Auditing Evaluation and Management Services
Raemarie Jimenez, CPC, CPC‐I, CANPC, CRHC
Di t
Director of Exam Content, AAPC
fE
C t t AAPC
1
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Course Objectives
• Discuss Tools Used to Audit E/M Services
• Discuss Coding E/M Services using 1995 and 1997 CMS Documentation Guidelines
• Discuss Gray Areas in the Documentation Guidelines
• Audit E/M Cases 2
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What You Need to Get Started
•
•
•
•
•
•
3
Medical Record
Remittance Advice (Post Payment)
1995 CMS Documentation Guidelines
1997 CMS Documentation Guidelines
Audit tool/form For non‐Medicare payers, policies regarding E/M services
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1995 vs. 1997
Documentation Guidelines
• Medicare allows physicians and providers to choose between the 95 and the 97 DGs, whichever set results in the greatest b
benefit.
fit
• Many non‐Medicare payers follow Medicare documentation guidelines but you must check with your payer policies.
•Know your payer policy. MACs have different guidance for the documentation requirements for selecting E/M services. Best practice is to use your MACs E/M audit tool if available. 4
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History
• History elements include:
– Chief complaint: Reason for the visit – History of Present Illness: Description of the development of the patient’s presenting illness/disease/injury
– Review of Systems: Inventory of the body systems obtained through questioning
– Past, Family and Social History
5
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HPI
• Must be documented by the provider
• 8 elements
– Location: RUQ abdominal pain, ear pain, chest pain, open wound on the arm
– Quality: throbbing pain, dull ache, itchy skin
– Severity: extreme pain, intolerable pain, 8 on a scale of 1 to 10
– Duration: it started this morning, the pain started two days ago
6
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HPI continued
– Timing: the symptoms come and go, constant ringing in the ears, it lasts for brief moments and subsides
– Context: MVA (motor vehicle accident), fell off a ladder, cut myself while slicing onions
– Modifying factors: the symptoms did not improve with Tylenol, a heating pad helps the muscle aches
– Associated signs and symptoms: sore throat and Associated signs and symptoms: sore throat and
runny nose, chest pain with radiating pain in the arm, abdominal pain and no nausea or vomiting
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History of Present Illness
Brief
Extended
8
One to three elements of HPI
(Some payers allow status of 1‐2 chronic illnesses)
Four or more elements of HPI
*1997 Status of three chronic illnesses (depends on your payer. Some will allow use of chronic illnesses with 1995 DGs as well )
illnesses with 1995 DGs as well.) CPT® copyright American Medical
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HPI Example
Chief Complaint: HEADACHE. HPI: This started 9 PM. It was gradual in onset and has been constant. No abrupt onset. Onset during rest. Is still present. It is described as similar to previous headaches. Located in the right hemicranial region. No neck pain. Not located in the facial region. Severity: it is described as severe. Modifying factors: worsened by bright light and noise; relieved by nothing; (no relief with Tylenol). She has had moderate photophobia of the right eye and left eye. The patient has had nausea. No preceding symptoms, numbness weakness or vomiting No blurred vision
numbness, weakness or vomiting. No blurred vision. CPT® copyright American Medical
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Review of Systems
• Can be documented by ancillary staff
• Can be updated from a previous encounter. Must include where the previous information came from. An auditor must be able to find the previous note.
• “All others reviewed and negative” is not accepted by all payers
accepted by all payers
• When can you pull ROS from statements made in the HPI?
10
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Review of Systems
• Constitutional: fatigue, weakness, fever
• Eyes: blurred vision, itching, doubled vision
• Ears, Nose and Throat: vertigo, ear pain, runny nose, E
N
d Th t
ti
i
sinus pain, bleeding gums, difficulty swallowing, sore throat
• Cardiovascular: chest pain, tightness, palpatations, edema
• Respiratory: cough, shortness of breath, wheezing
R i t
h h t
f b th h i
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Review of Systems continued
• Gastrointestinal: indigestion, nausea and vomiting, abdominal swelling, diarrhea, constipation
• Genitourinary: painful urination, irregular menses, Genitourinary: painful urination irregular menses
incontinence
• Musculoskeletal: muscles cramps, pain, limitations on walking, joint swelling
• Integumentary: rash, sores, itching, breast pain
12
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Review of Systems continued
• Neurological: numbness, tingling, fainting or unconsciousness, disorenitation
• Psychiatric: depression, stress, suicidal thoughts
Psychiatric: depression stress suicidal thoughts
• Endocrine: blood sugar reading at home, increased thirst or appetite
• Hematologic/Lymphatic: Easy bruising, fevers that come and go, swollen glands
• Allergic/Immunologic: allergies to medication, hives All i /I
l i ll i t
di ti
hi
or itching
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Review of Systems
Problem Pertinent
Extended 1
2‐9
Complete
10
Pertinent positives and negatives and “all other systems
reviewed and negative” are accepted by most payers as a
complete ROS
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ROS Example
REVIEW OF SYSTEMS
No fever, muscle aches, sinus pressure, ear pain or sore throat No head injury chest pain or
or sore throat. No head injury, chest pain or abdominal pain. LMP now and 1 month ago‐nl, on BCP. All systems reviewed and otherwise negative, except as recorded above.
15
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ROS Example The ROS is Complete. The provider reviewed the following systems: constitutional, musculoskeletal ENT cardiovascular
musculoskeletal, ENT, cardiovascular, gastrointestinal, genitourinary. The provider also indicated that all other systems were reviewed and negative. Depending on your payer rules this statement can be
on your payer rules this statement can be counted as complete. This is not accepted by all payers. 16
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Past, Family, & Social History
• Can be documented by ancillary staff
• Can be updated from a previous encounter. Must indicate the date of the previous encounter and updated information
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Past, Family, & Social History
Pertinent
One item from one of the elements
One item from all three elements (New, Initial Hospital)
One item from two of the three elements (Est., ED, subsequent)
Complete
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Past, Family & Social History Example
PAST HISTORY: Hyperhydrosis, Migraines
Medications: See Nurses Notes
Allergies: NKDA
Allergies: NKDA
SOCIAL HISTORY: Smoker: less than 1 pack per day. No alcohol use or drug use.
FAMILY HISTORY: History of migraine headaches
headaches.
The PFSH is Complete for this example. At least one item from each element is met. 19
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Determine Level of History
History
HPI
ROS PFSH
PF
Brief (1 3)
Brief (1‐3)
N/A
N/A
EFP
Brief (1‐3)
Problem Pertinent (1)
N/A
D
Extended (4+)
Extended (2‐9) Pertinent (1)
C
Extended (4+)
Complete (10+)
20
Complete (ED=2)
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Physical Examination
The 1995 Guidelines • General Multi‐System
• Single Systems –
l
referred to, but not defined
f
d
b
d f d
• For complete written 1995 E&M Guidelines go to: http://www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf
The 1997 Guidelines
• General Multi‐System
• 10 Single Organ Systems
10 Si l O
S
• For complete written 1997 E&M Guidelines go to: http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf
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Physical Examination
95/97 recognize the same body areas: •
•
•
•
•
•
•
22
Head and face Neck Chest, including breasts and axillae Abdomen Genitalia, groin, buttocks Back, including spine ,
g p
Each extremity CPT® copyright American Medical
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Physical Examination
95/97 recognize the same organ systems: •
•
•
•
•
•
•
•
•
•
•
•
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Constitutional (e.g., vital signs, general appearance) ( g,
g ,g
pp
)
Eyes Ears, nose, mouth and throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal
Musculoskeletal Skin
Neurologic Psychiatric Hematologic/lymphatic/Immunologic CPT® copyright American Medical
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Exam‐1995 Guidelines
Problem Focused
One body area and/or system
Expanded Problem Focused Detailed
Limited two to seven body areas and/or systems
Extended two to seven body areas and/or systems
Comprehensive
Eight or more systems
**Payer rules may vary regarding expanded problem focused versus detailed
24
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Exam‐1995 Guidelines
• Various Rules for EPF versus Detailed
– The amount of detail
The amount of detail per body system and/or area
per body system and/or area
– EPF=2‐4 body areas/systems, Detailed=5‐7 body areas and/or systems
– Four elements must be documented for at least four systems for Detailed
– Some payers allow for 8+ body areas and/or Some payers allow for 8+ body areas and/or
systems for Comprehensive
25
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Exam Example‐1995 DG
PHYSICAL EXAM Appearance: Alert. Appears to be in pain. Vital Signs: Have been reviewed. Eyes: Mild photophobia present. Pupils equal, round and reactive to light. Eyes normal inspection No conjunctival findings or nystagmus No
Eyes normal inspection. No conjunctival findings or nystagmus. No abnormal funduscopic findings. ENT: Nose normal. Pharynx normal. Neck: Normal inspection. Neck supple. No meningeal signs or lymphadenopathy. CVS: Normal heart rate and rhythm. Heart sounds normal. Pulses normal. No cardiac murmur. Respiratory: No respiratory distress. Breath sounds normal. Abdomen: Abdomen soft and nontender. No organomegaly. Back: Normal inspection. No CVA tenderness. Skin: Skin warm and dry. Normal skin color. No rash. Normal skin turgor. Extremities: Extremities exhibit g
normal ROM, No lower extremity edema. Neuro: Oriented X 3. Alert. Mood/affect normal. Speech normal. Cranial nerves normal (as tested). No cerebellar findings. No abnormal finger‐nose test. No motor deficit. CT Scan of head was negative.
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Exam‐1997 Guidelines General Multisystem
Problem Focused
One to five elements Expanded Problem Focused At least six elements Detailed
At least two elements from six areas/systems
OR at least twelve elements in two or more areas/systems.
Comprehensive
Perform all elements identified by a bullet in at least nine organ systems or body areas and document at
nine organ systems or body areas and document at least two elements identified by a bullet from each of nine areas/systems.
27
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Medical Decision Making (MDM)
There are three elements of MDM:
• Number of diagnosis and treatment options
• Amount of data • Risk associated with the patient’s presenting problem and management options
Two of the three components must be met for the level of MDM.
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MDM‐Number of Dx and Tx options
29
Problem Status
# x
Pts=
Self limited or minor
M=2
1
Est. prob. (to examiner) stable/improving
1
Est. prob. (to examiner) worsening
New prob. (to examiner) no add. w/u planned
/ l
d
New prob. (to examiner) add. w/u planned
2
Results
3
4
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Variation in Dx and Tx Options
30
Diagnosis and Treatment Options
Points
Each new or established problem for which the diagnosis and/or treatment plan is evident with or without diagnostic confirmation
1
2 plausible differential diagnoses, comorbidities or complications
2
3 plausible differential diagnoses, comorbidities or complications
3
4 or more plausible differential diagnoses, comorbidities
4
or more plausible differential diagnoses, comorbidities or or
complications 4
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Management Options
Management Options
Points
Do not count as treatment option’s notations such as: Continue “same” therapy or “no change” in therapy (including drug management) if specified therapy is not described (record does not document what the current therapy is nor that the physician reviewed it). 0
Drug management, per problem. Includes “same” therapy or “no change” in therapy if specified therapy is described <3 new or current medications per problem 1
Drug management, per problem. Includes “same” therapy or “no change” in therapy if specified therapy is described >3 new or current medications per problem 3
t
di ti
bl
2
Open or percutaneous therapeutic cardiac, surgical or radiological procedure; 1
minor or major 31
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Management Options
32
Management Options
Points
Physical, occupational or speech therapy or other manipulation 1
Closed treatment for fracture or dislocation 1
IV fluid or fluid component replacement, or establish IV access when fl d fl d
l
bl h
h
record is clear that such involved physician decision‐making and was not standard facility “protocol” 1
Complex insulin prescription (SC or combo of SC/IV), hyperalimentation, insulin drip or other complex IV admix prescription 2
Conservative measures such as rest, ice/heat, specific diet, etc. 1
Radiation therapy 1
Joint, body cavity, soft tissue, etc injection/aspiration /
1
Patient education regarding self or home care 1
Decision to admit to hospital 1
Discuss case with other physician 1
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MDM‐Amount of Data
Type of Data
Pts
Review and/or order clinical labs
1
Review and/or order X‐rays
1
Review and/or order other tests
1
Discussion of tests with performing MD
1
Independent review of image, tracing, or specimen
2
Decision to obtain records and/or obtain Hx from someone other
Decision to obtain records and/or obtain Hx from someone other than pt
1
Review and summarize old records, obtain history from someone 2
other than pt, discuss case with other MD
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Variation‐Amount of Data
Data
Points
Order and/or review medically reasonable and necessary clinical laboratory procedures. Note: Count laboratory panels as one procedure. 1–3 procedures 1
Order and/or review medically reasonable and necessary clinical laboratory procedures. >4 procedures 2
Order and/or review medically reasonable and necessary diagnostic imaging studies in Radiology section of CPT. 1–3 procedures 1
Order and/or review medically reasonable and necessary diagnostic i
imaging studies in Radiology section of CPT. i
di i R di l
i
f CPT
>4 procedures 2
Order and/or review medically reasonable and necessary diagnostic procedures in Medical section of CPT. 1–3 procedures 1
34
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Variation‐Amount of Data
Data
Points
Order and/or review medically reasonable and necessary diagnostic procedures in Medical section of CPT. >4 procedures 2
Discuss test results with performing physician 1
Discuss case with other physician(s) involved in patient’s care or consult another physician 1
Order and/or review old records. Order/review without summary 1
Order and/or review old records. Order/review with summary 2
Independent visualization and interpretation of an image, EKG or laboratory specimen not reported for separate payment. laboratory
specimen not reported for separate payment Note: Each Note: Each
visualization and interpretation is allowed one point. 1
Review of significant physiologic monitoring or testing data not reported 1
for separate payment (e.g., prolonged or serial cardiac monitoring data not qualifying for payment as rhythm electrocardiograms). 35
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Table of Risk
Level of Risk
Presenting Problem
Minimal
One self‐limited or minor Laboratory tests requiring Rest problem, e.g., cold, insect venipuncture Chest x‐rays Gargles bite, tinea corpis EKG/EEG Urinalysis Elastic bandages
Elastic bandages Ultrasound, e.g., echo‐
Superficial dressings
cardiography
Low
Two or more self‐limited or minor problems
One stable chronic illness, e.g., well controlled hypertension or non‐insulin dependent diabetes, cataract, BPH p
Acute uncomplicated illness or injury, e.g., cystitis, allergic rhinitis, simple sprain
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Diagnostic Procedures
Physiologic tests not under stress, e.g., pulmonary function tests
Non‐cardiovascular imaging studies with contrast, e.g., barium enema
Management Options Selected
Superficial needle biopsies Clinical laboratory tests requiring arterial puncture Skin biopsies Over‐the‐counter drugs Minor surgery with no
Minor surgery with no identified risk factors Physical therapy IV fluids without additives CPT® copyright American Medical
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Table of Risk, cont.
Level of Risk
Presenting Problem
Diagnostic Procedures
Management Options Selected
Moderate One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment Two or more stable chronic illnesses Undiagnosed new problem with uncertain prognosis, e.g., lump in breast Acute illness with systemic symptoms, e.g., pyelonephritis
pyelonephritis, pneumonitis, 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 biopsy Cardiovascular imaging studies with contrast and no identified risk factors, e.g., arteriogram, cardiac catheterization
catheterization Obtain fluid from body cavity, e.g., lumbar puncture, thora‐
centesis, culdocentesis
Minor surgery with identified risk factors Elective major surgery (open, percutaneous or endoscopic) with no identified risk factors Prescription drug management Therapeutic nuclear medicine IV fluids with additives Closed treatment of fracture or dislocation
fracture or dislocation without manipulation 37
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Table of Risk, cont.
Level of Risk
Presenting Problem
Diagnostic Procedures
Management Options Selected
High
One or more chronic illnesses with severe exacerbation, pro‐
with severe exacerbation, pro
gression, or side effects of treatment Acute or chronic illnesses or injuries that pose a threat to life or bodily function, e.g., multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal h
l
failure An abrupt change in neurologic status, e.g., seizure, TIA, weakness, or sensory loss
Cardiovascular imaging studies with contrast with
studies with contrast with identified risk factors Cardiac electrophysiological tests
Diagnostic endoscopies with identified risk factors Discography
Elective major surgery (open, percutaneous or
(open, percutaneous or endoscopic) with identified risk factors Emergency major surgery (open, percutaneous or endoscopic) Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Decision not to resuscitate or to deescalate care because of poor prognosis 38
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Determine MDM
39
MDM
#Dx
Data
Risk
Straight
h
forward
Minimal (1)
l( )
Minimal/
l/
none (1)
Minimall
Low
Limited (2)
Limited (2)
Low
Moderate
Multiple (3)
Multiple (3)
Moderate
High
Extensive (4)
Extensive (4)
High
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MDM Example
PROGRESS AND PROCEDURES
Demerol & Phenegan IV given.
Demerol & Phenegan IV given.
E.D. Course: H/o migraines, similar to previous. Gradual onset, not worst of life. Will give IV meds, hydrate and re check. DDX: migraine, non‐sp headache, doubt SAH, tumor, temporal arteritis, no hx of trauma, no s/s to suggest meningitis.
07:30 Pt feeling "much, much" better. Ready to go home.
07:30 ‐
Pt feeling "much much" better Ready to go home
Disposition: Discharged. Condition: good.
40
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MDM Example
Prescription Medications: Phenergan 25 mg tablets: take 1 orally every 6 hours as needed for nausea. Dispense ten (10). No refill. Generic substitute OK.
OTC Medications: Motrin IB 200 mg (available over the counter): take 3 orally every 8 hours for 2 days, as needed for pain.
41
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MDM Example
In this example we have a new problem to the examiner, no additional workup planned (3)
additional workup planned (3). Data points: 1 (CT Scan)
Risk: Moderate (prescription drug management)
MDM=Moderate
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EM Category
•
•
•
•
•
43
New Patient
Established Patient
Consultation‐AMA versus CPT
Initial Hospital Care‐AMA versus CPT
Subsequent Hospital Care
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Case 1 Example
Nurse note: Patient here today because of a football injury, parent thought it would get better but it has just got worse.
parent thought it would get better but it has just got worse. Patient has problem with his right shoulder. He was tackled in football practice and landed on shoulder.
Subjective:
CC: Shoulder injury
HPI: Has pain in the right shoulder since a football tackle.
44
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Case 1 Example
ROS:
Const: Denies chills, fatigue, fever and weight change. General health stated as good.
Eyes: Denies visual disturbance.
ld
b
CV: Denies chest pain and palpitations.
Resp: Denies cough, dyspnea and wheezing.
GI: Denies constipation, diarrhea. dyspepsia. dysphagia, hematochezia. melena, nausea and vomiting.
GU: Urinary: denies dysuria. frequency, hematuria, incontinence.
Musculo: Denies arthralgias, andmyalgia.
Skin: Denies rashes.
Neuro: Denies neurologic symptoms.
Current Meds: None
Allergies: NKDA
45
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Case 1 Example
Objective:
BP: 118/78 Pulse; 76 T: 98.0
Exam:
Const: Appears obese. No signs of apparent distress present.. ENMT: Auditory canals normal. Tympanic membranes are normal. Nasal mucosa is pink and moist. Dentition is in good repair. Posterior pharynx shows no exudate, irritation, or redness. Neck: Palpation reveals no lymphadenopathy. No masses appreciated. Thyroid exhibits no thyromegaly. No JVD. Resp: Respiration rate is normal. No wheezing. Auscultate good airflow. Lungs are clear bilaterally. CV: Rate is regular. Rhythm is regular. No heart murmur appreciated. Extremities; No clubbing. cyanosis or edema. Right shoulder is tender. No obvious deformation. Decreased ROM in abduction and extension. Abdomen: Bowel sounds are normoactive. Palpation of the abdomen reveals no CV, no tenderness, muscle guarding, rebound tenderness or tenderness. No abdominal masses. No palpable hepatosplenomegaly. Musculo: Walks with a normal gait. Skin: Skin is warm and dry.
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Case 1 Example
Assessment: Joint pain in the shoulder region.
Plan: Complete shoulder X‐ray, minimum of 2 views of the right shoulder. Possible clavicle fracture or rotator cuff. I note there are no neurosensory deficits.
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Case 2 Example
HISTORY AND PHYSICAL
The patient was seen in the oncology office today on a self‐referral basis. She has a history of a signet ring carcinoma most likely arising in the appendiceal cecal area and has been undergoing adjuvant FOLFOX‐6 therapy. Treatment was instituted in February this year and has been associated with significant peripheral neuropathy involving the hands, feet, and perioral region. At the present time, she is seeking to establish a new physician relationship.
48
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Case 2 Example
She is a 39‐year‐old female who in June of last year underwent a NovaSure
uterine ablation procedure because of menometrorrhagia. Because of persistent bleeding, however, she subsequently underwent a laparotomy in September last year. At the time of surgery, the omentum appeared to b
be embedded with tumor, and both ovaries were irregularly shaped with b dd d ith t
d b th
i
i
l l h
d ith
what appeared to be gross tumor on top. There were tiny, less than 1‐2 mm nodules on the anterior peritoneal wall, and she underwent a total abdominal hysterectomy, bilateral salpingo‐oophorectomy, omentectomy, appendectomy, and cytoreductive surgery to remove all visible masses greater than 2.5 cm. Pathologic review of the specimen demonstrated adenocarcinoma poorly differentiated signet ring cell type involving the omentum, peritoneum, bilateral ovaries, fallopian tubes, uterus, and appendix. At that time she also sustained a bladder laceration with left ureteral transection and required a transabdominal bladder exploration
ureteral transection and required a transabdominal bladder exploration, left ureteral reimplantation, bilateral double J‐stent insertion, and closure of vesicotomy. Postoperatively, she developed a wound infection with MRSA.
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Case 2 Example
PAST MEDICAL HISTORY: Her other past history is positive for Factor V Leiden deficiency which was diagnosed approximately 9‐10 years ago following the birth of her twins. At that time consideration was being given to put her on birth control pills; however, she gave a family history of significant blood p ;
,
g
y
y
g
clotting which initiated the screening. The studies were obtained through the hospital; and since that time, her sister was identified with the same mutation. However, the patient has had no thrombolic episodes. Her mother, maternal aunt, and maternal grandmother, however, have had episodes of clotting.
Ironically, the patient herself states she has been a bleeder. She has had difficulty controlling even minor cuts and also required suturing following a dental extraction with resultant prolonged bleeding episode.
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Case 2 Example
The patient is also has a positive history for mitral valve prolapse and depression.
PAST SURGICAL HISTORY: Past surgeries include a C‐section, tubal ligation, D & C, NovaSure implantation, total abdominal hysterectomy, bilateral salpingo‐
oophorectomy, total omentectomy, appendectomy, left ureteral reimplantation, and closure of vesicotomy.
CURRENT MEDICATIONS: Iron 325 mg three times a day and a multiple vitamin.
ALLERGIES Th
ALLERGIES: The patient has allergies to codeine, penicillin, and sulfa.
i
h
ll i
d i
i illi
d lf
SOCIAL HISTORY: She denies the use of alcohol and tobacco.
51
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Case 2 Example
GYN HISTORY: The patient is gravida 6, para 6 0 1 6.
FAMILY HISTORY: Positive for thrombolic episodes. Her mother recently died of a primary brain malignancy. Her father has carcinoma of the prostate. Two of her six children have had cleft palates.
REVIEW OF SYSTEMS: Discussion of system review is positive for neuropathy involving the fingers and toes and back pain. Remainder of the 14 system review is negative.
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Case 2 Example
PHYSICAL EXAMINATION:
GENERAL: The patient is in no distress. The patient is alert and oriented times three. VITAL SIGNS: Blood pressure 120/98. Weight is 194 pounds. Temperature: 98 2°. NEUROLOGY: No focal neurological deficits.
Temperature: 98.2
NEUROLOGY: No focal neurological deficits PSYCHIATRIC: PSYCHIATRIC:
Judgment, insight, orientation, memory, and mood are normal. SKIN: No abnormalities on inspection or palpation. EYES: PERRL, EOMI. Sclerae non icteric. EARS/NOSE/THROAT/MOUTH: No abnormalities noted on external inspection. Hearing, otologic, nose, mouth, and oropharynx reveal no abnormalities. NECK: Supple. RESPIRATORY: Lungs clear, effort normal. No rales, rhonchi, or wheezes appreciated. HEART: Regular rate and rhythm. ABDOMEN: There was a healed abdominal scar present. LYMPHATIC: I could not feel adenopathy in the cervical, supraclavicular, axillary, or inguinal regions. EXTREMITIES: No edema appreciated. MUSCULOSKELETAL: Gait and digits demonstrate no abnormalities. JOINT/BONE/MUSCLE: No abnormalities. Range of motion, strength, and stability are adequate.
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Case 2 Example
ASSESSMENT AND PLAN: I had a long discussion with the patient regarding the fact we would be happy to undertake her oncologic care.
Regarding her abdominal carcinomatosis, it appears she has a poorly differentiated signet ring carcinoma possibly arising in the appendiceal cecal differentiated
signet ring carcinoma possibly arising in the appendiceal cecal
area. We will continue her adjuvant FOLFOX therapy. We will try to make some dose adjustments in her Oxaliplatin. In the interim, it is suggested she start taking 200 mg of vitamin B6 daily. We will reinstitute treatment next week. We would anticipate that upon completion, she will then be referred back to Dr. P regarding a second look surgical procedure.
There is a history of Factor V Leiden deficiency, and we will attempt to obtain the original studies from the hospital.
Regarding her history of easy bruising, she will undertake a coagulation screen and will obtain a pro time, PTT, and screen her for von Willebrand’s.
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Case 3 Example
CONSULTATION REPORT
PHYSICIAN REQUESTING CONSULTATION: Dr. D.
BRIEF HISTORY: This patient is a 67‐year‐old patient who was noted to, incidentally, have a renal mass, as well as a possible pancreas cyst. He was admitted and underwent a right nephrectomy for his renal cell carcinoma. Two days into the postoperative period, a pancreas protocol computed tomography was performed and showed a neoplasm involving the head of g p y
p
p
g
the pancreas. We were asked to see the patient for further evaluation of this cystic neoplasm to determine if he needed surgery. Patient has not had previous pancreatitis or pancreas‐associated symptoms. He has never been jaundiced. 55
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Case 3 Example
Past medical history is significant for:
1. Coronary artery disease.
2. Diabetes mellitus.
3. Hypertension.
4. Gastroesophageal reflux disease.
PAST SURGICAL HISTORY:
1. Status‐post cholecystectomy in 1991.
2. Status‐post rotator cuff shoulder surgery.
3. Status‐post tonsillectomy.
4. Status‐post laparoscopic nephrectomy on June 25, 2008.
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Case 3 Example
MEDICATIONS:
1. Insulin.
2. Glipizide.
3. Omeprazole.
4. Benicar.
5. Hydrochlorothiazide.
ALLERGIES: NKDA 57
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Case 3 Example
SOCIAL HISTORY:
This patient drinks alcohol occasionally. He is a previous smoker, although, he stopped many years ago. He is currently retired.
FAMILY HISTORY:
Family history is significant for coronary artery disease and diabetes mellitus.
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Case 3 Example
PHYSICAL EXAMINATION:
Vital Signs: Blood pressure is 145/66, pulse 75, he is afebrile.
HEENT: On examination, his sclerae are anicteric. HENT is normal.
Neck: There is no axillary or cervical lymphadenopathy.
Chest: Cardiac exam shows regular rate and rhythm without murmurs.
Lungs: Clear to auscultation.
Abdomen: Soft, flat, nontender.
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Case 3 Example
LABORATORY AND X‐RAY DATA: Laboratory studies: White blood cells 11.7, hematocrit 30%, platelets 234, blood urea nitrogen 20, creatinine 1.4, p
,
,
p p
aspartate transaminase 30, alanine transaminase 31, alkaline phosphatase 90, total bilirubin 0.6, INR 1.1.
Computed tomography scan demonstrates a 3 to 4 centimeters complex cystic mass involving the head of the pancreas, consistent with mucinous neoplasm.
Prior cardiac catheterization showed 30% stenosis of the right coronary artery
Prior cardiac catheterization showed 30% stenosis of the right coronary artery with 70% stenosis of distal circumflex, recommended for medical management, ejection fraction of 60%.
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Case 3 Example
IMPRESSION AND RECOMMENDATIONS:
This is a 67‐year‐old patient two days status‐post right nephrectomy with computed tomography scan suggesting complex pancreatic cystic mass. This will require additional evaluation and possible pancreatectomy in the future. The patient will return to see us in six weeks and follow‐up in the liver clinic
liver clinic.
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Case 4 Example
Chief Complaint: lesion on forehead
HPI: This is a 73‐year‐old man. He is seen here for the first time today. He has a history of a squamous cell carcinoma on the left arm and a basal cell carcinoma on the right forehead near the temple‐both in January. He says he has a lesion on his forehead for approximately one year. He is concerned about what it is. He thinks it may be another skin cancer. He is also concerned about thinks it
may be another skin cancer He is also concerned about
a lesion just lateral to his right eye; he is concerned this may be a skin cancer too.
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Case 4 Example
It has been present for quite awhile as well. He would also like a full skin check today. He uses a hat for sun protection. He has skin check today. He uses a hat for sun protection. He has
lived in California and has had significant sun exposure in the past.
ROS: Otherwise well, no other skin complaints.
PMH: Coronary artery disease status post bypass surgery, history of squamous and basal cell carcinomas as noted above, hay fever, and hyperlipidemia. He has had lipomas removed.
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Case 4 Example
MEDICATIONS: Tylenol, tramadol, thyroxin, fish oil, flax seed oil, simvastatin, Zyrtec, 5% saline in eyes.
simvastatin, Zyrtec,
5% saline in eyes.
ALLERGIES: NKDA
FAMILY HISTORY: No family history of skin cancer or other skin problems.
SOCIAL HISTORY: Patient is a veterinarian. He is married.
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Case 4 Example
PE: General: awake, alert and oriented. No acute distress. Skin examination of the scalp, face, neck, chest, back, abdomen, right upper extremity, left upper extremity left lower extremity right lower extremity digits nails, and extremity, left lower extremity, right lower extremity, digits,
nails and
buttocks reveals a pink papule with pearly edges and telangiectasias goring through it on the left forehead. Lateral to the patient's right eye, there is a slightly yellowish skin‐colored lobulated papule consistent with sebaceous hyperplasia. On the patient's left helix, he has a scaly ill‐defined pink papule. He has a well‐healed scar near the right temple and also on the left arm with no evidence of recurrence of skin cancer. He has multiple pink red papules and macules consistent with benign angiomas.
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Case 4 Example
A/P: 1. Likely basal cell carcinoma, left forehead; biopsy performed.
Procedure Note: Informed consent obtained. Area cleaned with alcohol and then injected with 1% Lidocaine with epinephrine. The area was then cleansed with Hibiclens. A biopsy performed with a flexible Gillette blade. Hemostasis was achieved with aluminum chloride. Dressed with antibiotic ointment and band‐aid. Wound care was discussed with patient.
2. Actinic keratosis, left helix; Treated with cryotherapy freeze‐thaw‐freeze. Wound care discussed.
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Resources
• Cahaba FAQs for E/M http://www.cahabagba.com/part_b/education_and_outreach/evaluation_
and_management_services/faqs.htm
• Cigna Cigna “Tips
Tips for Preventing Most Common Evaluation and Management for Preventing Most Common Evaluation and Management
Service Coding Errors” http://www.cignagovernmentservices.com/partb/claims/cert/Articles/Arti
cle15.html
• First Coast E/M Interactive Worksheet http://medicare.fcso.com/EM/165590.asp
• Highmark EM Specialty Forms
https://www highmarkmedicareservices com/partb/reference/scoresheet
https://www.highmarkmedicareservices.com/partb/reference/scoresheet
s.html
• Trailblazers E/M Coding and Documentation Reference Guide
http://www.trailblazerhealth.com/Specialty%20Services/Evaluation%20an
d%20Management/default.aspx
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Resources
•
•
•
•
•
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NGS http://www.ngsmedicare.com/content.aspx?CatID=2&DOCID=3544
NHIC http://www.medicarenhic.com/providers/pubs/EvaluationandManagementBilling
Guide.pdf
Noridian Administrative Services https://www.noridianmedicare.com/cgi‐
bin/coranto/viewnews.cgi?id=EkZpEVAyylqZyOfqel&tmpl=part_b_viewnews&style
=part_ab_viewnews
Palmetto http://www.palmettogba.com/internet/eandm.nsf/Established_New?OpenForm
WPS http://www.wpsmedicare.com/j5macpartb/training/resources/provider_types/eva
landmngmnt.shtml
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CPT® Disclaimer
CPT copyright 2009 American Medical Association. All rights reserved.
Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association.
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