Evaluation and
Management Services
April 2013
INPATIENT AND OUTPATIENT SERVICES
MTA, Inc
What is E&M Coding?
Evaluation and Management
Codes (E&M)

Three to 5 levels of codes for each
type/location of visit


Can document using:



2
Reimbursement dependent on level
Documentation Guidelines
Time spent in counseling and
coordination of care
1997 guidelines best for psychiatry as
includes a single system exam.
MTA, Inc
Understanding Billing Codes and
Their Requirements
Evaluation and Management Codes (E&M)
 Work Based Coding Decision based on:



3
the type and comprehensiveness of the history;
extensiveness of the examination;
complexity of the medical decision-making
MTA, Inc
Understanding Billing Codes and
Their Requirements
Evaluation and Management Codes (E&M)

New or established client groupings




4
New: client who has not received any
professional services from the physician/nonphysician practitioner or another physician of the
same specialty or sub-specialty in the same group
within the past 3 years. OMH consider the clinic
the group.
On-call: original physician’s relationship to client
rules if a part of the group
No distinction of new/established in an
emergency room
Also for payers other than Medicare,
consultations may be available codes
MTA, Inc
Understanding Billing Codes and
Their Requirements
Evaluation and Management Codes (E&M)
Time is defined differently depending on
location:


Office and OP:

Face to face time


Inpatient


5
Non face to face time is not included but included in work value
for the service
Face to face time plus work on floor or unit – reviewing
charts, talking to family or other treatment staff, etc.
Counseling and coordination of care MUST take place at
bedside or on floor unit
MTA, Inc
The Three Key Components

History: counting elements and components

Examination: counting elements

Medical Decision Making (MDM): presenting
problems, additional information reviewed to
determine diagnoses and management options and
risk associated with management options.
-6-
MTA, Inc
History
Documentation of History will include some or
all of the following elements:
• Chief Complaint (CC)
• History of Present Illness (HPI): must be taken
by prescriber
• Review of Systems (ROS): can be documented
by pati
• Past Medical, Family, and/or Social History
(PFSH)
-7-
MTA, Inc
Elements of HPI








Timing: onset of illness; description of onset – rapid, slow,
intermittent
Severity: intensity; in pain management would use a 1-10 scale;
Quality: how does it feel? What is the quality of the symptom
Location: where is it felt?
Duration: if episodic, how long last? Felt intensely for how
long?
Context: risk factors present or absent; when is it worse and
when better – night, morning, in public, at work, etc.
Modifying Factors: what makes it better – any self-help,
symptoms management; what makes it worse – symptoms are
relieved by or symptoms are made worse by
Associated Signs and Symptoms – complains of and/or denies
-8-
MTA, Inc
Review of Systems (ROS)
A ROS is an inventory of body systems obtained through
a series of questions seeking to identify signs and/or
symptoms that the patient may be experiencing or has
experienced. The following systems are recognized:







-9-
Constitutional
Eyes
Ears/Nose/Mouth/Throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary







Musculoskeletal
Integumentary
Neurological
Psychiatric
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic
MTA, Inc
Review of Systems - ROS

An earlier ROS does not need to be re-recorded. Instead,
correlate to the previous ROS by noting the date and location
of the earlier ROS.

A review of systems may be recorded by ancillary staff or on a
form completed by the patient. To document that the physician
reviewed the information, there must be a notation
supplementing or confirming the information recorded by
others.

For a Complete ROS, you may document all positive or
pertinent negative responses and then state “all other systems
reviewed and negative”. At least 2 positive or pertinent negative
must be documented and then can do the round-up of all
others.
-10-
MTA, Inc
Past, Family, & Social History - PFSH
Past
Medical/Psych
History
Family History
Social history
-11-
Behavioral Health Treatment,
Medications
Hospitalizations, Allergies
Chronic Diseases
General Medical Hx, developmental Hx, if
appropriate
Parents, Siblings, Etc.
Specific Diseases Related to CC, e.g. substances, MH
Hereditary/Congenital Diseases
Marital Status/Family Structure
Employment and Military Hx
Legal Hx
Sexual History
Education
Hobbies
MTA, Inc
History - Special Exception

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 that
precludes obtaining a history.

History will be considered comprehensive

Example: “Unable to obtain history - patient
unconscious”
-12-
MTA, Inc
Documentation of History Summary:
3 of 3 required
History of
Present Illness
(HPI)
Review of Systems
(ROS)
Brief
N/A
Past, Family,
and/or Social
History
(PFSH)
N/A
Brief
Problem-Pertinent
N/A
1-3 elements
1 system
Expanded ProblemFocused
Extended
Extended
Pertinent
Detailed
4+ elements
2-9 systems
1 area
Extended
Complete
Complete
4+ elements
>9 systems
3 areas
Type of History
Problem-Focused
1-3 elements
Comprehensive
* Lowest level of the 3 components determines level of
-13-
history
MTA, Inc
1997 Documentation of Psych Examination




Problem Focused One to five elements identified
by a bullet.
Expanded Problem Focused At least six elements
identified by a bullet.
Detailed At least nine elements identified by a
bullet.
Comprehensive Perform all elements identified by
a bullet from constitutional and psyc section and
at least one element from the Muculoskeletal
section.
-14-
MTA, Inc
Medical Decision Making - MDM
Number of
Diagnoses or
Management
Options

Amount and/or
Risk of
Complexity of Data Complications and/or
to be Reviewed
Morbidity or
Mortality
Type of Decision
Making
Minimal
Minimal or none
Minimal
Straightforward
Limited
Limited
Low
Low Complexity
Multiple
Moderate
Moderate
Moderate Complexity
Extensive
Extensive
High
High Complexity
Remember, two of the three elements must be
met or exceeded.
Medical Decision Making - MDM
Number of
Diagnoses or
Management
Options

Amount and/or
Risk of
Complexity of Data Complications and/or
to be Reviewed
Morbidity or
Mortality
Type of Decision
Making
Minimal
Minimal or none
Minimal
Straightforward
Limited
Limited
Low
Low Complexity
Multiple
Moderate
Moderate
Moderate Complexity
Extensive
Extensive
High
High Complexity
Remember, two of the three elements must be met
or exceeded.
Coding E&M

Outpatient: often the MD must code the service
themselves



May have nursing or other billing back-up
Templates have to be helpful in assisting with the coding
Inpatient: professional coders will code the service based
only on your documentation


17
Templates: dictation or EMR provide guidance and reminders
Paper records: take your cheat sheets with you
MTA, Inc
Example: Documentation Outpatient

The client is a 23 year old female who needs a refill of their
prescription for Lithium and Klonopin. Client moved to area 2
months ago from Florida. Diagnosed with bi-polar disorder at
age of 17 years. States she is well-controlled on current
medications. States she is compliant with meds and uses
Klonopin only 2-3 times a week for sleep, usually after stressful
work days or fights with boyfriend.
18
MTA, Inc
Example: Documentation

( CC:The client is a 23 year old female who needs a refill of their
prescription for Lithium and Klonopin.) (PFSH 1: Client moved to area 2
months ago from Florida.) (HPI 1: Diagnosed with bi-polar disorder at age
of 17 years. HPI 2: States she is well-controlled on current medications. HPI
3: States she is compliant with meds and HPI 4: uses Klonopin only 2-3
times a week for sleep, usually after (PFSH 2: stressful work ) days or
(PFSH 3: fights with boyfriend. )
CC: yes
 PFSH: 1 count –only social history, no past medical or family hx
 ROS: none
 HPI: Brief to extended problem pertinent
Equals: Problem Focused History

19
MTA, Inc
HPI Factors








Timing: yes onset described
Severity: yes well controlled
Quality:
Location:
Duration:
Context: yes – use of Klonopin
Modifying Factors: yes - compliant with medication
Associated Signs and Symptoms:
20
MTA, Inc
Example: New Client

PX: WDWN female in no acute distress; temp 98.6, pulse 68, BP 120/70,
respirations 20. HEENT within normal limits; MSE normal, oriented x 3.



Impression: Bi-polar disorder, stable on present medications.


1995 Guidelines: 3 systems = Expanded problem focused – vitals, HEENT, MSE 1
element
1997 Guidelines: one system for psych – depends on completeness of MSE –
need more detail in documentation or cannot be counted – vitals and only 1
element of MSE
Client stable with known illness; even though med management brings it to
moderate level risk all other elements are for “straightforward”.
Plan: Prescription for 60 days; Lithium level now; client to check back
sooner if any problems; client referred to Health Center for annual checkup. No case management or other MH needs at this time. RTC in 60 days.
21
MTA, Inc
Example: Documentation




Problem-focused history
Problem to Expanded problem focused exam
Straightforward medical decision-making
Equals: 99201
22
MTA, Inc
How Codes Chosen


Outpatient Services chart
Inpatient Services chart
23
MTA, Inc
Special Coding Considerations
Time-based, Consultations, and Prolonged Services
Understanding Billing Codes and
Their Requirements
Evaluation and Management Codes (E&M)

If counseling and coordination of care are 50%
or more of the time spent in the encounter:



25
E&M become time-based codes
Counseling and coordination of care must be
documented
Time spent in C&CofC and total time must be
documented
MTA, Inc
Level of Service Based on Time


TEACHING PHYSICIANS: teaching physician may not
add time spent by the resident in the absence of teaching
physician to face-to-face time spent with the patient by
the teaching physician with or without the resident
present .
Example:


26
“30 of 45 minutes on the floor concerned the coordination of
____________ care and in discussion with patient and family
about treatment options. Will follow-up with them tomorrow
after they have had time to discuss.
“30 of 40 minutes spent at __________ bedside discussing
medications and plans to ………”
MTA, Inc
Consultation Services
Documentation required:






The service is provided by a physician/NPP whose opinion/advice regarding
the evaluation and management of a specific issue is being sought and has
been requested by a provider.
The request is recognition of the consultant’s expertise in a specific
medical area beyond the requesting provider’s knowledge;
The request must be documented in the medical record including
why and from who the consult is being sought.
A written report of the consultant’s findings, opinions, and
recommendations is documented in the inpatient record.
Intent is to return the patient to requesting provider for ongoing care of
the problem.
The consultant may:
 Perform or order diagnostic tests, or
 Initiate a treatment plan, including performing emergent procedures.
27
MTA, Inc
Prolonged Services




Only count the duration of direct face-to-face contact between the physician
and the patient (whether the service was continuous or not) beyond the
typical/average time of the E/M visit code billed for the same date of service.
Must be 30 minutes or more beyond the typical time assigned to the E/M level
coded
 Example: Average time for 99232 = 25 minutes, so a minimum of 55 minutes
would be required to also bill 99356.
Cannot bill prolonged services:
 Based on time spent reviewing charts or discussing a patient with house
medical staff without direct face-to-face contact with the patient.
 These are add-on codes must have an underlying inpatient E/M service on
the same date of service
 If the total duration of direct face-to-face time does not equal or exceed the
threshold time for the level of E/M service the provider is billing
When the E/M service is selected based on time, prolonged services may only
be reported as the companion code with the highest code level in that family of
codes (i.e., 99223, 99233, or 99255).
28
MTA, Inc
Split Visits








This is a shared visit between a physician and an NPP
(within scope of practice) from the SAME practice.
Can occur in hospital inpatient, outpatient (incident to)
or ED
Each perform a part of the E&M service
Physician MUST provide a face to face portion of the
E&M (clearly documented)
Same patient and same DOS
There is NO supervision requirement
Each documents their portion
Signatures and credentials of both
29
MTA, Inc
Split Visits


This is not simply a review of the work of the NPP –
physician must clearly perform a face to face portion of
the E&M
NO:





Seen and agree
Discussed and agree
Pt. seen and evaluated
Code is chosen using combined work and documentation
Billed at 100% of physician schedule
30
MTA, Inc
Split Visits

CNS makes a morning round and sees patient for
subsequent hospital visit


Interval history and exam
Psychiatrist comes later in pm and sees patient, reviews
earlier note, does brief exam and writes orders for labs,
makes medication changes.
31
MTA, Inc
Thank You!
For additional information: Mary Thornton
mthornton@marythornton.com
617-730-5800
32
MTA, Inc