ELEVATING YOUR DOCUMENTATION FOR OB/GYN E/M SERVICES

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Reproductive Medicine Administrative Consulting Inc. Reproductive Medicine Administrative Consulting Inc.

ELEVATING YOUR

DOCUMENTATION FOR

OB/GYN E/M SERVICES

Brad Hart, MBA, MS, CMPE, CPC, COGBC Reproductive Medicine Administrative Consulting

ACOG—District II 2014 1 Reproductive Medicine Administrative Consulting Inc. CONFLICT OF INTEREST DISCLOSURE STATEMENT

• I have no significant financial interest with any commercial or corporate enterprise. • I shall not discuss any off-label usage of any

FDA-approved medications or other products.

2 Reproductive Medicine Administrative Consulting Inc. Learning Objectives

At the conclusion of this session, attendees should be able to…

•Describe the key documentation requirements that

support particular E/M service levels.

•Promote excellence in E/M documentation by

differentiating between high quality and substandard documentation.

•Contribute to the construction of documentation

systems that facilitate the highest quality documentation and proper code selection in their practice. 3 Reproductive Medicine Administrative Consulting Inc. Disclaimer

•ICD-10 codes included in this presentation are not valid prior to the implementation date •ICD-10 codes included in this presentation

may be revised prior to implementation •ICD-9 codes should continue to be used until

transition date to ICD-10

4 Reproductive Medicine Administrative Consulting Inc.

Medicare OB/GYN E/M Distribution Outpt. Services - New

5 Reproductive Medicine Administrative Consulting Inc.

Medicare OB/GYN E/M Distribution Outpt. Services - Established

6 Reproductive Medicine Administrative Consulting Inc. Coding Principles

Document

what

was done

Document

why

it was done

Code

for what you document

7 Reproductive Medicine Administrative Consulting Inc. Coding Principles

•Physicians and staff must stay current and involved

•Physicians are responsible for the coding information on claims ! 8 Reproductive Medicine Administrative Consulting Inc. 9

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Medically Necessary Services

•AMA’s Model Managed Care Contract

definition:

“Health care services or procedures that a

prudent physician would provide to a patient

for the purpose of preventing, diagnosing, or treating an illness, injury, disease or it’s symptoms in a manner that is:

10 Reproductive Medicine Administrative Consulting Inc.

Medically Necessary Services

•In accordance with generally accepted

standards for medical practice; •Clinically appropriatein terms of type,

frequency, extent, site, and duration; and •Not primarily for the economic benefit of the

health plans and purchasers or for the convenience of the patient, physician, or other health care provider.”

11 Reproductive Medicine Administrative Consulting Inc.

CODING FOR E/M SERVICES

12 Reproductive Medicine Administrative Consulting Inc.

Diagnosis Coding and E/M Services

•Physicians are paid for medical “services” they provide

•Clinical need for each service must be “justified” by a code from ICD

•ICD-9/ICD-10-CM code must “support” level

of service reported

•All clinically relevant diagnoses should be reported 13 Reproductive Medicine Administrative Consulting Inc.

Understanding E/M Services

• Developed in 1992 to

accommodate RBRVS

• Describes outpatient and

inpatient “visits” • Divided into categories,

subcategories, and levels of service 14 Reproductive Medicine Administrative Consulting Inc.

Selecting E/M Services

•Identify Category and Subcategory

•Type of service and/or

•Place of service 15 Reproductive Medicine Administrative Consulting Inc. Categories/Subcategories

•Office or Other Outpatient Services

•New Patient

•Established Patient

•Consultations

•Office or Other Outpatient

•Inpatient 16 Reproductive Medicine Administrative Consulting Inc.

Selecting E/M Services

•Review CPT instructions

•Information both at beginning of section and

preceding some code families

•Select the Level of Service

•CPT definitions •Documentation Guidelines 17 Reproductive Medicine Administrative Consulting Inc.

How Do You Choose Levels of E/M Services?

• History • Exam

• Medical Decision Making

• Counseling

• Coordination of Care

• Nature of Problem

• Time

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Reproductive Medicine Administrative Consulting Inc. Key Components • History • Exam

• Medical Decision Making

19 Reproductive Medicine Administrative Consulting Inc. Contributing Components •Counseling •Coordination of Care •Nature of presenting problem

20 Reproductive Medicine Administrative Consulting Inc. Reference

Time

21 Reproductive Medicine Administrative Consulting Inc. RVU Comparison

Level Estab. New Consult

1 .56 1.21 1.37 2 1.22 2.08 2.57 3 2.04 3.02 3.52 4 3.01 4.64 5.10 5 4.03 5.78 6.36 22 Reproductive Medicine Administrative Consulting Inc.

Summary of E/M Codes

•Not all E/M services selected using key components

•Time not always an option •Not all distinguish between new and

established patients 23 Reproductive Medicine Administrative Consulting Inc. New Patient

•Professional services defined as face-to-face services reported by a specific CPT code (s) •Patients are:

•Self-referred, referred by friend

•Sent by a health care provider for treatment

24 Reproductive Medicine Administrative Consulting Inc.

New Patient Subcategory

•In covering situations, the patient’s encounter is reported as if the unavailable

physician/QHP had seen the patient

•APN and PAs are considered as working in the

exact same specialty/subspecialty as physician with whom they are working •Classification applies only to:

•Office or Other Outpatient Services

•Preventive Medicine Services

25 Reproductive Medicine Administrative Consulting Inc. New vs. Established

•Mary is seen in the emergency department by

Dr. Phillips. Dr. Phillips asks her to come to his office for follow-up. In the office, Mary is seen by Dr. Phillip’s partner, Dr. Wickham.

Mary is Dr. Wickham’sestablishedpatient.

26 Reproductive Medicine Administrative Consulting Inc. New vs. Established

•Lydia has been seeing Dr. Bennett for years. Dr. Bennett leaves the Longbourne Medical Group and joins the Pemberley Medical Group. Lydia comes to the new practice to see Dr. Bennett within three years of her last visit. Lydia is Dr. Bennett’sestablished

patient.

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Reproductive Medicine Administrative Consulting Inc. New vs. Established

•Kitty has been seeing Dr. Darcy for years. Dr. Darcy leaves the Longbourne Medical Group. Kitty then sees Dr. Gardiner, another general gyn at the Longbourne Medical Group. Kitty is

Dr. Gardiner’sestablishedpatient

28 Reproductive Medicine Administrative Consulting Inc. New vs. Established

•Dr. Hurst and Dr. Collins are both in solo practice. Dr. Hurst goes on vacation and asks Dr. Collins to cover for her. During that time, Dr. Hurst’s patient, Jane, sees Dr. Collins. Jane is Dr. Collins’establishedpatient.

29 Reproductive Medicine Administrative Consulting Inc. New vs. Established

•Elizabeth, who recently moved to the local area, was seen in the ED for pelvic pain. An ultrasound was performed and was normal. The ED physician telephones Dr. Bingley, the on-call gynecologist, to discuss Elizabeth’s care. 30 Reproductive Medicine Administrative Consulting Inc. New vs. Established

•Dr. Bingley does not come in to see Elizabeth, but suggests she be seen in her office the following day.

•When Elizabeth sees Dr. Bingley, she is

considered anewpatient since Dr. Bingley

did not provide a face-to-face service.

31 Reproductive Medicine Administrative Consulting Inc.

SELECTING AND

DOCUMENTING LEVELS OF

E/M SERVICES

32 Reproductive Medicine Administrative Consulting Inc. Key Components • History • Exam

• Medical Decision Making

33 Reproductive Medicine Administrative Consulting Inc. Contributing Components •Counseling •Coordination of Care •Nature of presenting problem

34 Reproductive Medicine Administrative Consulting Inc. Reference

Time

35 Reproductive Medicine Administrative Consulting Inc. Category Requirements • Visits requiring 3 of 3 key components •New Outpatient •Consultations •Initial Inpatient •Initial Observation care •ED services • Visits requiring 2 of 3 key components •Established Outpatient •Subsequent inpatient •Subsequent observation care 36

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Reproductive Medicine Administrative Consulting Inc. Time Factors

•Physician may perform PE, obtain history BUT

may spend most of the encounter providing

counseling,OR

•All of the visit involves counseling with patient/family 37 Reproductive Medicine Administrative Consulting Inc.

Using Time To Determine Levels

• Time may be the key

factor for the selection of the level of service when

counseling and/or coordination of care dominates the encounter(more than 50%) 38 Reproductive Medicine Administrative Consulting Inc. Counseling

•Discussion with patient and/or family

•Test results

•Prognosis

•Risks/benefits of management options

•Instructions

•Compliance issues

•Risk factor reduction

•Education 39 Reproductive Medicine Administrative Consulting Inc. Documentation • Document description of the counseling/ coordination activities

• Document total time

and time spent counseling with the patient 40 Reproductive Medicine Administrative Consulting Inc. Measuring Time

Outpatient: Time spent by the

provider face-to-face with the patient and/or family

Inpatient: Time spent both

with the patient and on the patient’s unit or floor

• Report using the code with the

closest actual time

• Verify Medicare contractor

policy as may vary from CPT

41 Reproductive Medicine Administrative Consulting Inc.

Typical Times for Outpatient E/M Services

Outpatient - New

Codes 99201 99202 99203 99204 99205 Times 10 min. 20 min. 30 min. 45 min. 60 min.

Outpatient - Established

Codes 99211 99212 99213 99214 99215 Times 5 min. 10 min. 15 min. 25 min. 40 min.

Outpatient - Consultations

Codes 99241 99242 99243 99244 99245 Times 15 min. 30 min. 40 min. 60 min. 80 min.

42 Reproductive Medicine Administrative Consulting Inc.

Time Factors: Hester

•Hester is a 55 year-old new patient referred to Dr. Dimmesdale by her friend to discuss treatment options for menorrhagia. Another physician has suggested a vaginal

hysterectomy and Hester would like to discuss other options including alternative surgical approaches. She refuses a physical exam today. 43 Reproductive Medicine Administrative Consulting Inc. Hester

•Dr. Dimmesdale spends 40 minutes discussing

the risks and benefits of various treatment options with Hester. She will make a return appointment once she has determined her preferred course of treatment.

44 Reproductive Medicine Administrative Consulting Inc. Dr. Dimmesdale Hester

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by line) 1.N92.6 Irregular menstruation, unspecified 2.

3.

22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 23. PRIOR AUTHORIZATION NUMBER 24. A. DATE(S) OF SERVICE From To MM DD YY MM DD YY B. POS D. PROCEDURES, SERVICES/SUPPLIES

(Explain Unusual Circumstances) CPT/HCPCS MODIFIER E. DX POINTER F. $ CHARGES G. DAYS OR UNITS I. ID. QUAL J. RENDERING PROVIDER ID. # 11 99204 1 1 NPI NPI Typical times for E/M codes are included in the CPT-4 code descriptors.

Code 99203 lists 30 minutes as its “typical time”. Code 99204 lists 45 minutes as its “typical time”.

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Reproductive Medicine Administrative Consulting Inc. ICD-10-CM

•Index for Menorrhagia directs coder to:

• N92 (Excessive, frequent and irregular

menstruation) and

•N95 (Menopausal and other perimenopausal

disorders 46 Reproductive Medicine Administrative Consulting Inc. ICD-10-CM

•N92.0 Excessive and frequent menstruation

withregularcycle

•N92.1 Excessive and frequent menstruation

withirregularcycle

•N92.2 Excessive menstruation at puberty •N92.3 Ovulation bleeding 47 Reproductive Medicine Administrative Consulting Inc. ICD-10-CM

•N92.4 Excessive bleeding in the premenopausal period

•N92.5 Other specified irregular menstruation

N92.6 Irregular menstruation, unspecified

•Documentation for case was insufficient to select a specific ICD code

•“Other specified” means there was specific clinical documentation but not a code to describe the condition 48 Reproductive Medicine Administrative Consulting Inc. Reminders

•Times in CPT are typical times only

Timerequirementsdo not have to be met

when selecting codes based onkey

components

Keycomponent requirementsdo not have to

be metwhen selecting codes based ontime

Timerequirementsmust be metand

documented whendetermining factor for

level of service 49 Reproductive Medicine Administrative Consulting Inc.

Time vs. Key Components

•Timecannotbe used when service was extended because:

•History was extensive

•Patient was a poor historian

•Physical exam was lengthy

•Key components must be used in these

instances 50 Reproductive Medicine Administrative Consulting Inc. DOCUMENTATION IS CRITICAL! 51 Reproductive Medicine Administrative Consulting Inc.

In the old days…

52

•This was billed as 99214 – It was a follow up pap smear

– There was an abnormal pap 3 months earlier

Reproductive Medicine Administrative Consulting Inc. 99214-25 58100 76830 53 Today Reproductive Medicine Administrative Consulting Inc. It gets worse 54 99214-25 76830

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Reproductive Medicine Administrative Consulting Inc. Importance of Documentation

•The medical record facilitates:

•Evaluation and planning of treatment

•Communication among providers

•Accurate claims review and payment

•Utilization review and quality of care activities

•Collection of data 55 Reproductive Medicine Administrative Consulting Inc. 1992 Documentation Guidelines

•E/M codes restructured for RBRVS

•AMA released Principles of Documentation

•Developed by representatives from insurance

industry, payers and providers

•Continue to be part of Medicare’s Documentation

Guidelines 56 Reproductive Medicine Administrative Consulting Inc. Principles of Documentation

•Complete and legible

•Documentation should include:

•Reason for encounter

•Relevant history and exam

•Assessment, impression, diagnosis

•Plan of care

•Date and legibility of observer

57 Reproductive Medicine Administrative Consulting Inc. Principles of Documentation

•Documentation should include (cont’d):

•Rationale for ordering tests and ancillary services

•Past and present diagnosis accessible

•Risk factors identified

•Progress and response to treatment

Documentation should support CPT and ICD

codes reported on claim

58 Reproductive Medicine Administrative Consulting Inc. 1995 and 1997 Documentation Guidelines1995 •Exam based on number of organ systems/body areas examined •Criticized for not

reflecting work of specialists • 1997 •Created single-organ system exams to reflect work of specialists •Criticized for complexity of system 59 Reproductive Medicine Administrative Consulting Inc.

Gynecologists and The DGs

•Comprehensive Exam

•1995 guidelines less restrictive

•8 organ systems vs. 9 systems in 1997 DGs

•Less than comprehensive exams

•1997 DGs recognizes work of single organ

system exam

•Pelvic exam has 9 specific elements under 1997 vs.

representing only 1 organ system in 1995 DGs

60 Reproductive Medicine Administrative Consulting Inc. 61 Reproductive Medicine Administrative Consulting Inc. Documenting Services in 2014

•Electronic Health Records (EHR) present both opportunities and challenges

•Increased efficiency/ improvements in quality of care

•Concern about accuracy and specificity of clinical information 62 Reproductive Medicine Administrative Consulting Inc. Documenting Services in 2014

•Medicare Carrier Manual:

•Thevolume of documentationshouldnotbe the

primary influence upon which a specific level of service is billed

Medical necessityof a service is the overarching

criterion for payment in addition to the individual requirements of a CPT code

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Reproductive Medicine Administrative Consulting Inc. Documenting Services in 2014

•Medicare has noted increase frequency of identical information across services (copy/paste)

•Providers must select codes based on content

of service and support selection with documentation 64 Reproductive Medicine Administrative Consulting Inc. Documenting Services in 2014

•OIG Work Plans have focused on E/M codes

suggested or determined by EHRs and templated notes

•Review of multiple E/M services for the same provider and same patient to identify improper payments 65 Reproductive Medicine Administrative Consulting Inc. Documenting Services in 2014

•Other government and non-government

payers initiating similar reviews

•Must consider theintegrityof the medical record

•Information that is not customized to the individual patient may jeopardize patient care

66 Reproductive Medicine Administrative Consulting Inc. 67 Reproductive Medicine Administrative Consulting Inc.

Selecting Levels of Service

•History •CC •HPI •ROS •PFSH •Exam •1995 vs. 1997 68 Reproductive Medicine Administrative Consulting Inc.

Selecting Levels of Service

•Medical Decision Making

•Diagnoses •Data •Risk 69 Reproductive Medicine Administrative Consulting Inc. Rosemary

•History of Present Illness:

Rosemary is a 28-year-old G-0referred for

consultation by Dr. Thyme for evaluation of irregular uterine bleeding. She states that she has had vaginal bleeding for the past three months on a daily basis requiring the use of one to ten pads/day. She also reports the passage of large clots.

70 Reproductive Medicine Administrative Consulting Inc. Rosemary

•She had irregular cycles after the onset of menarche at the age of 14. These were initially controlled with OCP. She stopped the OCP 18 months ago because she wanted a break from the pill.

•After stopping the OCP, she had cycles 50-60 days apart, then began to bleed continuously 3 months ago. She has noted increased acne and some hair growth on her chin.

71 Reproductive Medicine Administrative Consulting Inc. Rosemary

•Past Medical History: Negative for HTN, DM, CA, and

TB

•Social History: She does not smoke or drink alcohol.

No history of drug abuse

•Family History: Negative for HTN, DM, CA, and TB.

Her mother had a hysterectomy for irregular uterine bleeding at the age of 35.

•ROS: No fatigue or weakness. No heart or lung

symptoms. No GI problems. No neurologic complaints.

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Reproductive Medicine Administrative Consulting Inc. Rosemary •Physical Exam: BP 120/80; P 80; Ht 68; Wt. 225#; BMI 34

General:WDWNF in NAD. A & O x 3. •Neck:Supple without thyromegaly or

lymphadenopathy. •Chest:clear •CV:RRR

Breasts:No masses, galactorrhea, or retraction. No axillary lymphadenopathy

73 Reproductive Medicine Administrative Consulting Inc. Rosemary

Abdomen:BS+. Soft and non-tender without

masses or organomegaly.

Skin:Increased hair on chin and cheeks and

below umbilicus

Pelvic:External genitalia normal. Urethral meatus

and urethra normal. Bladder no tenderness or fullness. Cervix and vagina normal. Copious, clear cervical mucous. Uterus normal size, shape, and consistency. Adnexa neg. RV: confirms

74 Reproductive Medicine Administrative Consulting Inc. Rosemary

•Laboratory: Urine pregnancy test negative •Ultrasound: Transvaginal ultrasound

performed. Findings revealed a normal uterus with a thin endometrium. Ovaries are enlarged with multiple subcapsular cysts “typical of PCOS” 75 Reproductive Medicine Administrative Consulting Inc. Rosemary •Assessment:

•Menometrorrhagia secondary to chronic

anovulation

•Hirsutism

•Obesity

•Probable PCOS but will confirm with hormonal

data 76 Reproductive Medicine Administrative Consulting Inc. Rosemary • Plan:

1. Provera 10 mg/day for 10 days. 2. Restart OCP

3. Will check testosterone, LH, FSH, TSH, DHEA-S, prolactin, fasting comprehensive metabolic profile, insulin, and lipids

4. Return in 2 weeks to discuss findings of test results and determine further testing and/or management options. 77 Reproductive Medicine Administrative Consulting Inc. Rosemary

•Consider the level of service for Dr. Thyme’s consultation with Rosemary

•All 3 key components must be met or exceeded

•Next, consider the level of service if

Rosemary was Dr. Thyme’s established patient

•Only 2 of 3 key components required

78 Reproductive Medicine Administrative Consulting Inc. Consultations 99241 99242 99243 99244 99245 HISTORY

CC Required Required Required Required Required HPI 1-3 elements 1-3 elements > 4 elements OR> 3 chronic or

Inactive conditions > 4 elements OR > 3 chronic or Inactive conditions > 4 elements OR > 3 chronic or Inactive conditions ROS N/A 1 system 2-9 systems 10-14 systems 10-14 systems PFSH N/A N/A 1 element 3 elements 3 elements Level PF Expanded PF Detailed Comprehensive Comprehensive

PHYSICAL EXAMINATION

1995 1 system 2-4 systems 5-7 systems > 8 systems > 8 systems 1997 1-5 elements 6-11 elements > 12 elements Comprehensive Comprehensive Level PF Expanded PF Detailed Comprehensive Comprehensive

MEDICAL DECISION MAKING

Dx Mgmt Options Minimal Minimal Limited Multiple Extensive Data Reviewed Minimal orNone Minimal orNone Limited Moderate Extensive Risk Minimal Minimal Low Moderate High Level SF SF Low Moderate High

TIME

Face-to-face 10/15 min. 20/30 min. 30/40 min. 45/60 min. 60/80 min.

New Patients/Consultations 79 Reproductive Medicine Administrative Consulting Inc. Established Pt. 99211 99212 99213 99214 99215 HISTORY

CC N/A Required Required Required Required HPI N/A 1-3 elements 1-3 elements OR> 3 chronic or

Inactive conditions > 4 elements OR > 3 chronic or Inactive conditions > 4 elements OR > 3 chronic or Inactive conditions ROS N/A N/A 1 system 2-9 systems 10-14 systems PFSH N/A N/A N/A 1 element 2 elements Level N/A PF Expanded PF Detailed Comprehensive

PHYSICAL EXAMINATION

1995 N/A 1 system 2-4 systems 5-7 systems > 8 systems 1997 N/A 1-5 elements 6-11 elements > 12 elements Comprehensive Level N/A PF Expanded PF Detailed Comprehensive

MEDICAL DECISION MAKING

Dx Mgmt Options N/A Minimal Limited Multiple Extensive Data Reviewed N/A Minimal or

None Limited Moderate Extensive Risk N/A Minimal Low Moderate High Level N/A SF Low Moderate High

TIME Face-to-face 5 min.

supervision 10 min. 15 min. 25 min. 40 min.

Office or Other Outpatient Services

80 Reproductive Medicine Administrative Consulting Inc.

Selecting E/M Services

•Proper coding and reimbursement means:

•Selecting code from proper category

•Selecting appropriate level of service

•Supporting selection with documentation

•CPT definitions

•CMS Documentation Guidelines

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Selecting E/M Services

•Based on “physician work”

•History, Exam, MDM, or time

•Includes servicesmedically necessaryto evaluate/tx the patient

•Code selection must be supported by “work”

and “medical necessity”

82 Reproductive Medicine Administrative Consulting Inc.

Medical Decision Making

•Level determined by:

•Number of diagnosis or management options

•Amount and/or complexity of data

•Risk to the patient

83 Reproductive Medicine Administrative Consulting Inc.

Selecting the Level of MDM Level of Medical Decision Making Number of diagnoses or management options Amount and/or complexity of data to be reviewed Risk of complications and/or morbidity or mortality Straightforward (99241, 99242, 99201, 99202, 99212)

Minimal Minimal or None Minimal

Low complexity

(99243, 99203, 99213)Limited Limited Low

Moderate complexity

(99244, 99204, 99214)Multiple Moderate Moderate

High complexity

(99245, 99205, 99215)Extensive Extensive High

Based on 2 of 3 areas 84 Reproductive Medicine Administrative Consulting Inc.

MDM is the “overarching criterion”

Level 1 Level 2 Level 3 Level 4 Level 5

BP Check Yeast

Infection Pregnancydiagnosis Irregularperiods, weight gain, hirsutism Empty uterus, rising beta Injection with no physician on site Brief discussion of birth control Recurrent yeast infection Recurrent yeast infection with systemic condition Heavy bleeding, known anemia 85 Reproductive Medicine Administrative Consulting Inc. New Patients/Consultations Outpatient 99201 99202 99203 99204 99205 HISTORY

CC * Required Required Required Required Required HPI * 1-3elements 1-3elements 4 + elements 4 + elements 4 + elements ROS * N/A Pertinent 2-9 systems 10-14 systems 10-14 systems PFSH * N/A N/A 1 of 3 elements 3 of 3 elements 3 of 3 elements

PHYSICAL EXAMINATION

1997 1-5elements 6-11elements 12 or >elements Comprehensive Comprehensive 1995 System ofComplaint 2-4systems 5-7 systems 8 or > systems 8 or > systems

MEDICAL DECISION MAKING

SF SF Low Moderate High TIME

Face-to-face 10/15 min. 20/30min. 30/40 min. 45/60 min. 60/80 min.

86 Reproductive Medicine Administrative Consulting Inc.

Office or Other Outpatient Services

Est.

Patient 99211 99212 99213 99214 99215 HISTORY

CC * N/A Required Required Required Required HPI * N/A 1-3 elements 1-3 elements 4 + elements 4 + elements ROS * N/A N/A Pertinent 2-9 systems 10-14 systems PFSH * N/A N/A N/A 1 of 3 elements 2 of 3 elements

PHYSICAL EXAMINATION

1997 N/A 1-5 elements 6-11 elements 12 or > elements Comprehensive 1995 N/A System ofComplaint 2-4 systems 5-7 systems 8 or > systems

MEDICAL DECISION MAKING

N/A SF Low Moderate High TIME

Face-to-face 5 min.supervision

10 min. 15 min. 25 min. 40 min.

87 Reproductive Medicine Administrative Consulting Inc. History • Four Types: •Problem-focused •Expanded problem-focused •Detailed •Comprehensive 88 Reproductive Medicine Administrative Consulting Inc. Components of History • Chief Complaint (CC) • History of Present Illness (HPI) • Review of Systems (ROS)

• Past, Family, and/or Social History (PFSH) 89 Reproductive Medicine Administrative Consulting Inc.

Key Documentation Guidelines

•CC required for all levels

•Extent dependent on clinical judgment •No specific format requirements •Describe circumstances which preclude

obtaining history

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Reproductive Medicine Administrative Consulting Inc.

Key Documentation Guidelines

•ROS/PFSH may be recorded by pt. or staff

•Provider must supplement/confirm info

•ROS/PFSH updated by:

•New information or noting change

•Noting date/location of previous information

•Note all positive and pertinent negatives in ROS 91 Reproductive Medicine Administrative Consulting Inc.

History of Present Illness

•Eight elements: •Location •Quality •Severity •Duration •Timing •Context •Modifying factors •Associated signs/symptoms 92 Reproductive Medicine Administrative Consulting Inc.

Documenting the HPI

• Brief •1-3 elements • Extended (99243+, 99203+, 99214+) •4+ elements,OR •Comments on 3 or more chronic or inactive conditions 93 Reproductive Medicine Administrative Consulting Inc. Review of Systems • 14 systems: •Constitutional •Eyes •ENT, mouth •Cardiovascular •Respiratory •Gastrointestinal •Genitourinary •Musculoskeletal •Integumentary (skin and/or breasts) •Neurological •Psychiatric •Endocrine •Hematologic/Lymp. •Allergic/Immun. 94 Reproductive Medicine Administrative Consulting Inc.

Documenting the ROS

•Problem Pertinent (99242, 99202, 99213) •System of complaint •Extended (99243, 99203, 99214) •2-9 systems •Complete (99244, 99245, 99204, 99205, 99215) •10 individual systems

•*Pertinent pos/neg. plus“all other systems neg” •Comment on hx. form 95 Reproductive Medicine Administrative Consulting Inc.

Past, Family, Social History

• PFSH consists of 3 areas

•Past History-Patient’s past

•Family History-Family medical events •Social History-Age appropriate review of activities 96 Reproductive Medicine Administrative Consulting Inc. Documenting the PFSH •Pertinent (99243, 99203, 99214) •1 of 3 areas •Complete (99244, 99245, 99204, 99205, 99215)

•3 of 3 for new and comprehensive assessments

•2 of 3 for established outpatient and ED

97 Reproductive Medicine Administrative Consulting Inc.

Choosing the Level of History

Type HPI ROS PFSH

PF Brief

(1-3) None None EPF Brief

(1-3) ProblemPertinent None Detailed Extended

(4+) Extended(2-9) Pertinent(1 of 3) Comp. Extended

(4+) Complete(10+) Complete(2 of 3 or 3 of 3)

Chief complaint required for all types.

Requirements for all components must be met for a given type.

98 Reproductive Medicine Administrative Consulting Inc. New Patients/Consultations Outpatient 99241 99242 99243 99244 99245 HISTORY

CC * Required Required Required Required Required HPI * 1-3

elements 1-3elements 4 + elements 4 + elements 4 + elements ROS * N/A Pertinent 2-9 systems 10-14 systems 10-14 systems PFSH * N/A N/A 1 of 3 elements 3 of 3 elements 3 of 3 elements

PHYSICAL EXAMINATION 1997 1-5

elements 6-11elements 12 or >elements Comprehensive Comprehensive 1995 System of

Complaint 2-4systems 5-7 systems 8 or > systems 8 or > systems MEDICAL DECISION MAKING

SF SF Low Moderate High TIME

Face-to-face 10/15 min. 20/30min. 30/40 min. 45/60 min. 60/80 min.

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Reproductive Medicine Administrative Consulting Inc.

Office or Other Outpatient Services

Est.

Patient 99211 99212 99213 99214 99215 HISTORY

CC * N/A Required Required Required Required HPI * N/A 1-3 elements 1-3 elements 4 + elements 4 + elements ROS * N/A N/A Pertinent 2-9 systems 10-14 systems PFSH * N/A N/A N/A 1 of 3 elements 2 of 3 elements

PHYSICAL EXAMINATION

1997 N/A 1-5 elements 6-11 elements 12 or > elements Comprehensive 1995 N/A System of

Complaint 2-4 systems 5-7 systems 8 or > systems MEDICAL DECISION MAKING

N/A SF Low Moderate High TIME

Face-to-face 5 min.supervision

10 min. 15 min. 25 min. 40 min.

100 Reproductive Medicine Administrative Consulting Inc. “Ms. Rafferty was unable to keep her appointment, but she faxed her symptoms” 101 Reproductive Medicine Administrative Consulting Inc. Examination • Four Types •Problem-focused •Expanded problem-focused •Detailed •Comprehensive 102 Reproductive Medicine Administrative Consulting Inc.

Choosing the Level of Exam

TYPE OF EXAM 1995 REQUIREMENTS 1997 REQUIREMENTS

Problem Focused 1 body area or

organ system 1-5 elements

Expanded Problem Focused

2-4 organ systems

including affected area 6-11 elements

Detailed 5-7 organ systems

including affected area 12 or more elements

Comprehensive 8 or more

organ systems Not defined

Multi-System Not defined 2elements from at least

9areas/systems

Single Organ

System Not defined All1element in allelements inshadedunshadedboxesboxes103

Reproductive Medicine Administrative Consulting Inc. New Patients/Consultations Outpatient 99201 99202 99203 99204 99205 HISTORY

CC * Required Required Required Required Required HPI * 1-3elements 1-3elements 4 + elements 4 + elements 4 + elements ROS * N/A Pertinent 2-9 systems 10-14 systems 10-14 systems PFSH * N/A N/A 1 of 3 elements 3 of 3 elements 3 of 3 elements

PHYSICAL EXAMINATION

1997 1-5elements 6-11elements 12 or >elements Comprehensive Comprehensive 1995 System ofComplaint 2-4systems 5-7 systems 8 or > systems 8 or > systems

MEDICAL DECISION MAKING

SF SF Low Moderate High TIME

Face-to-face 10/15 min. 20/30min. 30/40 min. 45/60 min. 60/80 min.

104 Reproductive Medicine Administrative Consulting Inc. Dr. Thyme Rosemary

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by line)

1.N92.1 Excessive and frequent menstruation with irregular cycle

2.L68.0 Hirsutism

3.Z68.34 BMI between 34.0-34.9, adult

22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 23. PRIOR AUTHORIZATION NUMBER 24. A. DATE(S) OF SERVICE From To MM DD YY MM DD YY B. POS D. PROCEDURES, SERVICES/SUPPLIES

(Explain Unusual Circumstances) CPT/HCPCS MODIFIER E. DX POINTER F. $ CHARGES G. DAYS OR UNITS I. ID. QUAL J. RENDERING PROVIDER ID. # 11 99243 123 1 NPI 11 81025 1 1 NPI 11 76830 1 1 NPI CPT Codes CPT Description

99243 Level III Outpatient consultation

81025 Urine pregnancy test

76830 Transvaginal ultrasound 105 Reproductive Medicine Administrative Consulting Inc.

Office or Other Outpatient Services

Est.

Patient 99211 99212 99213 99214 99215 HISTORY

CC * N/A Required Required Required Required HPI * N/A 1-3 elements 1-3 elements 4 + elements 4 + elements ROS * N/A N/A Pertinent 2-9 systems 10-14 systems PFSH * N/A N/A N/A 1 of 3 elements 2 of 3 elements

PHYSICAL EXAMINATION

1997 N/A 1-5 elements 6-11 elements 12 or > elements Comprehensive 1995 N/A System ofComplaint 2-4 systems 5-7 systems 8 or > systems

MEDICAL DECISION MAKING

N/A SF Low Moderate High TIME

Face-to-face 5 min.supervision

10 min. 15 min. 25 min. 40 min.

106 Reproductive Medicine Administrative Consulting Inc. Dr. Thyme Rosemary

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by line)

1.N92.1 Excessive and frequent menstruation with irregular cycle

2.L68.0 Hirsutism

3.Z68.34 BMI between 34.0-34.9, adult

22. MEDICAID RESUBMISSION CODE ORIGINAL REF. NO. 23. PRIOR AUTHORIZATION NUMBER 24. A. DATE(S) OF SERVICE From To MM DD YY MM DD YY B. POS D. PROCEDURES, SERVICES/SUPPLIES

(Explain Unusual Circumstances) CPT/HCPCS MODIFIER E. DX POINTER F. $ CHARGES G. DAYS OR UNITS I. ID. QUAL J. RENDERING PROVIDER ID. # 11 99214 123 1 NPI 11 81025 1 1 NPI 11 76830 1 1 NPI CPT Codes CPT Description

99214 Level IV Established Outpatient

81025 Urine pregnancy test

76830 Transvaginal ultrasound 107 Reproductive Medicine Administrative Consulting Inc.

USING E/M SERVICES

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Reproductive Medicine Administrative Consulting Inc. New Patients/Consultations Outpatient 99201 99202 99203 99204 99205 HISTORY

CC * Required Required Required Required Required HPI * 1-3elements 1-3elements 4 + elements 4 + elements 4 + elements ROS * N/A Pertinent 2-9 systems 10-14 systems 10-14 systems PFSH * N/A N/A 1 of 3 elements 3 of 3 elements 3 of 3 elements

PHYSICAL EXAMINATION

1997 1-5elements 6-11elements 12 or >elements Comprehensive Comprehensive 1995 System ofComplaint 2-4systems 5-7 systems 8 or > systems 8 or > systems

MEDICAL DECISION MAKING

SF SF Low Moderate High TIME

Face-to-face 10/15 min. 20/30min. 30/40 min. 45/60 min. 60/80 min.

109 Reproductive Medicine Administrative Consulting Inc.

Office or Other Outpatient Services

Est.

Patient 99211 99212 99213 99214 99215 HISTORY

CC * N/A Required Required Required Required HPI * N/A 1-3 elements 1-3 elements 4 + elements 4 + elements ROS * N/A N/A Pertinent 2-9 systems 10-14 systems PFSH * N/A N/A N/A 1 of 3 elements 2 of 3 elements

PHYSICAL EXAMINATION

1997 N/A 1-5 elements 6-11 elements 12 or > elements Comprehensive 1995 N/A System ofComplaint 2-4 systems 5-7 systems 8 or > systems

MEDICAL DECISION MAKING

N/A SF Low Moderate High TIME

Face-to-face 5 min.supervision

10 min. 15 min. 25 min. 40 min.

110 Reproductive Medicine Administrative Consulting Inc. Hope

•CC/HPI: Hope is a 22-year-old established patient with complaints of mild vaginal itching and irritation for the last 3-4 days.

111 Reproductive Medicine Administrative Consulting Inc. Hope •Exam: •Pelvic:

External genitalia:mild redness.

Vagina:thick, white, curdy discharge.

Wet mount:positive for candida.

112 Reproductive Medicine Administrative Consulting Inc. Hope

• Assessment: Vaginal candidiasis

• Plan:

1. Clotrimazole cream and vaginal inserts X 7 days 2. RTO prn. 113 Reproductive Medicine Administrative Consulting Inc.

Office or Other Outpatient Services

Code History Exam DecisionMedical

Making Face to

Face Time

99211 Requires physician’s supervision only 5 min. 99212 Problem-focused Problem-focused Straightforward 10 min. 99213 Expanded

problem-focused Expandedproblem-focused Low 15 min. 99214 Detailed Detailed Moderate 25 min. 99215 Comprehensive Comprehensive High 40 min.

Established Patient 114 Reproductive Medicine Administrative Consulting Inc. Charity

•CC/HPI: Charity is a 25-year-old established patient with complaints of vaginal discharge and discomfort for the last 1-2 weeks. The discharge is described as a thin greenish discharge that recently has become quite profuse. 115 Reproductive Medicine Administrative Consulting Inc. Charity

•ROS: She complains of mild dysuria and

dyspareunia.

•Past history: She is sexually active and is on oral contraceptives. She does not use condoms. She has no history of previous STIs. Her last pap smear was 6 months ago and normal. 116 Reproductive Medicine Administrative Consulting Inc. Charity •Exam •Constitutional: BP 120/80; Wt.125; Ht. 64 inches

•Pelvic: External genitalia: Vulva is inflamed,

Vagina:Large amount of greenish-yellow discharge

in vaginal fornix. Vaginal mucosa: red and inflamed.

Cervix:Punctate, red “strawberry” spots.

Bimanual:Slight discomfort on palpation. No

localization.

Wet mount:Suggestive of trichomonas. Cultures

taken.

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Reproductive Medicine Administrative Consulting Inc. Charity

•Assessment: Probable trichomonas. She was

counseled regarding STIs and the use of condoms.

•Plan:

1. Will screen for STI’s

2. Metronidazole 500mg. bid X 7 days

3. Will call with test results and schedule appointment as necessary 118 Reproductive Medicine Administrative Consulting Inc.

Office or Other Outpatient Services

Code History Exam DecisionMedical

Making Face to

Face Time

99211 Requires physician’s supervision only 5 min. 99212 Problem-focused Problem-focused Straightforward 10 min. 99213 Expanded

problem-focused Expanded problem-focused

Low 15 min.

99214 Detailed Detailed Moderate 25 min. 99215 Comprehensive Comprehensive High 40 min.

Established Patient 119 Reproductive Medicine Administrative Consulting Inc. Patience

•CC/HPI: Patience is a 48-year-old established patient with complaints of recurrent vaginitis. She has had 3 episodes of yeast in the last 6 months. The last episode, which was 4 weeks ago, required 2 courses of therapy. The discharge is again thick and white. She has significant external irritation and itching.

120 Reproductive Medicine Administrative Consulting Inc. Patience

•ROS: She is also complaining of dysuria, frequency, and urgency. She denies polydipsia or polyphagia. She has had a weight gain of 10 lbs. over the last 6-8 months. Menses have been irregular for the last 18 months, occurring about 6-8 weeks apart. She has no menopausal symptoms.

121 Reproductive Medicine Administrative Consulting Inc. Patience

•Past history: She is married and sexually active. She has had no recent illness or oral antibiotic use. She has no history of STIs. Her last pap smear was 10 months ago and normal.

•Family history: Mother developed Type II DM at about age 58. 122 Reproductive Medicine Administrative Consulting Inc. Patience •Constitutional: BP 130/86; Wt. 160 lbs.; Ht.65” •Pelvic:

External genitalia:Mild erythema

Vagina:Moderate amount of thick, white,

discharge

Cervix:Significant area of patchy white discharge

Bladder:Tender to palpation

Uterus:Normal size, shape

Adnexa:Non-tender without masses

123 Reproductive Medicine Administrative Consulting Inc. Patience

Wet mount:Positive for candida. • U/A:Positive for increased WBC’s. Both

urine and vaginal cultures taken. • Assessment:

1. Recurrent candidiasis.

2. Need to rule out diabetes and consider re-infection by partner.

3. Probable UTI. Will wait for culture results prior to initiating therapy.

124 Reproductive Medicine Administrative Consulting Inc. Patience • Plan: 1. Fluconazole 150 mg. X 1 dose

2. FBS and 2 hour pp in the AM. Will call with test results

3. RTO in 7-10 days for follow-up.

125 Reproductive Medicine Administrative Consulting Inc.

Office or Other Outpatient Services

Code History Exam DecisionMedical

Making Face to

Face Time

99211 Requires physician’s supervision only 5 min. 99212 Problem-focused Problem-focused Straightforward 10 min. 99213 Expanded

problem-focused Expandedproblem-focused Low 15 min. 99214 Detailed Detailed Moderate 25 min. 99215 Comprehensive Comprehensive High 40 min.

Established Patient

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Reproductive Medicine Administrative Consulting Inc. QUESTIONS?

Brad Hart, MBA, MS, CMPE, CPC, COBGC bhart@rmaci.com

(862) 438-1678

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References

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