Evaluation &
Management
Services
UCSF Clinical Enterprise Compliance Program
Documentation & Reporting
New Approach to the Same Old
Story
UCSF Clinical Enterprise Compliance Program
UCSF Clinical Enterprise
Compliance Program
CECP Education Series
Wanda T. Ziemba MFA RHIT CPC
Medical Center Compliance
Manager & CECP Educator
UCSF Clinical Enterprise Compliance Program
MGBS Brown Bag Series
March 17, 2006
UCSF Clinical Enterprise Compliance Program
Agenda

Brief presentation
– E&M Issues
– Consultation Guidelines
– Teaching Physician Guidelines
– Questions
UCSF Clinical Enterprise Compliance Program
The New, New, New Guidelines
UCSF Clinical Enterprise Compliance Program
Documentation Guidelines

1995 E&M Guidelines
– Body Areas & Organ Systems
– One “Point” for Each BA/OS
– Favored Primary Care

1997 E&M Guidelines
– “Bullet” System
– Discrete Examination Elements
– Fair to Specialists
UCSF Clinical Enterprise Compliance Program
NHIC




You may use either the
1995 or the 1997
guidelines, whichever
provides the most
advantage
NHIC reviews according
to the 1997 guidelines
Easier to validate content
More difficult to support
higher levels
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History
 1995/1997-10+
documented ROS
required
 1999-proposed 2 of 3 history
elements
 Focused to comprehensive
 2002 – menu options for history
UCSF Clinical Enterprise Compliance Program
Physical Examination

1995/1997-detailed
– Lower extremity exams required for
comprehensive
– Detailed exam
1999-proposed 200+ list
 Exact requirements not yet known
 2003 – scenario based

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Medical Decision
 1995/1997-calculated
based on
– Problems
– Data reviewed/ordered
– Risk table
 1999-proposed
one table
encompassing all three areas
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Seven Components of
Evaluation & Management
Services
The SOAP Note Expanded,
Revisited and Beaten Into
Submission
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Key Elements

History as related to the patient’s
presentation

Physical Exam as related to the
patient’s presentation

Medical Decision in managing patient
UCSF Clinical Enterprise Compliance Program

New patients, consultations, ED and Admits –
3 of the 3 key elements

Established patients,
subsequent hospital
care – 2 of the 3 key
elements

Medical Decision is
prime
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Contributing Elements

Counseling with the patient and/or
family

Coordination of care

Nature of the presenting problem

Time
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Purpose

Remember the primary focus of the
medical record

Continuity of patient care

Legal documentation

Legible progress notes

Not just for “billing”
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History

Focused
– (CC, 1-3 HPI)

Expanded
– (CC,1-3 HPI, 1 ROS)

Detailed
– (CC,4+ HPI, 2-9 ROS, 1 PFSHx)

Comprehensive
– (CC, 4+ HPI, 10+ ROS, 2-3 PFSHx)
UCSF Clinical Enterprise Compliance Program
25yo m dilated & hypertrophic CM w/ mild MR,
hyperthyroidism
Concerns re: STDs; contact 1 wk ago, irritation,
burning on urination, OTC tinactin, no Δ
No D/C, partner x 1 w/yeast infx,
Ǿ IVD/Tattoos – energy level Ǿ Δ
Ǿ CP, Ǿ CHF Sx’s, Ǿ palps
↑weight 5 lbs
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CC
HPI
ROS
PFSHx
Genital
irritation
Duration;
context;
assoc.
s&s;
modifying
factors
Constitutional;
cardiovascular
Partner w/yeast
infx;
Dilated &
hypertrophic CM;
mild MR;
hyperthyroidism
4 HPI
2 ROS
2 PFSHx
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Level
Detailed

How specific should
the medical record
documentation be?
Is “negative” or
“benign” appropriate
when detailing
examination
findings?
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Physical Examination

Focused
– (1-5 bullets, 1 BA/OS)

Expanded
– (6-11 bullets, 2-7 BA/OS)

Detailed
– (12 bullets, 2-7 BA/OS)

Comprehensive
– (18+ bullets, 8+ organ systems)
UCSF Clinical Enterprise Compliance Program
The patient is a 25 year old white male, alert &
orient x 3,
cooperative and in NAD.
VS: 110/70, 60, 5’9”, 179 lbs
AT NC PERRLA EOMI Neck Ǿ LAD
Ǿ TM
PMI ND S1 S2 (↑ A2) HS nml apex
CTAB no retractions
R shoulder notable >> larger L shoulder?
Ǿ C/C/E nml pulse + foreskin, Ф irritation Ф
discharge
Ǿ no mass test Ф hernia
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BA/OS
1995
1997 Comment
Cons
1
2
GA & VS (when at least 3)
Eye
1
1
Pupils & iris
Head
1
ENMT
1
1
TM
CV
1
4
Auscultation, palpation, edema, pulses
Resp
1
2
Auscultation & effort
Ext
2
MS
Under MS in 1997 guidelines
Not in 1997 guidelines
3
Inspection/palpation 3 areas
Lymph
1
1
Cervical
GU
1
3
Penis, testicles, hernia
Psych
1
2
Mood & affect, orientation
Neuro
1
EOMI
– Cranial
nerves
Enterprise
Compliance
Program
1UCSF Clinical
BA/OS
1995
1997
Totals
8 OS
Comprehensive
20 Bullets, 6 systems with
2 or more PE elements
Detailed
3 BA
N/A
Totals
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The Extreme Extremities
Extremities are obvious in the 1995
guidelines (remember to not count Body
Areas for the comprehensive level of
service)
 Where do extremities belong in the
1997 guidelines?
 Varies with specialty performing service
and presenting problem

UCSF Clinical Enterprise Compliance Program
The Nebulous Neck
Neck is considered a body area and yet
is listed separately in the 1997
guidelines
 Placement will be determined by the
physical examination findings
 May be Musculoskeletal, Lymphatic,
Endocrine

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Problems, Data, Risk
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Medical Decision

Presenting problem
– New/established, improving/worse,selflimiting

Data reviewed
– Type, independent review, discussion

Risk
– Selected from the Morbidity/Mortality Table
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Are You a Psychic
How can you tell if there has been an
independent review of source materials
or films?
 Note the language documented

– Personally reviewed; wet reading

Consider the level of detail in the
medical record
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Medical Necessity/Time
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Time


More than 50% of total face-to-face time
Counseling

Treatment options, risks & benefits,
patient/family education, discussion of
results

Choose based on total time
Document both total and counseling time
Only on E&M’s with suggested time


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Consultations


New guidelines
require the request
as well as the
opinion to be
documented in the
medical record
Must be requested
by a faculty
physician
UCSF Clinical Enterprise Compliance Program
Transmittal R788
Deletion of follow-up and confirmatory
consultations
 Revised definitions
 Updated documentation requirements
 Second opinion s are assigned Inpatient
Consultation codes if the consultation
requirements have been met

UCSF Clinical Enterprise Compliance Program

Carriers shall instruct physicians and qualified
NPPs that a consultation request may be
verbal however the verbal interaction
identifying the request and reason for a
consult shall be documented in the medical
record by the requesting physician or
qualified NPP, and also by the consulting
physician or qualified NPP in the patient’s
medical record.
UCSF Clinical Enterprise Compliance Program
Teaching Regulations –
History

IL372 – initial teaching institution
guidelines
– Intermediary Letter Outlining the extent of
Attending participation required for
reporting purposes
– Basic guidelines; no address of current
technology such as EHR or macros
– Medicare only
UCSF Clinical Enterprise Compliance Program
Medicare reimburses for clinical
activities under Part A and Part B
 Part A represents hospital services
and GME funds (Facility)
 Part B is attending physician
services (Pro-Fee)

UCSF Clinical Enterprise Compliance Program

Medicare will
reimburse for
services
predominantly
supplied by the
House Staff when the
faculty physician
personally provides
direct services and
the medical record
reflects that face-toface encounter
UCSF Clinical Enterprise Compliance Program
Further Refinements to the
Medicare regulations

Transmittal 1780 – November 22, 2002
– Developed specific language
– Detailed definitions
– Additional guidelines for surgical and
anesthesia services
UCSF Clinical Enterprise Compliance Program
January 13, 2006 Transmittal

Revised Definitions
– Resident, Interns & Fellows
– Student
– faculty Physician
– Direct Medical Services
– Physically Present
UCSF Clinical Enterprise Compliance Program
Three Scenarios

The faculty physician personally
performs all the required elements of
the E&M service without a resident
– The attending documents as if in a nonteaching setting
UCSF Clinical Enterprise Compliance Program

The resident performs the elements
required for the E&M service either
jointly with or in the presence of the
faculty physician
– The faculty physician’s note should
reference or “link” to the resident’s note
UCSF Clinical Enterprise Compliance Program

The resident performs the required
elements in the absence of the faculty
physician; the faculty physician
independently performs the required
elements with or without the resident
present and, as appropriate, discusses
the case with the resident.
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Acceptable Linkage


“See resident’s note for details; I saw and
evaluated the patient and agree with the
resident’s findings and plans as written”
“I was present with the resident during the
history and physical examination; I discussed
the case with the resident and agree with the
findings and pan as documented in the
resident's note.”
UCSF Clinical Enterprise Compliance Program
Unacceptable Linkage
“Agree with the above”
 “Rounded, reviewed, agree”
 Countersignature only
 “Seen and agree”
 “Patient seen and evaluated”

UCSF Clinical Enterprise Compliance Program
The resident may not document the
presence of the faculty physician
 The faculty physician should document
some pertinent details to satisfy the
Medi-Cal requirements
 Physical presence must be documented
by the faculty physician

UCSF Clinical Enterprise Compliance Program
 However,
Medi-Cal will not
reimburse for any indirect patient
care (22 CA CCR § 51503)
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 No
reimbursement for services
supervising house staff
 No reimbursement allowed for
attending “teaching” time
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When Will Medi-Cal Pay?
(1) They are performed for necessary
treatment of the patient;
(2) They are not an exercise of
teaching supervision without direct
patient care services being provided;
(3) They do not duplicate any medical
services billed by any other provider;
and
UCSF Clinical Enterprise Compliance Program

4) The faculty physician is not on
salary or contract to the hospital for the
direct patient care services provided.
No professional fees are payable for
services provided independently by
residents or students in a teaching
setting.
UCSF Clinical Enterprise Compliance Program
The Medi-Cal program, through its
intermediary, will pay allowable MediCal rates for direct patient care services
in a teaching setting when directly
provided by faculty physicians only
when such services are provided and
billed in accordance with program
policies and regulations of the
Department of Health Services and
when:
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Errors?
What Happens If Our Practice
Misunderstands the Regulations?
UCSF Clinical Enterprise Compliance Program

Some practices are developing
compliance plans; CMS is very
interested in how providers code and
document.
UCSF Clinical Enterprise Compliance Program
Carrier Audits

Just what are the chances that my practice
will face a carrier audit? How can I plan for
targeted areas?
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Now you know the answers…
UCSF Clinical Enterprise Compliance Program