the
constraints imposed by the urgency of the
patient’s clinical condition and/or mental
status:
• a comprehensive history;
• a comprehensive examination;
• medical decision making of high complexity
22
1/12/2013
The Acuity Caveat
CMS
• If the physician is unable to obtain a history
from the patient or other source, the record
should describe the patient's condition or
other circumstance which precludes obtaining
a history.
The Acuity Caveat
• Inability to obtain a history from a patient or perform
a comprehensive exam is a clinical decision based
on the judgment of the EDMD.
• Coders cannot be expected to make a medical
decision, therefore the EDMD must document that
the clinical condition of the patient limited the history
or examination of the patient.
• CMS expects the EDMD to make a good faith effort
to get the patient's medical history either from the
patient, family or old records.
23
1/12/2013
The Acuity Caveat
• At a minimum the EDMD must document the
th t th
t
bt i d ii.e.
reason that
the hi
history
was nott obtained,
"Hx unobtainable due to dementia", "Severity
of patients injury precludes obtaining a full
history".
• Best practice would be to also document the
source of any documented history and/or that
no other sources of history were available.
Examination
• The extent of examinations performed and
d
t d iis d
d t upon clinical
li i l
documented
dependent
judgment and the nature of the presenting
problem(s). They range from limited
examinations of single
body areas to general
multi--system
multi
24
1/12/2013
Examination
Body areas:
H d iincluding
l di th
• Head,
the fface
• Neck
• Chest, including breasts and axillae
• Abdomen
g
, buttocks
• Genitalia,, groin,
• Back, including spine
• Each extremity
Examination
Organ systems:
tit ti
l
• C
Constitutional
• Eyes
• Ears, nose, mouth and
throat
• Cardiovascular
• Respiratory
• Gastrointestinal
•
•
•
•
•
•
G
it i
Genitourinary
Musculoskeletal
Skin
Neurologic
y
Psychiatric
Hematologic / lymphatic
/ immunologic
25
1/12/2013
Examination
• Documentation of normal or negative is acceptable on
any examined body area(s) or system(s) with the
exception of the area(s) or system(s) that are
symptomatic or affected.
• Pertinent findings from the physical examination must
be documented for each affected or symptomatic area
system.
or system
• All body areas and organ systems examined must be
documented individually with relevant positive or
negative findings appropriate to that area or system.
Examination
• The content and type of examination required by
the patient is dependent upon the patient’s
patient s history
history,
nature of the presenting problem, and physician’s
clinical judgment.
• While it may be a physician’s preference to perform
a detailed or comprehensive examination at every
visit, only the level of physical examination that is
medically necessary should be used in the
selection of the code.
26
1/12/2013
Examination
Exam
1995 E&M DG
a limited examination of
Problem
the affected body area or
Focused
organ system
Numerical
Interpretation
1 Body Area or
Organ System
a limited examination of
Expanded the affected body area or
2-4 Body areas or
Problem organ system and other
systems
Focused symptomatic or related
organ system(s).
Examination
Exam
1995 E&M DG
an extended examination of the
affected body area(s) and other
Detailed
symptomatic or related organ
system(s).
a general multi-system
multi system examination
or complete examination of a single
organ system. - The medical record
Comprehensive for a general multi-system
examination should include findings
about 8 or more of the 12 organ
systems.
Numerical
Interpretation
5-7 Body
areas or
systems
8 or more
Organ
systems
27
1/12/2013
Medical Decision Making
Medical decision making is measured by:
• the number of possible diagnoses and/or the
number of management options
• the amount and/or complexity of medical
records, diagnostic tests, and/or
other information reviewed
• the risk of complications,
morbidity and/or
mortality
Marshfield Clinic Scoring
• Marshfield Clinic – 32 site and 600 physician
lti
i lt clinic
li i based
b
d iin M
hfi ld WI
multispecialty
Marshfield,
• The E&M documentation guidelines were
beta--tested at Marshfield Clinic before HCFA
beta
released them in 1994
• As part of that process, clinic staff helped
their regional Medicare carrier to develop an
audit worksheet that included a scoring
system for the MDM
28
1/12/2013
Marshfield Clinic Scoring
• The score sheets never made it into the
d
t ti guidelines
id li
documentation
• Used by physicians, professional coders and
payers to evaluate documentation
• CMS acknowledges that its reviewers use
score sheets but says their use is neither
encouraged nor prohibited.
CMS Documentation Guidelines
The number of possible diagnoses and/or the
b off managementt options
ti
th
number
thatt mustt b
be
considered is based on
• the number and types of problems
addressed during the encounter,
• the complexity of establishing a diagnosis
• the management decisions that are made by
the physician.
29
1/12/2013
CMS - Number of possible
diagnoses / management options
• Decision making for a diagnosed problem is
i th
di
d problem.
bl
easier
than th
thatt ffor an undiagnosed
• Number & type of diagnostic tests ordered
may indicate increased complexity.
• Need to seek advice from others may
indicate increased complexity.
CMS - Number of possible
diagnoses / management options
• The initiation of, or changes in, treatment
h ld b
t d
should
be d
documented.
• If referrals are made or consultations
requested, the record should indicate to
whom or where the referral made or
consultation is requested.
30
1/12/2013
CMS - Number of possible
diagnoses / management options
• An assessment, clinical impression, or
di
i should
h ld b
t d it may b
diagnosis
be d
documented,
be
explicitly stated or implied.
• For a presenting problem without an
established diagnosis
diagnosis, the assessment or
clinical impression may be stated in the form
of a differential diagnoses or as "possible",
"probable", or "rule out" (R/O) diagnoses.
Number of Diagnoses /
Treatment Options
Minimal diagnoses or mgmt options
Limited diagnoses or mgmt options
Multiple diagnoses or mgmt options
Extensive diagnoses or mgmt options
31
1/12/2013
Marshfield ScoringScoring- Number of
Diagnoses / Treatment Options
Problems to Examining Physician
S
lf-limited
li it d or Mi
Self
SelfMinor
Points
i t
1 point
Est. Problem (to examiner)
stable or improving
1 point
Est. Problem (to examiner)
worsening
2 points
Marshfield ScoringScoring- Number of
Diagnoses / Treatment Options
Problems to Examining Physician
New Problem (to examiner)
no additional work
work--up planned
Points
3 points
New Problem (to examiner)
additional workwork-up planned
4 points
32
1/12/2013
Marshfield ScoringScoring- CMS Q&A
• Q: Some of my colleagues claim that a new
problem is one that is new to the examining
physician. Are they correct?
• A: "The decision making guidelines were
designed to give physicians credit for the
complexity of their thought processes. Giving
a physician more credit for handling a
problem he or she is seeing in a patient for
the first time, even when that problem has
been previously identified or diagnosed, is
within the spirit of the guidelines."
Marshfield ScoringScoring- Number of
Diagnoses / Treatment Options
New Problem, no add’l workwork-up planned
3 points
New Problem, add’l workwork-up planned
4 points
2 common definitions
A. Additional diagnostic work
work--up after the
current E&M service is completed.
B. Diagnostic work
work--up during the current E&M
service.
33
1/12/2013
Marshfield ScoringScoring- Number of
Diagnoses / Treatment Options
1 point = minimal diagnoses or mgmt options
2 points = limited diagnoses or mgmt options
3 points = multiple diagnoses or mgmt options
4 points = extensive diagnoses or mgmt
options
CMS - Amount and/or Complexity of
Data to be Reviewed
• The amount and complexity of data to
be reviewed is based on the types of
diagnostic testing ordered or reviewed.
34
1/12/2013
CMS - Amount and/or Complexity of
Data to be Reviewed
• A decision to obtain and review old medical records
and/or obtain history from sources other than the
patient increases the amount and complexity of
data to be reviewed.
– Relevant finding from the review of old records,
and/or the receipt of additional history from the
y, caretaker or other source should be
family,
documented. If there is no relevant information
beyond that already obtained, that fact should be
documented. A notation of "Old records reviewed"
or "additional history obtained from family" without
elaboration is insufficient.
CMS - Amount and/or Complexity of
Data to be Reviewed
• Discussion of contradictory or unexpected
t t results
lt with
ith the
th physician
h i i who
h performed
f
d
test
or interpreted the test is an indication of the
complexity of data being reviewed.
– The results of discussion of laboratory, radiology
or other diagnostic tests with the physician who
performed or interpreted the study should be
documented.
35
1/12/2013
CMS - Amount and/or Complexity of
Data to be Reviewed
• If a diagnostic service (test or procedure) is
ordered planned
ordered,
planned, scheduled
scheduled, or performed at the
time of the E/M encounter, the type of service, e.g.,
lab or xx--ray, should be documented.
– The review of lab, radiology and/or other
diagnostic tests should be documented. An
entry in a progress note such as "WBC
WBC elevated
elevated"
or "chest x-ray unremarkable" is acceptable.
Alternatively, the review may be documented by
initialing and dating the report containing the test
results.
CMS - Amount and/or Complexity of
Data to be Reviewed
• On occasion the physician who ordered a test may
personally review the image
image, tracing or specimen to
supplement information from the physician who
prepared the test report or interpretation; this is
another indication of the complexity of data being
reviewed.
– The direct visualization and independent
interpretation of an image, tracing or specimen
previously or subsequently interpreted by
another physician should be documented.
36
1/12/2013
Marshfield- Amount and/or
MarshfieldComplexity of Data to be Reviewed
Review and/or order of clinical lab tests
1
Review and/or order of tests in the
radiology section of CPT
1
Review and/or order of tests in the
medicine section of CPT
1
Discussion of test results with performing
physician
1
Marshfield- Amount and/or
MarshfieldComplexity of Data to be Reviewed
Decision to obtain old records and/or
bt i hi
t
ffrom other
th than
th patient
ti t
obtain
history
Review and summarization of old records
and/or obtaining history from someone
other than patient and/or discussion of
case with another health care provider
Independent visualization of image,
tracing or specimen itself (not simply
review of report)
1
2
2
37
1/12/2013
RISK OF SIGNIFICANT COMPLICATIONS,
MORBIDITY, AND/OR MORTALITY
• The following table may be used to help determine whether
the risk of significant complications, morbidity, and/or
mortality is minimal, low, moderate, or high. Because the
determination of risk is complex and not readily quantifiable,
the table includes common clinical examples rather than
absolute measures of risk.
• The assessment of risk of selecting diagnostic procedures
and management options is based on the risk during and
immediately following any procedures or treatment.
Level of
Risk
Presenting Problem
Diagnostic Procedures
Ordered
Management Options
Selected
1 self-limited or minor problem
Laboratory tests via
venipuncture X-rays,
EKG/EEG, Urinalysis
Ultrasound
rest; gargles bandages;
Dressings
2 or more self-limited or minor
problems; 1 stable chronic illness;
acute uncomplicated illness/injury
Physiological w/o stress; lab
tests via arterial puncture;
superficial biopsies; noncardiovascular imaging
w/contrast
minor surgery no risk
factors; OTC drugs; IV
therapy no additives;
PT& OT
Moderate
chronic illness w/exacerbation; 2
stable chronic illnesses;
acute illness w/systemic
symptoms; complicated acute
injury
Physiological tests w/stress;
deep biopsies; obtain fluid from
body cavity; endoscopies or
cardiovascular imaging no risk
factors
minor surgery w/risk
factors; prescription drug
mgmt; IV therapy
w/additives; closed tx
fracture or dislocation;
High
chronic illness w/severe
exacerbation; illness/injury that
pose a threat to life or bodily
function; abrupt change in
neurological status
Endoscopies or cardiovascular
imaging w/risk factors;
emergency surgery; drug
therapy w/monitoring;
decision for DNR;
Parenteral controlled
substances
Minimal
Low
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1/12/2013
RISK OF SIGNIFICANT COMPLICATIONS,
MORBIDITY, AND/OR MORTALITY
Level of
Risk
Presenting Problem
Minimal 1 self-limited or minor problem
Low
2 or more self-limited or minor problems;
1 stable chronic illness;
acute uncomplicated illness/injury
RISK OF SIGNIFICANT COMPLICATIONS,
MORBIDITY, AND/OR MORTALITY
Level of
Risk
Presenting Problem
chronic illness w/exacerbation;
2 stable chronic illnesses;
Moderate
acute illness w/systemic symptoms;
complicated acute injury
High
chronic illness w/severe exacerbation;
illness/injury that pose a threat to life or function;
abrupt change in neurological status
39
1/12/2013
RISK OF SIGNIFICANT COMPLICATIONS,
MORBIDITY, AND/OR MORTALITY
Level of
Ri k
Risk
Diagnostic Procedures Ordered
Minimal
Laboratory tests via venipuncture, X-rays,
EKG/EEG, Urinalysis, Ultrasound
Low
Physiological
stress;
Ph siological w/o
/o stress
lab tests via arterial puncture;
superficial biopsies;
Non-cardiovascular imaging w/contrast
RISK OF SIGNIFICANT COMPLICATIONS,
MORBIDITY, AND/OR MORTALITY
• The assessment of risk of selecting
di
ti procedures
d
d managementt
diagnostic
and
options is based on the risk during and
immediately following any procedures or
treatment.
40
1/12/2013
RISK OF SIGNIFICANT COMPLICATIONS,
MORBIDITY, AND/OR MORTALITY
Level of Risk
Minimal
Low
Management Options Selected
rest; gargles bandages; Dressings
minor surgery no risk factors;
OTC drugs; IV therapy no additives;
PT& OT
RISK OF SIGNIFICANT COMPLICATIONS,
MORBIDITY, AND/OR MORTALITY
Level of
Risk
Management
Options
Selected
g
p
minor surgery w/risk factors;
prescription drug mgmt;
Moderate
IV therapy w/additives;
closed tx fracture or dislocation;;
emergency surgery;
Drug therapy w/monitoring;
High
decision for DNR;
Parenteral controlled substances
41
1/12/2013
Level of
Risk
Presenting Problem
Diagnostic Procedures
Ordered
Management Options
Selected
1 self-limited or minor problem
Laboratory tests via
venipuncture X-rays,
EKG/EEG, Urinalysis
Ultrasound
rest; gargles bandages;
Dressings
2 or more self-limited or minor
problems; 1 stable chronic illness;
acute uncomplicated illness/injury
Physiological w/o stress; lab
tests via arterial puncture;
superficial biopsies; noncardiovascular imaging
w/contrast
minor surgery no risk
factors; OTC drugs; IV
therapy no additives;
PT& OT
Moderate
chronic illness w/exacerbation; 2
stable chronic illnesses;
acute illness w/systemic
symptoms; complicated acute
injury
Physiological tests w/stress;
deep biopsies; obtain fluid from
body cavity; endoscopies or
cardiovascular imaging no risk
factors
minor surgery w/risk
factors; prescription drug
mgmt; IV therapy
w/additives; closed tx
fracture or dislocation;
High
chronic illness w/severe
exacerbation; illness/injury that
pose a threat to life or bodily
function; abrupt change in
neurological status
Endoscopies or cardiovascular
imaging w/risk factors;
emergency surgery; drug
therapy w/monitoring;
decision for DNR;
Parenteral
controlled substances
Minimal
Low
Medical Decision Making
Must meet or
exceed 2 out of 3
Straight
Forward
Low
Moderate
High
Complexity Complexity Complexity
Dx or Treatment
Options (points)
1 = Minimal 2 = Limited
3 = Multiple
4 or more =
Extensive
Data Points
1 = Minimal 2 = Limited
3 = Multiple
4 or more =
Extensive
Moderate
High
Level of Risk
Minimal
Low
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1/12/2013
Nature of Presenting Problem
Medicare Carrier's Manual
6 1 (A)
section 30
30.6.1
• Medical necessity of a service
is the overarching criterion for
payment in addition to the
individual requirements of a
CPT code.
code
Nature of Presenting Problem
Medicare Carrier's Manual section 30.6.1 (A)
ld nott be
b medically
di ll necessary or appropriate
i t
• It would
to bill a higher level of evaluation and management
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
billed. Documentation should support the
level of service reported.
43
1/12/2013
CMS Q&A - NOPP
Q. When scoring medical records, how is medical
necessity considered?
A. All services paid by Medicare must be reasonable and
necessary as defined in Title XVIII of the Social
Security Act, Section 1862(a)(1)(A).
– no payment may be made for any expenses incurred
for items or services which are not reasonable and
necessary for the diagnosis or treatment of injury or
to improve the functioning of a malformed body
member.
Therefore, medical necessity is the first consideration in
reviewing all services.
Nature of Presenting Problem
• The nature of the presenting problem will normally
determine the extent of the history and exam required.
• A minor presenting problem which requires low level
decision making usually does not warrant extensive history
taking or an extensive physical examination. If the physician
elects to perform a comprehensive history with a
comprehensive exam for a chronic
chronic, minor or stable problem
that does not require a significant change of therapy, it is not
appropriate to bill for a high level code.
44
1/12/2013
Nature of Presenting Problem
• The chief complaint or reason for the encounter
establishes the medical necessity and
reasonableness for services.
• The medical necessity and reasonableness of the
level of service billed is directly correlated to the
nature of the presenting problem
problem.
• It cannot be stressed enough that the volume of
documentation is not the sole indication of the level
of service.
Nature of Presenting Problem
• Documentation that is aimed to meet the
id li
ffor paymentt but
b t is
i excessive
i ffor
guidelines
the treatment of the patient on the visit in
question will not increase the level assigned
to that visit.
• Services performed “in the absence of signs
or symptoms” are excluded from payment
under the Medicare Program.
45
1/12/2013
Nature of Presenting Problem
99281
ti problem(s)
bl ( ) are self
lf lilimited
it d or minor.
i
• presenting
99282
• presenting problem(s) are of low to moderate
severity.
99283
• presenting problem(s) are of moderate severity.
Nature of Presenting Problem
99284
• presenting problem(s) are of high severity, and
require urgent evaluation by the physician but
do not pose an immediate significant threat to
life or physiologic function.
99285
• presenting problem(s) are of high severity and
pose an immediate significant threat to life or
physiologic function.
46
1/12/2013
Selecting the E&M Code
• History, exam and MDM
bi to
t determine
d t
i th
combine
the
highest available E&M
code for the encounter.
• NOPP is final p
piece of
the puzzle for final code
assignment.
Selecting the E&M Code
99281
• patient for removal of sutures from a
well
well--healed uncomplicated laceration.
• patient tetanus toxoid immunization.
• patient with several uncomplicated
insects bites.
47
1/12/2013
Selecting the E&M Code
99282
• 20 year old student who presents with
painful sunburn with blister formation on
the back.
• A child presenting with impetigo localized
to the face.
face
• Patient with a minor traumatic injury of an
extremity with localized pain, swelling and
bruising.
Selecting the E&M Code
99282
• An otherwise healthy patient whose chief
complaint is a red, swollen cystic lesion on
the back.
• Patient presenting with a rash on both
legs after exposure to poison ivy.
ivy
• Young adult patient with injected sclera
and purulent discharge from both eyes
without pain, visual disturbance or history
of foreign body in eye.
48
1/12/2013
Selecting the E&M Code
99283
S
ll active
ti ffemale
l complaining
l i i off vaginal
i l
• Sexually
discharge who is afebrile and denies
experiencing abdominal or back pain.
• Well
Well--appearing 8
8--yearyear-old child, who has a
fever,
diarrhea
f
di h and
d abdominal
bd i l cramps, iis
tolerating oral fluids and not vomiting.
Selecting the E&M Code
99283
ti t with
ith an inversion
i
i ankle
kl injury,
i j
h iis
• P
Patient
who
unable to bear weight on the injured foot and
ankle.
• Patient who has a complaint of acute pain
associated with a suspended foreign body in the
painful eye.
eye
• Healthy young adult patient who sustained a
blunt head injury with local swelling and bruising
without subsequent confusion, loss of
consciousness or memory deficit.
49
1/12/2013
Selecting the E&M Code
99282 vs. 99283
• 99282 - Patient with a minor traumatic
injury of an extremity with localized pain,
swelling and bruising.
• 99283 - Patient with an inversion ankle
injury, who is unable to bear weight on the
injured foot and ankle.
Selecting the E&M Code
99282 vs. 99283
• 99282 - Young adult patient with injected
sclera and purulent discharge from both
eyes without pain, visual disturbance or
history of foreign body in eye.
• 99283 - Patient who has a complaint of
acute pain associated with a suspended
foreign body in the painful eye.
50
1/12/2013
Selecting the E&M Code
99284
• 4-year
year--old child who fell off a bike,
sustaining a head injury with a brief loss of
consciousness.
• An elderly female who has fallen and is
now complaining of pain in her right hip
and is unable to walk.
Selecting the E&M Code
99284
• Female present with flank pain and
hematuria.
• Female presenting with lower abdominal
pain and vaginal discharge.
discharge
51
1/12/2013
Selecting the E&M Code
99283 vs. 99284
• 99283 - Patient with an inversion ankle
injury, who is unable to bear weight on the
injured foot and ankle.
• 99284 - An elderly female who has fallen
and is now complaining of pain in her right
hip and is unable to walk.
Selecting the E&M Code
99283 vs. 99284
• 99283 - Healthy young adult patient who
sustained a blunt head injury with local
swelling and bruising without subsequent
confusion, loss of consciousness or
memory deficit.
deficit
• 99284 - 4-year
year--old child who fell off a bike,
sustaining a head injury with a brief loss of
consciousness.
52
1/12/2013
Selecting the E&M Code
99283 vs. 99284
• 99283 - Sexually active female complaining
of vaginal discharge who is afebrile and
denies experiencing abdominal or back pain.
• 99284 - Female p
present with flank p
pain and
hematuria.
• 99284 - Female presenting with lower
abdominal pain and vaginal discharge.
Selecting the E&M Code
99285
• Patient with a complicated overdose requiring
aggressive management to prevent side effects from the
ingested material.
• Patient with a new onset of raid heart rate requiring IV
drugs.
• Patient exhibiting active, upper gastrointestinal bleeding.
• Previously healthy adult patient who is injured in an
automobile accident and is brought to the emergency
department immobilized and has symptoms compatible
with intraintra-abdominal injuries or multiple extremity
injuries.
53
1/12/2013
Selecting the E&M Code
99285
• Patient with an acute onset of chest pain
compatible with symptoms of cardiac ischemia
and/or pulmonary embolus.
• Patient who presents with a sudden onset of “the
worst headache of her life”, and complains of a stiff
neck, nausea, and inabilityy to concentrate.
• Patient with a new onset of a cerebral vascular
accident.
• Acute febrile illness in an adult, associated with
shortness of breath and an altered level of
alertness.
Selecting the E&M Code
Must meet all elements for a selected
code.
E&M
History
Exam
MDM
NOPP
99281
Problem
Focused
Problem
Focused
Straight
Forward
Self-Limited or
Minor
99282
Expanded
Problem
Focused
Expanded
Problem
Focused
Low
Low to Moderate
99283
Expanded
Problem
Focused
Expanded
Problem
Focused
Moderate
Moderate
99284
Detailed
Detailed
Moderate
High
99285
Comprehensive
Comprehensive
High
High w/ threat
to life or function
54
1/12/2013
Feel Free to Contact Me
Todd Thomas, CCS
CCS--P
(405) 749
749--2633
www.ERcoder.com
Todd@ERcoder
Todd@ERc
oder.com
.com
55