Evaluation and Management Codes (E & M) are used on both the CMS-‐1500 form and the UB-‐04 but may be determined by separate criteria. For professionals such as physicians, nurse practitioners, physician’s assistants etc… the codes are driven by all guidance provided within the CPT codebook (American Medical Association). That section has a specific introduction and provides for the overall use of the code. In addition to those instructions, when submitting the claim to Medicare there are two guidelines utilized to determine what level of service was achieve. The provider has the choice of which of these two guidelines to choose but may not intermix their criteria or use both to determine the level. In other words, once the criteria are chosen they should stick with only that criterion. These will be discussed further in this section but are known as the 1995 and 1997 E & M guidelines. When auditing,
the auditor should ask for written confirmation as to which guideline was utilized by the professional in their selection of the codes.
If you are a facility (hospital) then the CPT codebook provides specifics on the intent of the code only. From that point CMS has provided eleven (11) points, which should be placed into a policy to ensure accurate code selection. When auditing a facility the auditor should ask for a copy of the policy for the facility outlining their methodology.
ASSIGNMENT OF NON-‐FACILITY (PROFESIONAL) EVALUATION AND MANAGEMENT (E&M) CODES
Medicare is divergent in the methods of assigning evaluation and management service procedure codes when it comes to professionals versus facilities. The facility E & M will be discussed in detail within the “Assign and Validate APC Codes” section of the manuals. In this section we will focus on professional services evaluation and management codes. These codes begin with 99, xxx and are found within the first section of the CPT codebook (AMA). These codes have specific instructions on when to apply them and to assign them and provide coding guidelines. Above and beyond that which is presented within CPT, there are two different methods as defined by CMS. These are known as the 1995 and 1997 standards. Since 1997, there have been proposals to change these guidelines and update them however; despite multiple attempts this has never been accomplished.
1995 GUIDELINES:
On the CMS website there is a complete description and downloadable pdf describing both methods as well as an over view of the evaluation and management concepts. These are:
• Evaluation and Management Services Guide:
http://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide-‐ICN006764.pdf • 1995 Guidelines for Evaluation and Management:
http://www.cms.gov/MLNProducts/Downloads/1995dg.pdf
There are significant differences between the 1995 standards and the 1997 standards. One significant difference is the 1995 standard tend to be more subjective in approach. Let’s review the 1995 guidelines.
“This publication provides definitions and documentation guidelines for the three key components of E/M services and for visits which consist predominately of counselling or coordination of care. The three key components-‐-‐history, examination, and medical decision making-‐-‐appear in the descriptor’s for office and other outpatient services, hospital observation services, hospital
inpatient services, consultations, emergency department services, nursing facility services, domiciliary care services, and home services… The descriptors for the levels of E/M services recognize seven components, which are used in defining the levels of E/M services. These components are:
• history; • examination;
• medical decision making; • counselling;
• coordination of care;
• nature of presenting problem; and • time.
The first three of these components (i.e., history, examination and medical decision making) are the key components in selecting the level of E/M services. An exception to this rule is the case of visits which consist predominantly of counselling or coordination of care. For these services, time is the key or controlling factor to qualify for a particular level of E/M service.
History
The levels of E/M services are based on four types of examination that are defined as follows: • Problem Focused -‐-‐ a limited examination of the affected body area or organ system.
• Expanded Problem Focused -‐-‐ a limited examination of the affected body area or organ system and other symptomatic or related organ system(s).
• Detailed -‐-‐ an extended examination of the affected body area(s) and other symptomatic or related organ system(s).
• Comprehensive -‐-‐ a general multi-‐system examination or complete examination of a single organ system
Each type of history includes some or all of the following elements: • Chief complaint (CC);
• History of present illness (HPI); • Review of systems (ROS); and
• Past, family and/or social history (PFSH)…
The chart below shows the progression of the elements required for each type of history. To qualify for a given type of history, all three elements in the table must be met. (A chief complaint is indicated at all levels.)
Type of History History of Present
Illness (HPI) Review of Systems (ROS) Past, Family and/or Social History (PFSH)
Type of History
Prob. Focused Brief N/A N/A Problem Focused
Expanded Prob
Focused Brief Problem Pertinent N/A Expanded Problem Focused
Detailed Extended Extended Pertinent Detailed
Comprehensive Extended Complete Complete Comprehensive
Documentation Guidelines (DG) – The CC, ROS and PFSH may be listed as separate elements of history, or they may be included in the description of the history of the present illness
Examination
For purposes of examination, the following body areas are recognized: • Head, including the face
• Neck
• Chest, including breasts and axillae
• Abdomen
• Genitalia, groin, buttocks • Back, including spine • Each extremity
For purposes of examination, the following organ systems are recognized: Constitutional (e.g., vital signs, general appearance)
• Eyes
• Ears, nose, mouth and throat • Cardiovascular • Respiratory • Gastrointestinal • Genitourinary • Musculoskeletal • Skin • Neurologic • Psychiatric • Hematologic/lymphatic/immunologic
Medical Decision Making
The levels of E/M services recognize four types of medical decision-‐making: • straight-‐forward,
• low complexity,
• moderate complexity, and • high complexity
Medical decision-‐making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by:
• the number of possible diagnoses and/or the number of management options that must be considered;
• the amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analysed; and
• the risk of significant complications, morbidity and/or mortality, as well as comorbidities, associated with the patient's presenting problem(s), the diagnostic procedure(s) and/or the possible management options.”47
1997 EVALUATION & MANAGEMENT GUIDELINES
The other method designed for professional services is the 1997 method. This method is less subjective and involves bulleted items. Like the 1995 standards the 1997 standards are based on seven criteria. These are:
• history; • examination;
• medical decision making; • counselling;
• coordination of care;
• nature of presenting problem; and • time.
“The first three of these components (i.e., history, examination and medical decision making) are the key components in selecting the level of E/M services. In the case of visits, which consist predominantly of counselling or coordination of care, time is the key or controlling factor to qualify for a particular level of E/M service.
Because the level of E/M service is dependent on two or three key components, performance and documentation of one component (e.g., examination) at the highest level does not necessarily mean that the encounter in its entirety qualifies for the highest level of E/M service. These Documentation Guidelines for E/M services reflect the needs of the typical adult population.”48
The key difference between the 1995 and 1997 is in the Review of Systems (ROS) and the Examination portion of the guidelines. This is different as the 1997 standards set forth the number of body systems that must be reviewed to reach each of the levels.
47 http://www.cms.gov/MLNProducts/Downloads/1995dg.pdf 48 http://www.cms.gov/MLNProducts/Downloads/MASTER1.pdf
“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.
For purposes of ROS, the following systems are recognized: • Constitutional symptoms (e.g., fever, weight loss) • Eyes
• Ears, Nose, Mouth, Throat • Cardiovascular
• Respiratory • Gastrointestinal • Genitourinary • Musculoskeletal
• Integumentary (skin and/or breast) • Neurological • Psychiatric • Endocrine • Hematologic/Lymphatic • Allergic/Immunologic •
A problem pertinent ROS inquires about the system directly related to the problem(s) identified in the HPI. Below are the documentation guidelines (DG)
• DG: The patient's positive responses and pertinent negatives for the system related to the problem should be documented.
An extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number of additional systems.
• DG: The patient's positive responses and pertinent negatives for two to nine systems should be documented.
A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems.
• DG: At least ten organ systems must 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.49
As you can see within this section specific guidelines as to the number of systems reviewed and documented are present. However, in the 1995 standards there are no such specifications making this one area of difference between the two standards. Similar standards with specific numbers of criteria are present within the Past Medical, Family and Social History sections. The other area of diversity is within the examination portion of the guidelines.
“These types of examinations have been defined for general multi-‐system and the following single organ systems:
• Cardiovascular
• Ears, Nose, Mouth and Throat • Eyes • Genitourinary (Female) • Genitourinary (Male) • Hematologic/Lymphatic/Immunologic • Musculoskeletal • Neurological • Psychiatric • Respiratory • Skin
To qualify for a given level of multi-‐system examination, the following content and documentation requirements should be met:
• Problem Focused Examination-‐should include performance and documentation of one to five elements identified by a bullet (•) in one or more organ system(s) or body area(s).
• Expanded Problem Focused Examination-‐should include performance and documentation of at least six elements identified by a bullet (•) in one or more organ system(s) or body area(s). • Detailed Examination-‐-‐should include at least six organ systems or body areas. For each
system/area selected, performance and documentation of at least two elements identified by a bullet (•) is expected. Alternatively, a detailed examination may include performance and documentation of at least twelve elements identified by a bullet (•) in two or more organ systems or body areas.
• Comprehensive Examination-‐-‐should include at least nine organ systems or body areas. For each system/area selected, all elements of the examination identified by a bullet (•) should be performed, unless specific directions limit the content of the examination. For each area/system, documentation of at least two elements identified by a bullet is expected.”50
In addition to the multisystem requirements there are requirements for the single body systems which dictate how many bulleted items within each organ system must be documented. As you can see the 1997 is much more stringent with fixed parameters.
We recommend that you review the entire 1997 standard, which can be found at: http://www.cms.gov/MLNProducts/Downloads/MASTER1.pdf
Auditing for the 95 or 97 guidelines is the mainstay of most professional auditors. Trailblazer Medicare has published through Scribid a fantastic electronic audit template, which leads the auditor and ensures
consistent application and conclusions. It also provides for an element of independence and objectivity as an outside third party contractor creates this tool. This tool can be found at:
http://www.scribd.com/doc/24737506/Trailblazer-‐Medicare-‐Audit-‐Tool http://www.e-‐medtools.com/Aqua_Medicare_Coding_Worksheet.html In order to access these tools you will be required to create an account.
Palmetto GBA has published a very clear interactive checklist for both new and established patients that can be used for auditing physician / physician extender E & M’s. This interactive template is easy to use and very clear. Please consult:
http://www.palmettogba.com/internet/eandm.nsf/Established_New?OpenForm
Other audit templates can be found at:
http://www.aace.com/advocacy/pdf/AUDITTOOLMEDICARE.pdf
http://www.acog.org/departments/dept_notice.cfm?recno=6&bulletin=157
Additionally, many specialty organisations such as ACOG, ACEP and others may have their own templates either free to their members or at a small charge.
UNDERSTANDING VISIT LEVELS FOR FACILITIES (FACILITY E & M)
Status indicator “V” designates the visit codes, also known as Evaluation & Management codes. These codes have special instructions on how to code these procedures. Visit codes follow the intent of CPT however, for facility billing, require each facility to create their own guidelines for assignment based on resource consumption. Facilities do not utilize the 1995 or 1997 standards previously addressed. Facility coding requirements are discussed in the 2011 OPPS final rule in the Federal Register, Vol .75, No. 226, November 24, 2010, p. 71988.
“Since April 7, 2000, we have instructed hospitals to report facility resources for clinic and emergency department hospital outpatient visits using the CPT E/M codes and to develop internal hospital guidelines for reporting the appropriate visit level.
Because a national set of hospital specific codes and guidelines do not currently exist, we have advised hospitals that each hospital’s internal guidelines that determine the levels of clinic and emergency department visits to be reported should follow the intent of the CPT code
descriptors, in that the guidelines should be designed to reasonably relate the intensity of hospital resources to the different levels of effort represented by the codes.”
Because the facility is supposed to create the visit code guidelines according to resources, Medicare provided eleven (11) points that must be followed in the 2008 OPPS Final Rule. These are:
“In addition, we note our expectation that hospitals’ internal guidelines would comport with the principles listed below.
1. The coding guidelines should follow the intent of the CPT code descriptor in that the guidelines should be designed to reasonably relate the intensity of hospital resources to the different levels of effort represented by the code (65 FR 18451).
2. The coding guidelines should be based on hospital facility resources. The guidelines should not be based on physician resources (67 FR 66792).
3. The coding guidelines should be clear to facilitate accurate payments and be usable for compliance purposes and audits (67 FR 66792).
4. The coding guidelines should meet the HIPAA requirements (67 FR 66792).
5. The coding guidelines should only require documentation that is clinically necessary for patient care (67 FR 66792).
6. The coding guidelines should not facilitate upcoding or gaming (67 FR 66792).
7. The coding guidelines should be written or recorded, well documented, and provide the basis for selection of a specific code.
8. The coding guidelines should be applied consistently across patients in the clinic or emergency department to which they apply.
9. The coding guidelines should not change with great frequency.
10. The coding guidelines should be readily available for fiscal intermediary (or, if applicable, MAC) review.
11. The coding guidelines should result in coding decisions that could be verified by other hospital staff, as well as outside sources.
Throughout the U.S. there are many different types of guidelines, as developed by the individual facility. In most cases, hospitals are trending toward the development of “matrix” types of guidelines based on points. Of all the systems reviewed by the government, Medicare finds this system requires the least additional documentation, is harder to “game” and represents a valid approach toward the
determination of the evaluation and management (E & M) for facilities. Under the point system, every non-‐separately billable (no CPT code) item that is performed by nursing / ancillary services is reviewed and placed into a matrix. By adding up the points a level of service is achieved. This is only one of the many systems that have been created. For further discussion of the CMS standpoint on each of the models out there we recommend:
• Federal Register, Vol. 71, No 226, 11/24/2006, Rules and Regulations beginning on page 68125 A sample of this type of charge captures and audit tool has been created for illustration purposes only.