Evaluation & Management
Services
1
What is documentation and why is it
important?
 Medical record documentation is required
for reporting pertinent findings, facts and
observations about a patients health
history.
 The medical record documents patient care
showing the chronology of treatment,
communication between physicians,
quality of care, and collection of data.
2
General principles of documentation

Medical record should be complete
and legible.

Documentation should include:




Chief complaint
Exam and Diagnostic Test results
Assessment
Plan
3
E/M Coding
 Key Components



History
Physical Examination
Medical Decision Making
 Contributory Factors

Nature of the presenting problem
• Medical Necessity drives code selection



Extent of counseling
Coordination of care
Time
4
E/M Guidelines
 Medicare and Commercial Insurance

CMS 1995 and 1997 E/M guidelines
• Use either set
• 1997 approved by AMA
 Medicaid


Does not use ‘95 or ‘97 guidelines
Uses AMA guidelines found in the CPT book
• E/M Service Guidelines section list “Instructions
for selecting a Level of E/M Service”
5
Medical Necessity
 A service that is reasonable and
necessary for the diagnosis and
treatment of illness or injury, or to
improve the functioning of a malformed
body member.
Government definition
6
STEP ONE - HISTORY
7
 Definitions

History
Chief complaint (CC)
• Reason for the visit

History of present illness (HPI)
• chronological description of the development of the patient’s
illness from the 1st sign and/or symptom to the present.

Review of systems (ROS)
• is an inventory of body systems obtained through a series of
questions asked by the physician seeking to identify signs
and/or symptoms that the patient may be experiencing or has
experienced

Past, Family, Social, History (PFSH)
8
History
 Definitions - Cont
 Past, Family, Social, History (PFSH)


The PFSH consists of a review of one or more of the
following three areas of the patient’s history:
• Past History (P)
• Family History (F)
• Social History (S)
The PFSH is considered to be interval history for
subsequent inpatient visits.
• Interval history - any new history information obtained since
the last “physician-patient” encounter
9
History
 Problem Focused




Chief Complaint
Brief HPI (1-3)
No ROS
No PFSH
 Expanded Problem
Focused




Chief Complaint
Brief HPI (1-3)
Problem pertinent ROS (1)
No PFSH
ALL 3 elements must be
met: HPI,ROS,PFSH,
FOR A NEW PATIENT.
Detailed
 Chief Complaint
 Extended HPI (4 or status of
3 chronic/inactive)
 Extended ROS (2-9)
 Pertinent PFSH (1)
Comprehensive
 Chief Complaint
 Extended HPI (4 or status of
3 chronic/inactive)
 Complete ROS (10)
 Complete PFSH (2 or 3
based on category of E/M)
10
CPT History Guidelines
(Medicaid)
 Problem focused: CC; brief HPI
 Expanded problem focused: CC; brief HPI, problem
pertinent ROS
 Detailed: CC; extended HPI, problem pertinent ROS
extended to include a review of limited number of
additional systems; pertinent PFSH directly related to the
patient’s problems
 Comprehensive: CC; extended HPI, ROS which is
directly related to the problem(s) identified in the HPI plus
a review of all additional body systems; complete PFSH
11
Elements of History
HPI








Location
Quality
Severity
Duration
Timing
Context
Modifying factors
Associated signs and symptoms
12
Elements of History - HPI
 Location – place, whereabouts, site, position. Where on
the body is the patient experiencing signs or symptoms?
(e.g., pain in groin)
 Quality
– A description, characteristics, or statement to
identify the type of sign or symptom. (e.g., burning pain
in groin)
 Severity – Degree, intensity, ability to endure. (e.g.,
History of mild burning pain in groin that has become
more intense)
13
Elements of History - HPI
 Duration – Length of time. How long has patient been
experiencing the signs or symptoms? (e.g., History of
intermittent mild burning pain in groin that has become
more intense and frequent for the last two weeks)
 Timing – Regulation of occurrence. A description of
when the patient experiences signs or symptoms (e.g.,
history of intermittent mild burning in groin that has
become more intense and frequent for the last two
weeks).
14
Elements of History - HPI
 Context – Circumstances, cause, precursor, outside
factors. A description of where the patient is or what
the patient does when the signs or symptoms are
experienced (e.g., history of intermitted mild burning
pain in groin that has become more intense and
frequent for the last two weeks since the patient bent
down to pick up son and continues to feel intense pain
when bending).
15
Elements of History - HPI
 Modifying Factors – Elements that change, alter or
have some effect on the complaint or symptoms (e.g.,
history of intermittent mild burning pain in the groin
that has become more intense and frequent for last
two weeks since the patient bent down to pick up son;
continues to feel intense pain when bending. Patient
currently on Motrin 800 mg BID for past 3 weeks
without relief)
 Associated Signs and Symptoms – Factors or
symptoms that accompany the main symptoms. What
other factors does patient experience in addition to
this discomfort/pain? (e.g., Shortness of breath, lightheadedness, nausea/vomiting)
16
Elements of History - ROS













Constitutional (e.g., fever, weight loss/gain, lack of appetite)
Eyes
Ears, nose, throat, mouth
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary (skin and/or breast)
Neurological
Psychiatric
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic
17
Documentation Example of ROS
 Patient denies loss of consciousness. He
has not had any bowel or bladder
problems. All other systems are negative.
18
Evaluation of Sample ROS
 Patient denies loss of
consciousness or
bowel/bladder
problem. All other
systems are negative.
 Neurological = loss
of consciousness
 Gastrointestinal = no
bowel Program
 Genitourinary = no
bladder problems
 All other neg
19
Element of History - Past/Family/Social
History - (PFSH)
 Past History: the patient’s history of illnesses,
operations, injuries, treatments, medications.
 Family History: a review of medical events in
the patient’s family, including diseases which
may be hereditary or place the patient at risk.”
 Social History: Contains marital status and/or
living arrangements; current employment;
occupational history; use of drugs, alcohol and
tobacco; level of education, sexual history; or
other relevant social factors.
20
Body Areas vs. Organ Systems
The exam components are divided up between body areas and organ
systems. These can be combined when counting elements for exam.
 BODY AREAS







Head, incl. Face
Neck
Chest, incl. Breasts &
axillae
Abdomen
Genitalia, groin, buttocks
Back, incl. Spine
Each extremity
 ORGAN SYSTEMS












Constitutional (vitals & general
appearance)
Eyes
ENT, mouth
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
Neurologic
Psychiatric
Hematologic/Lymphatic/Immunologic
21
History CASE STUDY
New patient is complaining of a white
vaginal discharge for the past 2 days with
a heavier flow in the morning. There is no
change with Monistat. Patient denies
itching burning with urination or fever.
Patient has had 2 sexual partners in the
past 60 days
22
History CASE STUDY
 What is the patient’s CC ?

Vaginal Discharge
 What are the patient’s Elements of HPI?
1.
2.
3.
4.
Location - vaginal
Duration - past 2 days
Timing - a heavier flow in the morning
Modifying factor - There is no change with Monistat
 What is the Level of HPI?

Ans: Detailed
CASE STUDY
New patient is complaining of a white vaginal discharge for the past 2
days with a heavier flow in the morning. There is no change with
Monistat. Patient denies itching burning with urination or fever.
Patient has had 2 sexual partners in the past 60 days
23
History CASE STUDY
 What is/are the ROS?



Integumentary - itching
Genitourinary - burning with urination
Constitutional - fever
 What is the Level of ROS?
Ans: Detailed
 What is/are the patient’s PFSH



PH (past history) – N/A
FH (family History) - N/A
SH – (social history) - Patient has had 2 sexual partners in the
past 60 days
 What is the Level of PFSH?
Ans: Detailed
CASE STUDY
New patient is complaining of a white vaginal discharge for the past 2 days with a
heavier flow in the morning. There is no change with Monistat. Patient denies itching
burning with urination or fever. Patient has had 2 sexual partners in the past 60 days
24
History CASE STUDY ANSWER/EXPLANATION
 History Level = Detailed (3 of 3)




CC
HPI = Extended (4+ elements)
ROS = Extended (3 elements)
PFSH = Pertinent (1 element)
EXAMPLE
CC - Vaginal discharge
HPI - New patient is complaining of a white vaginal (location)
discharge for the past 2 days (duration) with a heavier flow in the
morning (timing). There is no change with Monistat (modifying factor).
ROS - Patient denies itching (integumentary), burning with urination
(genitourinary) or fever (constitutional).
25
PFSH - Patient has had 2 sexual partners in the past 60 days (social)
STEP TWO – EXAMINATION
Performed by Physician
26
Physical Exam
 Problem Focused


(95)<1 body area/
organ system
(97) 1-5 elements
 Expanded
Problem Focused


(95) 2-4 body areas/
organ systems
(97) 6 - 11 elements
 Detailed


(95) 5-7 body areas/organ systems
(97) 12 elements in 2+areas/systems
 Comprehensive

(95) 8 organ systems
(97) General exam: Perform all
elements document at least 2 elements
in each of 9 areas/systems

27
CPT Physical Exam Guidelines
(Medicaid)
 Problem focused: limited exam of the affected
body area or organ system
 Expanded problem focused: limited exam of the
affected body area or organ system and other
symptomatic or related organ system(s)
 Detailed: extended exam of the affected body
area(s) and other symptomatic or related organ
system(s)
 Comprehensive: general multi-system exam or
a complete exam of a single organ system
28
Physical Exam Example
 Vaginal Discharge Exam


Constitutional
• BP, temp, pulse
Genitourinary
• Examination of external genitalia
• Examination of cervix
 What is the Level of the Physical Exam?
ANS: Problem Focused = (At least two body
areas/organ systems)
CASE STUDY
New patient is complaining of a white vaginal discharge for the past 2 days
with a heavier flow in the morning. There is no change with Monistat.
Patient denies itching burning with urination or fever. Patient has had 2
sexual partners in the past 60 days
29
STEP THREE
MEDICAL DECISION-MAKING
30
MEDICAL DECISION-MAKING
 MDM refers to the complexity of
establishing a diagnosis and/or
selecting a management option.
 MDM is the function of 3 variables
1. Number of diagnoses and/or management options
2. Amount &/or complexity of data that must be
obtained, reviewed &/or analyzed
3. Risk of significant complications, morbidity &/or
mortality
31
Number of Diagnosis and/or
Management Options
Self Limited or Minor; stable, improving,
worsening
x1
Established Problem*; stable, improved
x1
Established Problem*; worsening
X2
New Problem*; no workup planned
X3
New Problem*; addl. workup planned
x4
Total Diagnosis or management options
32
Amount and/or Complexity of Data
 Documentation should include:
 Diagnostic service:
• Ordered, planned, scheduled or performed

Review of tests results
• Simple notation or initialing & dating

Decision to obtain old records or additional History

Relevant findings from review of old records

Discussion of results with performing physician

Direct visualization and interpretation
33
Risk of Complications, Morbidity
and/or Mortality
 Refers to patient’s level of risk at the
visit
 Sources of risk



Presenting problem
Diagnostic procedures ordered
Management options selected
 Illustrated by clinical examples in
“Table of Risk”
34
Documented Example of MDM
A/P (assessment/plan): By history, suspect
possible herniated disk. Patient will be
referred for MRI scan. Prescribe Motrin
800 mg, tid with food, Vicodin for pain.
35
Evaluation of MDM
A/P: By history,
suspect possible
herniated disk.
Patient will be
referred for MRI
scan. Prescribe
Motrin 800 mg, tid
with food, Vicodin
for pain.
 Number of dx/tx
options = new
problem with addl
workup
 Amt/complexity
of data = ordered
MRI
 Risk = prescription
management
36
Decision Making
 Straightforward


#Diagnostic/treatment
options (0 -1)
Amt./complexity of data
 Moderate Complexity


(0 -1)

Risk (minimal)
 Low Complexity

#Diagnostic/treatment
options (2)

Amt./complexity of data

#Diagnostic/treatment
options (3)
Amt./complexity of data (3)
Risk (moderate)
 High Complexity



#Diagnoses/mgmt options (4)
Amt./complexity of data (4)
Risk (high)
(2)

Risk (low)
37
Decision Making
Straightforward



minimal number of diagnoses or management options considered.
little, if any, amount or complexity of data reviewed.
minimal risk of complications or morbidity or mortality (expectation of
full recovery without functional impairment).
Low Complexity



limited number of diagnoses or management options considered.
limited amount and complexity of data reviewed.
low risk of complications or morbidity or mortality (uncertain outcome
or increased probability of prolonged functional impairment.
38
Decision Making
Moderate Complexity
 multiple number of diagnoses or management options considered.
 moderate amount and complexity of data reviewed.
 moderate risk of complications or morbidity or mortality (uncertain
outcome or increased probability of prolonged functional impairment or
high probability of severe prolonged functional impairment).
High Complexity
 extensive number of diagnoses or management options considered
 extensive amount and complexity of data reviewed
 high risk of complications or morbidity or mortality (uncertain
outcome or increased probability of prolonged functional impairment
or high probability of severe prolonged functional impairment) .
39
CPT MDM Guidelines
(Medicaid)
 Complexity measured by:



# of possible diagnoses and/or the number of
management options that must be considered.
Amount/complexity of records, tests, other
information that must be obtained, reviewed, and
analyzed.
Risk of significant complications, morbidity,
mortality, as well as co-morbidities, associated
with the patient’s presenting problem(s), the
diagnostic procedure(s) and/or the possible
management options.
40
Table of Risk Examples
Presenting Problem
 Minimal – One self-limited or minor problem.
 Low – Two or more minor problems, one stable
chronic illness, acute uncomplicated illness.
 Moderate – Chronic illness with exacerbation, two of
more stable chronic illnesses, undiagnosed new
problem with uncertain prognosis, acute illness with
systemic pneumonitis, acute complicated injury
 High – Chronic illness with severe exacerbation,
acute or chronic illness that poses threat to life,
abrupt change in neurologic status.
41
Decision Making Example
 Vaginal Discharge Exam

New problem, additional workup planned
• Lab is ordered (4)

Review/order tests in 8xxxx series (1)
 What is the Level of Medical Decision Making?

ANS: Moderate (2 0f 3)
Moderate decision making
• Undiagnosed new problem with uncertain prognosis
• Prescription drug management
– Prescription written



Extensive # Diagnosis/treatment options
Minimal amount of data to be reviewed
Table of Risk - Moderate
42
Level Assignment
EXAMPLE/CASE STUDY CPT BOOK
 History = Detailed
 Physical Exam = Problem Focused
 Decision Making = Moderate
 What is the code for a New & Established
Patient?
ANSWER
Level = 99203, new patient
If Established Patient = 99214
43
Contributing Factors
 Presenting Problem





Minimal
Self-Limited/Minor
Low Severity
Moderate Severity
High Severity
 Time


FACE-TO-FACE
Time is a key factor ONLY when:
• Counseling or coordination of care takes up OVER
50% of the total visit time
44
Consultation Code Selection
45
Definition of Consultation
 “A type of service provided by a physician
whose opinion or advice regarding evaluation
and/or management of a specific problem is
requested by another physician or other
appropriate source.”
 Payment for consultation is often significantly
higher than other E/M service
46
Consultation vs. Referral
Consultation:




Requires a physician
request for an opinion
or advice.
Request and reason for
consult must be
documented.
Evidence of opinion
and/or advice
communicated back to
requesting physician.
Referral:




Is a transfer of care for
treatment of a specified
problem.
Is for a known problem.
Physician plans to
manage the patient’s
care and treatment.
No report to referring
physician is required.
UPIN is required.
47
Four Elements That Distinguish
A Consultation
1.
2.
A type of service provided
by a physician whose
opinion or advice
regarding evaluation
and/or management of an
unknown or uncertain
problem is requested by
another physician or
appropriate source.
The written or verbal
request for a consultation
must be documented in
the medical record.
3. The consulting physician
may initiate diagnostic
or therapeutic services
at the consultation or
subsequent visit.
4. The consulting physician’s
opinion and any services
ordered or performed must
be:
a) Documented in the
medical record; and
b) Communicated by
written report to the
requesting physician or
other appropriate
source.
48
Types of Inpatient Consultations
 Initial Inpatient



No difference in new or
established
 Follow-up Inpatient

Used to complete an
initial consultation
Reported one time
during hospital stay
• Complete initial
consult, initiated by
consulting physician
Requires 3 of 3 key
components be
documented
• Subsequent consult,
initiated by attending
physician

Requires 2 of 3 key
components be
documented
49
Counseling/Coordination of
Care
 Main factor determining code when takes up
MORE than 50% of the total visit time

Documentation:
• Total visit time
• Time spent in Counseling/Coordination of Care
– Face to face
• Subject/ content
 Code level is based on the total visit time

not just the time spent in counseling
50
Counseling Examples
 Established patient, 20 minute visit to followup on oral contraceptive use


NP 99213
RN 99211 (MA 99213)
 15 minutes of a 20 minute visit spent
counseling the patient on alcohol and
cigarette use during pregnancy


NP 99213
RN 99211 (MA 99213)
51
Definitions
 New Patient

Has not received face-to-face services
from
• ANY provider in the agency
• Within past 3 years (AMA)
 Established Patient

Has received face-to-face services from
• ANY provider in the agency
• Within past 3 years (AMA)
52
Selecting a Level of E/M
 Identify



Place of service (POS) = where (office)
Type of service (TOS) = what
(Problem/Preventive)
Status of Patient = who (New/Established)
 Determine the extent of history - physical
exam - decision making - counseling

Must consider all factors, and make sure adequate
DOCUMENTATION in chart to justify code.
53
Office
99201-99215
 Report Problem visit (vs. Preventive visit)
 99201-99205, 99212-99215 performed by
MD, NP, PA,CNS
 99211 - Ancillary staff i.e. RN, LPN, CNA

MD/NP must be in the clinic
 Report only 1 E/M per day
 Report diagnostic tests, studies,
procedures separately
54
Office
99201-99215
(Medicaid)
 99201-99205, 99212-99215 may be
performed by any staff of a “certified family
planning clinic”. Staff may be MD, NP, PA,
RN, CMA or unlicensed personnel acting in a
coordinated manner to provide the service(s).
 Other reporting requirements are the same as
other providers
55
Preventive Medicine Services
56
Preventive Medicine
99381-99397
 Routine management of patients without
presenting problems, i.e. annual, routine,
well child exams
 Performed by (MD,NP,PA,CNS)

Includes other clinic staff if Medicaid
 Codes


New/established patients
Age
 Not used for scheduled follow-up visits for
specified problems
57
CASE STUDY

Susan Johnson was referred to Dr. Jones’ office for
her opinion of Susan’s chronic low back pain
radiating to the leg. Dr. Jones took a detail history,
performed a detailed examination, and medical
decision making was of low complexity.
99243
58

CASE STUDY
Michael, age 38, scheduled an annual physical
exam with Dr. Graves. He has been Dr. Graves’
patient for 15 years and had his last annual physical
2 years ago.
First - Identify
Place of service (POS) = where (office)
Type of service (TOS) = what (Problem/Preventive)
Status of Patient = who (New/Established)
Determine the extent of history - physical exam - decision making counseling
99395
59
CASE STUDY
A 2-year-old boy with bacterial pneumonia is
hospitalized and has had 5 days of antibiotic therapy.
Today the child developed a fever of 101.1 F with a mild
rash on his torso. In a subsequent hospital visit, the
attending physician performed a problem-focused
history and examination. The MDM complexity was low.
99231
60